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KEY WORDS

Community occupational

therapy

Health promotion

Occupational

therapy

services

MARCIA FINLAYSON JEANETTE EDWARDS

ntegrating

the concepts

health

promotion nd

community into occupational

therapy practice

ABSTRACT

ealth reform activities in Canada have encouraged health

care professionals to examine new and innovative ways to share their skills, not

only with other professionals, but

with

the public. Historically, occupational

therapists have been encouraged by

leaders in the profession

to expand their

practice and

to share their skills through

active participation with their

communities. Health

promotion

has been identified

as a

process through which

this expansion can be pursued. In order for occupational therapists to

contribute to their communities

in a

meaningful

way, the concepts of health

promotion and

community require definition, development

and

reflection

within their model of practice. Through a discussion of

these

concepts,

this

paper encourages

occupational therapists to develop, expand

and

integrate

new practice roles within

the

community by integrating health

promotion

into

their practice.

RSUM

entreprise de la rforme de la sant au Canada a

encourag les professionnels de la sant examiner de nouvelles faon de

partager leurs comptences, non seulement avec d'autres professionnels, mais

aussi avec le public. Historiquement, les ergothrapeutes ont t encourags

par les leaders de leur profession tendre leur pratique et partager leurs

comptences par le biais de leur participation active au sein de leur milieu. La

promotion de la sant a t dfinie comme un processus par lequel cette

expansion peut tre envisage. Afin que les ergothrapeutes puissent contribuer

leur milieu de faon significative, des concepts relatifs la promotion de la

sant et de l'environnement communautaire ont besoin d'tre dfinis, dvelopps

et penss en fonction de leur modle de pratique. Par une discussion de ces

concepts, cette tude encourage les ergothrapeutes dvelopper et adopter

de nouveaux rles au sein de leur pratique communautaire en intgrant la

promotion de la sant dans leur pratique.

Mania Finlayson, BMR, OTM,

0.T. (C)

was

the Project Coordinator

Manitoba for the

CAOT Seniors

ealth

Promotion

Project upon initiation of this

paper.

She is cu rrently a ful l

time graduate

student in the

Department

of Community

Health

Sciences

at

the University of

Manitoba. Direct

correspondence to 1240

Wolseley Avenue, Winnipeg, Manitoba,

R3G 1H4.

Jeanette Edwards,

MHA, CHE,

BOT,

OTL1, 0.T. (C) was a member

of

the CAOT

Seniors Health

Promotion

Project s

Manitoba

Resource Group upon

the initiation of this paper. She is

the

Executive Director

of the

Health Action

Centre, 425

Elgin Avenue, Winnipeg,

Manitoba.

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Health

promotion

has become one of the most signifi-

cant concepts

within health care reform currently

underway

in all

provincial

jurisdictions and in Canada

as a nation.

Is occupational therapy prepared to grasp

this concept and

integrate it into practice?

The

Cana-

dian Association of

Occupational Therapists (CAOT)

Seniors' Health Promotion

Project has demonstrated

that the profession has

the

potential to assume these

new roles (Letts,

Fraser, Finlayson & Walls, 1993).

In

January of 1992,

the C A O T Seniors' Health

Promotion

Project introduced

a

series

of

Health Pro-

motion Issue Papers.

In the

first

issue paper, the

authors introduced

a conceptual model of

occupa-

tional therapy

and

health

promotion

(Finlayson &

Edwards, 1992). This

current paper is intended to

expand on

those ideas, to provide further understand-

ing of the

history behind occupational therapy

and

health

promotion, and to

explore the concepts of

health promotion and

community for future inclusion

in the

client-centred

model.

Further, this paper is intended to encourage occu-

pational therapists to develop, expand and integrate

new practice roles within

the community by integrat-

ing health promotion into their practice. It is not

the

intention of this paper to prescribe practice roles,

but

rather to challenge

occupational therapists to reflect

on

the

history

of the profession, and to apply this knowl-

edge to their current practice realities.

BACKGROUND AND

HISTORY

Maurer

and

Teske

(1989)

state that one of the barriers

to occupational therapists engaging in health promo-

tion

and

wellness activities is the lack

of a

meaningful

model of practice which enables understanding

and

development in

these areas. The authors

of this paper

feel that it is not the lack of a model

per se, but

it is

rather

the lack

of articulation of

health promotion

and

community concepts

within the

current practice model

(CAOT, 1991) that

pose the barrier to the

profession's

exploration of these areas

and the potential roles

within them.

Although the terminology used today in health

promotion is relatively new, its

basic concepts can be

traced back to ancient Greek and Oriental writings.

Early civilizations recognized that health

and

well-

being were affected by social interactions

between

individuals,

as well

as the interactions

between indi-

viduals

and

their environments (Johnson, 1986).

These core beliefs

about health continued up until

the

mid-19th century, when health was valued

as a

process and an aspiration of

life itself, rather than

an

outcome. Consequently, individuals were concerned

with their daily and

community activities.

(Johnson,

1986, p.755).

With

the invention of microscopes, and the mass of

technology which followed, health became

the do-

main of the professionals rather than the

domain

of

individuals

and of communities.

As technology has

grown, health has evolved from

a process of living to

an outcome to be achieved (Rachlis Kushner,

1989).

Meyer, an early advocate for

occupational therapy,

recognized the potential breadth

of the profession

when he stated: Our special work, which

tries

to do

justice

to special human needs, I feel is destined to

serve again as the centre of a

great

gain for the normal

as well [as

the

sick]. (1922, 1977, p.642)

Although

the

early writings in

occupational therapy

recognized

the value of occupation in the overall

health of people, the profession

did little in the

area

of

preventive health practices between

the 1920's and

1960's

but

rather concentrated solely

on curative

approaches, abandoning the philosophy

of

preventive

health (Reitz, 1992, p.51). Reilly (1962) reminded

the

profession of

its philosophy and roots - that occupa-

tional therapy believes that health can be influenced by

engagement in

meaningful activity.

Brunyate (1967)

stated that occupational therapy

had a vital, distinct and

elsewhere unattainable con-

tribution to make to restorative, preventive and main-

tenance health

(Brunyate, 1967, p.262).

Later,

she

encouraged occupational therapists to take

a more

active role in

community

and

preventive health (Wiemer,

1972).

Finn (1972)

challenged occupational therapists to

learn

more about the

political,

social and

economic

factors of a

community and

their

influence on health.

In the inaugural Canadian

Association of Occupational

Therapists'

Muriel Driver

Memorial

Lecture in 1975,

Bassett noted that occupational therapists

must re-

spond to the need

for research in

health promotion and

determine effective

ways

of helping persons

bridge the

gap between hospital

and the

community.

Finn

(1977)

later challenged therapists to consider

the

development of

alternative models

ofpractice,

and

to investigate

a role expansion

from therapist to health

agent.

Ten years

later,

Stan reiterated this

challenge

stating, We must

ask where we can

use

our

talents and

take our skills beyond

the

boundaries of

currently

subsidized health care to provide

services

not

met

by

institutions,

private practices

or public health.

As

individuals, we need to be prepared to take

the

risks

of

operating outside

of the

system (Stan,

1987, p.169).

Now,

71

years after Meyer's first

suggestion

that

occupational therapy could

serve the

well

population

in addition

to

the disabled

population, the profession

is faced with

a political

and economic

situation

that

requires

a

response. The

cost of providing

the

present

illness care system has stretched

the

financial resources

of the provincial and

federal governments.

The

pre-

dicted escalation

in

costs

of the

present system will be

beyond the

resources of the present tax

base (Carswell-

Opzoomer, 1990, p.199).

In addition,

although health

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care costs have

been escalating at alarming

rates, the

overall health

of populations

has not drastically im-

proved (Johnson, 1986; Rachlis Kushner, 1989). In a

landmark

document on health and

health care in

Canada, Lalonde (1974) reintroduced

the concept

that

health was influenced by a variety of determinants

including human biology, lifestyles, environment and

the organization of medical

care. de

Leeuw (1989)

identified

the

Lalonde

report as the

overall roots of

health

promotion as a concept.

Within the

next de-

cade, the

World Health Organization also broadened

its definition of health to a resource for

everyday life,

not the objective of living (WHO,

1984).

Between

1974

and 1984, the World Health Organi-

zation defined primary health care

as

essential health

care made

universally accessible

to individuals and

families in the

community by means

acceptable to

them, through their

full participation and

at a

cost that

the

community and country

can afford.

(WHO,

1978).

Canada

continued

in its development of health

promotion concepts and principles with the release of

the publication

Achieving Health for All

(Epp, 1986).

This document

outlined

the challenges to health

for all,

and

identified mechanisms and

strategies by which

health promotion should be pursued. Later that same

year, the

Canadian

Public

Health

Association, in

con-

junction with the

World Health Organization, hosted

the first international conference

on

health

promotion.

The result of this event was

the

Ottawa Charter

on

Health Promotion

(WHO, Health

&

Welfare Canada &

CPHA, 1986).

CORE

CONCEPTS OF

HEALTH

PROMOTION

Health promotion

has been defined by the

World

Health Organization as the process of enabling

people

to increase control over, and to improve, their health

(Epp,

1986).

Enabling, mediating

and

advocating

are

means through which health

promotion activities are

pursued. These terms

are

defined

as:

Enable: Involves providing

people and

com-

munities with information and support

to

identify

and address health issues...

Mediate: Involves linking the

many sectors

that influence

health...

Advocate: Involves supporting and

fighting

for favourable

conditions for

health

...

(Letts et

al,

1993,

p.

9)

It is through these essential means that actions

to

develop personal skills, create supportive environ-

ments, reorient health services and strengthen commu-

nity actions are pursued. These means and actions are

the

critical foundations

in the building of healthy

public policy and therefore of health

promotion (WHO

et al,

1986).

Ultimately, health

promotion is helping

people

help

themselves. Within health

promotion,

people identify

their health needs,

and

utilize available tools/informa-

tion to elicit

change in

their own lives. It is

the

responsibility therefore,

for the

professionals working

within the scope

of health promotion to provide

the

necessary tools/information which promotes

the em-

powerment

or

enablement for change.

Professionals

cannot empower

or enable clients, but

can provide

information in

order that people

may go through

the

process of empowering themselves, of

taking control

over their own health

as they see fit.

Health

promotion

therefore, is

a

continuous process

of

development

and change

that involves many

people

working together in

collaborative ways. It is a

process

that requires one to listen and

understand what is

important

to both individuals

and

communities,

and

then to facilitate action

to satisfy these self-identified

needs. A commitment to health

promotion

means

a

commitment to change

(Letts

et al, 1993, p.10).

If

activities

are

to

support the

health promotion

process,

they

must

be guided

and owned by the

recipients of the information

(individuals

and

commu-

nities). Effective

health

promotion must have grass

roots ownership. Health

promotion is a mechanism

through which a continuum between

the

individual

and the

environment is created. Within this continuum

the

individual effects

the environment to make change

and the environmental response enhances the

individual's health

and

well-being.

The manual, For

the Health of It: Occupational

Therapy Within

a

Health

Promotion

Framework, (Letts

et al,

1993)

summarizes these ideas by identifying that

the health promotion process is participatory,

intersectoral,

integrative and

continuous.

Raeburn (1992)

and Green and Raeburn (1988) state

that health promotion is one of the first and

few truly

interdisciplinary enterprises, with

the consumer

being

critical to

the process.

Within the health

promotion

concept, experts do not exist as each person makes

contributions

to

the process. This new health paradigm

integrates health

and

health care into community life

with consumers

and citizens playing

an active role

(Carswell-Opzoomer, 1990, p.201).

CORE CONCEPTS

OF

OCCUPATIONAL

THERAPY

Occupational therapy has been described

as a

blend

of art and science

(Peloquin, 1989). The art of occupa-

tional therapy utilizes

the

therapeutic use of self,

human relationships

and emphasizes

the dignity

and

rights

of the

individual regardless

of the

individual's

past

or present circumstances or future potential

(Mosey,

1981, p.23).

Occupational therapists believe that individuals

need to be engaged,

and

that

engagement in

purpose-

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ful activity can contribute to well-being

and

quality

of

life. Occupational therapists also believe that

a balance

of occupations

(self-care,

productivity, leisure) con-

tributes to a

sense of well-being

(CAOT, 1991).

Within

the

practice of occupational therapy,

the

environment, both human

and non-human, is integral

to

the functioning

of an individual. The

environment

influences

all aspects of

daily functioning, from

the

values that one holds, to the ability to

interact,

to

the

reactions

one has to

stress and stressors.

The

environment is

a

tool which creates change,

as

well

as a

tool that can be adapted to facilitate function

(Reed & Sanderson,

1983).

In

achieving occupational

performance,

each individual both

influences and is

influenced by his/her environment (Townsend,

Brintnell & Staisey, 1990, p.71).

With this in mind,

occupational therapists need to consider

the different

components of the

environment i.e. physical, social,

cultural,

economic

and institutional

(Law,

1991),

in

order to truly understand

clients and their

past,

present

and future

functional abilities

and

potentials.

Law (1991)

offered a taxonomy

of the environment

which places

these components

on a

matrix with levels

of

the environment

-

individual, household,

neighbourhood, community and

province/country.

Slae

suggested that these components

and

levels were

interlocking,

and

challenged occupational therapists

to use

this interlocking matrix to consider

the broader

systems operating within

the

environment,

and how

they impacted

on

health

and

occupational perfor-

mance.

Through this broad review of the core concepts

of

occupational therapy,

one can see that although sci-

ence is an

integral

part of the

profession, it is the

process

and

approach to

a client

that makes it

a unique

profession. The

Occupational

nerapy Guidelines for

Client-Centred Practice

state: Thus

the

occupational

therapy approach is

unique

rather than

the

specific

skills used by

the

therapist. It is this that constitutes the

art

of therapy

(CAOT, 1991, p.6).

Mosey adds With-

out

art, the

occupational therapy process is only

the

application

of scientific knowledge

in a

sterile v acuum

(1981, p.25).

OCCUPATIONAL THERAPY

AND

HEALTH

PROMOTION: A NATURAL PARTNERSHIP

Health promotion is

a

process of

integration and

partnership between individuals

and communities.

The authors

of

this paper

have

chosen to use the

definition of

community

as

noted

in the

Manitoba

Department of H ealth, Health Advisory Network, Pri-

mary Health C are Task Force's Interim Report

(1993).

A community is

an interactive group of people (who

may live in a

geographical location)

who cooperate

in

common activities and/or solve mutual concerns.

Articulation of

this context enables occupational

therapists to be involved in

integrating individuals into

their environments,

and subsequently into

the

larger

context of

their community.

The

authors feel that this process requires

a

broader

exploration and

understanding

of the

community and

how it interacts with occupational performance. Un-

fortunately,

the Occupational Therapy Guidelines for

Client

Centred Practice

(1991)

neglects to define

com-

munity or related

concepts such

as

community mobi-

lization or

community development.

By expanding the

conceptualization of the

environ-

ment within

the

client-centred practice model to delin-

eate

the importance

of the community

and the

need

for

kinship and

relatedness to others

and the need for a

sense

of individuality

and

selfness,

the

process of

exploration

and

understanding can begin (Cassidy,

1962).

Community implies fellowship,

a

state

of

shar-

ing

and joint

ownership. It implies

a

group

of

people

whose members hold something

in

common such as,

but

not

exclusive to, religion,

geography and/or cul-

tural similarity.

The processes which

are critical

in

ensuring

the

integration

of an

individual within communities

have

been previously described in this

paper, and are

based

on the means

and actions outlined

in the Ottawa

Charter

for Health

Promotion (WHO et al,

1986).

The

conceptual expansion

of the

environment to articulate

the

concepts

of

community provide

the means

for the

role expansion

from therapist to health

agent

encour-

aged by Finn

(1977). More

importantly, it focuses

on

the community as the agent of change and

recognizes

the capacity

of

individuals, and collections of individu-

als within communities, to articulate problems

and

to

set priorities for

their resolution (Hoffman & Dupont,

1992).

INTEGRATION INTO PRACTICE

How can occupational therapists expand their roles

and

enable communities to be agents of change? Many

examples currently exist

in Canada,

and each demon-

strates

the possible

ways that this

expansion

can

occur.

For the Health of It

(Letts et al,

1993)

identifies five

critical activities which are

necessary to integrate

health promotion and community into occupational

therapy practice. These activities include networking,

consulting, collaborating,

planning and

reflecting.

The

CAOT Seniors' Health Promotion Project is

a

good

example of how these five activities were applied by

occupational therapists

in

Manitoba and

Newfound-

land.

Specific

initiatives

undertaken during this Project,

and described

in

detail by Letts

et al

(1993),

include:

0

advocating for accessible transportation together

with seniors;

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0

collaborating with

a seniors' organization to de-

velop health-related educational video-tapes;

publishing a

health column in a provincial seniors'

newspaper; and

0 facilitating

the

development

of a seniors' writing

group and

newsletter committee within a seniors'

organization.

Although formal funding for

this Project -ended in

March

of

1993,

the commitment to health promotion

has continued. In Manitoba, a

voluntary group known

as the

'Partners

for

Health

Promotion'

has acted as a

catalyst to bring together

seniors'

groups

and occupa-

tional therapists

for

mutual learning. To

date

this group

has successfully linked practicing therapists with urban

and rural seniors'

groups to share health

information

both

in

person and

through written materials.

By acting as

resource

people,

occupational thera-

pists

in Manitoba have

also been working with a

core

area community

for the

past three years within various

community development

initiatives

(Health Action

Centre,

1992).

This

voluntary involvement has lead to

the

formal development

and funding

of a

neighbourhood

seniors'

council.

The purpose

of this

council is to identify gaps

in services, issues

related to

independent

living, and

to coordinate volunteers

and

programmes

to meet these needs.

Other examples

of the

ways in

which Canadian

occupational therapists

have

engaged

in the health

promotion

process with their communities

are

de-

scribed

in the May

1993

volume of

he

National Clark

Green,

1993).

The articles in

this publication

describe

partnerships, change

processes and

co-enterprises in

which occupational therapists

have

engaged across

the country.

In

each of the

above examples, it can be seen that

legitimate and

practical roles exist

for occupational

therapists who integrate health

promotion and com-

munity

concepts

into their practice. These roles can be

described

as

being enablers, mediators

and advocates.

CONCLUSION

Occupational therapists working with individuals

within

the

context

of a

community and

within a health

promotion

framework

must

be prepared to respond to

the needs of the

consumers in

practical yet creative

ways,

and focus

on collaboration. The

response needs

to be grounded

in a

belief

of

wellness, and a

belief that

the skills of

an .occupational

therapist are

equally

as

valuable to healthy persons

as to ill persons

as sug-

gested by Meyer (1922).

When working with individuals,

an

occupational

therapist

must view

the client

holistically,

and

this is

also the case

when working with a

community. Health

promotion

is integrative. Health

promotion

activities

must

be meaningful,

acceptable and

responsive to the

community

and

its needs. Health

promotion

is partici-

patory

and

continuous. Health

promotion

activities

must

also recognize all

of the

key players

and

stake-

holders

the individual, the people of the

neighbourhood,

the

politicians,

the

professionals,

the

community agencies,

the local

churches and

industry.

Health

promotion

is

intersectoral.

Occupational therapy has much to offer

in the area

of

health

promotion and

considering

the current

economics of health

care, and the

ever increasing

ethno-cultural

mix of the

Canadian

population,

it is

imperative that

the profession

make its skills available

to communities.

Health

promotion,

like occupational therapy, can

be considered

a

blend

of art and science.

Like occupa-

tional therapy, loss

of the art in

health promotion

means a failure in the process. The

true

art of health

promotion

is learning to

accept, and

then to endorse,

a

community's desire to establish its own course

of

action.

With

the

belief occupational therapists

have in

client-centred practice, and the experiences from which

they have learned,

the profession

is poised to link the

individual with

the community

in a manner that

promotes health

for all. As

Brockett

stressed, it is

important for the profession of

occupational therapy

to act immediately to

assume leadership for the

con-

tinuing legitimization

and maintenance of

health pro-

motion within occupational therapy practice

(1993,

p.19).

ACKNOWLEDGEMENTS

The

authors wish to acknowledge

the staff

of the CAOT

Seniors'

Health Promotion

Project for

assisting

in

integrating the ideas presented

in this paper -

Brenda

Fraser (National

Coordinator), Lori

Letts (Assistant

National

Coordinator), June Walls (Project Coordinator

- Newfoundland),

and Margaret

Brockett (Project Con-

sultant).

The

first author would also like to acknowledge

COTF

(Part-time scholarship - 1993;

Royal

Canadian

Legion fellowship

- 1994)

and the National Health

Research and

Development Program (M.Sc. fellow-

ship- 1993-1995) for

their financial support of her

graduate studies

and research.

REFERENCES

Bassett, J. (1975).

Muriel Driver M emorial

Lecture.

Canadian Journal of Occupational Therapy.

42,

91

96.

Brockett, M.

(1993).

Effecting change. The National,

10

(3),

18-19.

Bruyante, R.W. (1967).

After

50 years, what stature do w e

hold? American Journal of Occupational Therapy,

21,

262-267.

Canadian Association of

Occupational Therapists. (1991).

Occupational therapy guidelines for client-centred practice.

Toronto:

CAOT

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Carswell-Opzoomer, A.

(1990). Muriel D river

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