Australian Occupational Therapy Journal (2014) 61, 376–383
doi: 10.1111/1440-1630.12147
Feature Article
Examining an occupational perspective in a rural Canadian age-friendly consultation process Heidi M. Lauckner and Robin L. Stadnyk School of Occupational Therapy, Dalhousie University, Halifax, NS, Canada
Background/aim: The age-friendly community movement is a community-level approach to promoting seniors’ health that has yet to be thoroughly examined from an occupational perspective. Through the application of the Canadian Practice Process Framework to an age-friendly consultation process, the authors examined how agefriendly community consultations may provide strategies for occupational therapists to strengthen their work with communities. Methods: A consultation with a rural Canadian community was guided by the Age-Friendly Rural/Remote Communities Initiative. Focus groups were held with 35 older adults to identify age-friendly features of the community. Twenty key informants who provide services to seniors were also interviewed individually. Following the community consultation, we examined the relationship between the age-friendly community consultation process and occupational therapy community development practice processes using the Canadian Practice Process Framework. Results: The steps of the consultation process paralleled the occupational therapy practice process, with occupational issues implicitly identified in the age-friendly consultation. The age-friendly consultation process emphasised the importance of collaborative partnerships and the need for occupational therapists to adopt a facilitative rather than leadership role. Skills that enable occupation were used throughout this age-friendly consultation. Conclusions: The study suggests that the process of this age-friendly community consultation has relevance to occupational therapy theory and practice, and can provide a useful framework for collaborative consultative processes when working with communities.
Heidi M. Lauckner PhD, OT Reg (NS); Assistant Professor. Robin L. Stadnyk PhD, OT Reg (NS); Assistant Professor. Correspondence: Heidi M. Lauckner, School of Occupational Therapy, Dalhousie University, 5869 University Avenue, Forrest Building Room 215, PO Box 15000, Halifax, NS, Canada B3H 4R2. Email: [email protected] Accepted for publication 14 July 2014. © 2014 Occupational Therapy Australia
KEY WORDS community-based occupational therapy practice, age-friendly communities, Canadian Practice Process Framework, community development, application of practice process to community work.
Introduction Through family roles, work, and volunteering, older adults (aged 65+) contribute significantly to the lives of families and friends and add experience and commitment to their communities. Similar to many developed countries, older adults in Canada make up a small percentage of the population (13%), yet account for a disproportionately large percentage of total health-care costs (44%) (Turcotte & Schellenberg, 2007). Given that the number of older adults is expected to double over the next 30 years in countries like Canada and Australia (Australian Government Department of Health and Aging, 2012; Turcotte & Schellenberg, 2007), there is concern about how best to promote the health of older adults, encourage their continued contributions to communities, and reduce their reliance on health-care services. The creation of age-friendly communities is one internationally supported approach to promote older adults’ health (Public Health Agency of Canada (PHAC), 2009; World Health Organisation (WHO), 2007). The policies, services, settings and structures of age-friendly communities are designed to help older adults age actively; that is, to be safe, healthy, and involved (WHO, 2007). The age-friendly community movement arose in 2006 from a partnership between the World Health Organization (WHO) and 33 cities that sought input from older adults, caregivers, and service providers to identify key community features supporting participation, health, and security. Eight features were identified: outdoor spaces and buildings, transportation, housing, respect and social inclusion, social participation, communication and information, civic participation and employment, and community support and health services (PHAC, 2009; WHO, 2007). Inherent in the age-friendly community movement is the recognition that physical and social environments can enable or impede active community engagement.
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Also inherent in this approach is a commitment to bottom-up participation, where older adults’ experiences mark them as experts in the identification of age-friendly community features (WHO).
Age-friendly communities and occupational therapy Age-friendly communities embody concepts such as successful or positive ageing, active ageing (WHO, 2007), liveable communities (Lui, Everingham, Warburton, Cuthil & Bartlett, 2009), health promotion (Letts, Fraser, Finlayson & Walls, 1993), citizen engagement (Letts, 2003) and ageing in place (Chippendale & BearLehman, 2010), which have an effect on many of the ageing adults with whom occupational therapists work (Chippendale & Bear-Lehman; Kaminsky, 2010; O’Sullivan & Hocking, 2006; Siebert, 2007). For their part, in 2011 the Canadian Association of Occupational Therapists (2011) issued a position statement recommending that occupational therapists foster ageing in place at the community level by developing partnerships with older adults and community stakeholders. Age-friendly communities are one way to foster such active ageing and ageing in place at the community level. Despite encouragement to work at the community level (Townsend & Polatajko, 2007), some occupational therapists struggle to apply community development approaches in practice (Lauckner, Pentland & Paterson, 2007; Restall & Ripat, 2008). These struggles are at least in part because the majority of occupational therapy models focus on individual clients and provide limited practical guidance to community-level engagement through partnerships (Lauckner, Krupa & Paterson, 2011; Leclair, 2010). This article examines a community consultation process addressing one Canadian community’s age-friendliness, guided by the Age-Friendly Rural/Remote Communities Initiative (PHAC, 2009). The consultation asked community members to identify community features that were inclusive of older adults and features that were exclusive and needed improvement. Through their involvement in the consultation, the authors (both occupational therapists) acquired experience and reflected upon the occupational therapy process as it unfolded at the community level. Systematic examination of the authors’ learnings in relation to the Canadian Practice Process Framework (CPPF) (Craik, Davis & Polatajko, 2007) fostered a comparative analysis of the processes found in an age-friendly community consultation and occupational therapy practice. Results identified ways to strengthen the applicability of the practice model for occupational therapists working at the community level.
Methods The consultative process aimed to determine how a small rural community in Nova Scotia, Canada, could
become more age-friendly. The provincial Department of Seniors provided funding to support similar projects in many communities and recommended partnering with the local community centre and town government. With the town Mayor’s approval, the second author, who is also a resident of the town, volunteered as the project coordinator. Research Ethics Approval was received for this project from Dalhousie University in April of 2011. Major project decisions were made collaboratively with a steering committee which included the authors, and the consultation process was guided by the steps of the Age-Friendly Rural/Remote Communities Initiative (PHAC, 2009), as outlined in Table 1. During and following the consultative process, the authors engaged in a reflective process that explored the congruence between the age-friendly community consultation process and occupational therapy practice at the community level and the lessons that can be learnt from this consultation process to strengthen the applicability of the CPPF to communities. The focus of this article is on these reflections.
Data collection and analysis Thirty-five (35) older adults from the community participated in focus groups of 5–6 people or individual interviews lasting 1–1.5 hours. In addition, 20 key informants, selected for their knowledge of older adults and community services, were also interviewed. Older adults and key informants were asked questions derived from features identified as relevant to age-friendly communities: outdoor spaces and buildings, transportation, housing, respect and social inclusion, social participation, communication and information, civic participation and employment, and community support and health services (PHAC, 2009; WHO, 2007). Participants were asked to identify community features that promoted participation and those that limited their involvement. The researchers used qualitative content analysis (Sandelowski, 2000) to distil key issues identified by the community members. Key themes were reviewed by steering committee members and presented at a community forum where a group of 30 community members reviewed the findings, prioritised recommendations, and generated potential action plans.
Participants The majority of the 35 older adults involved in this study were between 60 and 79 years of age (69%), female (65%), had lived in the town for more than 10 years (62%), were married and living with a partner (60%), and self-identified as active in their community, in addition to self-identifying as educated, healthy and financially secure. Based on steering committee recommendations, twenty key informants who had expertise about the community and services for older adults were recruited from diverse community sectors. Key informants represented local government, community centres and service organisa© 2014 Occupational Therapy Australia
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TABLE 1: Age-friendly consultation process adapted from the age-friendly rural/remote communities initiative (PHAC, 2009) Age-friendly consultation steps
Description of consultation step within this project
1. Form a steering committee
The steering committee had representatives from eight different community groups including health-care services, businesses, faith communities, service organisations, police, Town Council, the authors and a project assistant who was hired through the grant. The role of steering committee members was to advise the consultation process. The steering committee informed the broader community of this project through a resolution at Town Council, newspaper articles, flyers distributed to faith communities, announcements at a local health fair and radio interviews with steering committee members. Older adults were invited to participate in this project through local advertisements and word of mouth. Because of their familiarity with the community, several steering committee members were involved in the recruitment of participants. Relevant data about the community were gathered by steering committee members from publically available sources and were summarised into a document that profiled the community. Older adults and key informants were asked questions derived from the eight features identified as relevant to age-friendly communities in the documents that guided this consultation process, which the steering committee revised to ensure they suited the community context. The authors, with the assistant of the hired project assistant and student research assistants, completed the content analysis and presented it to the steering committee for review and verification. The steering committee reviewed and discussed preliminary findings as a form of confirming and deepening understanding of the issues raised by the participants. The compiled findings were shared at a community forum with a group of community members, who set priorities and generated potential action plans Different steering committee members led initiatives such as holding a lifetime housing exposition, planning a safety workshop and installing benches. A pamphlet describing. the project findings was mailed out to all community members and a report was generated. Action plans are currently being implemented.
2. Raise awareness about the project 3. Recruit participants
4. Develop a community profile
5. Conduct focus groups and key informant interviews
6. Interpret results
7. Confirm findings with the community
8. Plan future actions with the steering committee
tions, the business sector, health services, faith communities, and residential facilities.
Reflective analysis: Congruence between an age-friendly community consultation and occupational therapy practice The authors examined their age-friendly community consultation process in the light of enabling skills (Townsend et al., 2007) and the CPPF (Craik et al., 2007).
Results Details of the consultation findings can be found in the final report (Lauckner, Stadnyk, Purcell, et al, 2012). Below is a brief summary of the findings from the consultation process.
Context Mahone Bay and area is a small coastal community (population 2658), with a high proportion of older adults who live predominantly in single dwelling homes that they © 2014 Occupational Therapy Australia
own. 24% of the area’s population is age 65 and over (Government of Nova Scotia, 2006), well above the provincial proportion of 15%. Local residents have a lower average individual income than all Nova Scotians. There is a higher proportion of university-educated people in this area (26%) in comparison with the province (22%), but also a higher proportion of people without high school diplomas (25% in the local area; 23% in the province). The area is known as a tourist destination and increasingly as an informal retirement community.
Age-friendly features and barriers Two key features of this community promoting its agefriendliness are its recognition as a small town and its diverse opportunities for participation. Barriers inhibiting its age-friendliness are its inaccessible housing, poor public spaces and transportation, limited health services and businesses, and infrequent sharing of community events and information, particularly for people who do not use the internet. Based on the priorities identified during the community forum, the steering committee has or is implementing measures to improve the walk-
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ability of the town (painting curbs to highlight transitions and adding benches in the town centre), raise awareness of transportation issues, explore housing options and information for older adults, and promote community connection through local radio.
Congruence between an age-friendly community consultation and occupational therapy at the community level Tables 2 and 3 summarise the results of the authors’ reflections and are further explored in the discussion.
Reflections and discussion Reflection on the relationship between age-friendly communities and occupational therapy practice focussed on their congruence and lessons learnt that could strengthen occupational therapy practice at the community level.
The congruence of an age-friendly community consultation with occupational therapy practice at the community level The CPPF involves collaborative and reflective processes engaged in by the occupational therapist and client (an individual, group or community) as they progress towards the client’s occupational goal (Craik et al., 2007). The Framework’s contextual elements con-
sist of society, practice and frame(s) of reference (Craik et al.); these elements encompass a further eight practice processes (see left column of Table 3; for a full description of the CPPF, see Davis, Craik & Polatajko, 2007). Drawing on the CPPF, occupational therapists move through the eight action points to help clients achieve their occupational goals (Davis et al., 2007) by using any combination of their enabling skills – adapting, advocating, coaching, collaborating, consulting, coordinating, designing/building, educating, engaging and specialising (Townsend et al., 2007). Complementing occupational therapy’s focus on enabling skills (Townsend et al.) is the WHO’s affirmation that an essential component of age-friendly settings is ‘enablement’ WHO, (2007, p. 6). The project coordinator drew upon a number of enabling skills, summarised in Table 2, as the project unfolded. The age-friendly community consultation process and occupational therapy community-level practice achieve congruency through complementary processes and transferable skills. Initial reflections on the CPPF and the age-friendly community process indicated some structural alignment: respective processes are situated within a broader context, and systematic processes gather information, collaboratively identify priorities/goals and evaluate outcomes. The Framework explicitly aims to address occupational goals, while the age-friendly community process specifically focuses on the environmental factors
TABLE 2: Key enabling skills (Townsend et al., 2007) used by the occupational therapist during the age-friendly community consultation process Age-friendly community consultation
Enablement skills demonstrated by the occupational therapist
1. Bring together a steering committee 2. Raise awareness about project
● ● ● ●
3. Recruit older adults and service providers to share their perspectives on the age-friendliness of the community 4. Gather information for a Community profile 5. Conduct focus groups and interviews 6. Interpret results 7. Confirm findings with the community 8. Plan actions with the steering committee
● ●
●
●
● ●
9. Evaluate process
●
Advocating for inclusion of particular groups from community Collaborating with Town, community centre, Chair, and community members to raise awareness of project Coordinating meetings, hiring of project assistant, necessary decision-making with steering committee Engaging steering committee to get them excited about the project, ensuring they have a voice Adapting the research and planning process to the local context Coordinating research processes and coordinating activities with project assistant and steering committee members who helped with recruitment Collaborating with and consulting with steering committee members regarding, how results are frames, how to carry out community consultation Collaborating with community on their interpretation of findings and with steering committee on their interpretation of meeting results Collaborating on production of documents by soliciting advice and feedback Coaching steering committee members to identify areas of action and follow-up on them Consulting with steering committee along the way regarding process
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TABLE 3: Key compatibilities between age-friendly communities and the Canadian Practice Process Framework (CPPF) (Davis et al., 2007) CPPF processes
Key compatibilities with age-friendly community (AFC) processes
1. Enter/Initiate 2. Set the stage
●
3. Assess/Evaluate
●
4. 5. 6. 7. 8.
Agree on objectives/plan Implement plan Monitor/modify Evaluate outcomes Conclude/Exit
● ● ● ●
At the onset of the CPPF and AFC processes, there is recognition of the importance of broader contextual factors and the need to negotiate how the interactions will unfold CPPF and AFC processes involve an assessment stage aimed at gathering relevant information about people’s abilities to engage in the activities that are important to them. Enablement skills are apparent in both the CPPF and the AFC processes Both the CPPF and the AFC processes require the objectives and plans to be discussed prior to implementation Both the CPPF and the AFC processes identify plans that enable occupation The CPPF and AFC processes support an evaluative process
that support or limit people’s involvement in their occupations. For example, in this study the age-friendly consultation elicited data about the environmentoccupation connection. Outdoor space accessibility was discussed in terms of walkability, transportation barriers were discussed in terms of the ability to reach a destination, and social inclusion was discussed in terms of knowing about and participating in community events. The similarities between the CPPF and the age-friendly community approach are summarised in Table 3. The age-friendly community consultation process also provided a vehicle through which participants could engage with their communities. For example, the participatory manner of the age-friendly process helped to stimulate community members’ contributions to the planning and implementation of community and health services (Ripat, Redmond & Grabowecky, 2010). This project’s participatory approaches aimed to create change at the community level, and also to sanction people to act collectively, thus creating valuable opportunities for meaningful engagement in collective occupations as part of the process (Leclair, 2010; Ripat et al.; Trentham, Cockburn & Shin, 2007). Regular meetings, collective decision-making processes and shared planning of a housing exposition – all of which occurred during the project – can be regarded as collective occupations. As with other community development projects facilitated by occupational therapists, the age-friendly community process can thus provide a system for engaging in occupation both as the ‘end’ and the ‘means’ of the process (Trentham et al.).
Lessons learnt from the age-friendly community process in relation to the Canadian Practice Process Framework Although the CPPF emphasised the occupational therapist’s contribution to and leadership during the age© 2014 Occupational Therapy Australia
friendly community consultation, this assumption did not accurately capture Robin’s experience as project coordinator. For instance, the Framework recognises a formal referral or contract sequence – which is the occupational therapist’s ‘call to action’ or first point of contact with the client – during the initial phases of the process. In this project, the call to action was directed by the funder jointly to the authors and the community members; the authors and the community representatives initiated the project together. Moreover, due to Robin’s connection with the community, no formal referral was made. Therefore, when applying the occupational practice process to community work, it is important to remember that the call to action may arise from the community through an invitation to partner in a project. Multiple points of entry exist in the age-friendly community consultation process: prior informal relationships, project initiation with partners, and information-sharing throughout the broad community. At the community level, previous community involvement, and informal relationships in particular, can foster partnerships and promote various ways of working together, enhancing the CPPF’s description of how the occupational practice process begins. The CPPF describes the occupational therapist during the assessment stage as using his/her frames of reference to analyse and interpret findings. This was realised with the community development models (Lauckner et al., 2011; Scharlach, 2009) that largely informed this project, and a locality development approach (Scharlach) that yielded active involvement by local institutions via the steering committee. However, offering more complexity to the findings are the age-friendly community consultation process’s intentionally collaborative mechanisms that integrate the community’s frame of reference: a steering committee, community profile development, and data collection
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from older community members. Guided by a community’s values, these collaborative partnerships illustrate how occupational therapists can resist the urge to establish a conventional client-therapist relationship (Lauckner et al.) and work with community members as colleagues instead. When goals are collaboratively identified and a plan is implemented, the CPPF emphasises ‘occupational therapy expertise’ for successful complex enablement (Davis et al., 2007, p. 258); in this project, the agefriendly community consultation process emphasised the expertise of the community. The nature of the agefriendly process guidelines for collaborative data collection and decision-making required that the project coordinator ensure that steering committee members did in fact steer the process. This required thoughtful facilitation interwoven with enablement skills that often occurred behind the scenes, such as efforts to collaborate with steering committee members between meetings. Enablement is recognised as a largely unseen process that risks being taken for granted or undervalued (Townsend et al., 2007), although ‘invisible enablement may actually be an indicator of success’ (Townsend et al., p. 114). The project coordinator’s enablement skills assisted in keeping the group focussed and goal-oriented, and provided concrete, achievable steps that allowed the project to progress. Thus, application of expertise in a community development context such as an age-friendly community consultation may be more subtle than the language of the CPPF implies. When applying the Framework to communities, it may be useful to look for and acknowledge implicit enablement skills. The CPPF implies that the occupational therapist is essential to the process and is usually in a leadership position. In contrast, in the age-friendly community consultation process, the occupational therapists were two of many contributors to the process, and leadership was shared. The steering committee was a vital component to promoting inclusive participation throughout the process. By including representatives from key decision-making bodies (e.g. Town Council) and informal community leaders (e.g. members of the community centre and the local faith communities), the steering committee was well placed to make informed decisions about how to best conduct the consultation and address the identified priorities. Although initial leadership around research processes was provided by the occupational therapists, the committee members’ intimate community knowledge offered ongoing guidance on how to apply research approaches appropriately to their community. Once the research was completed, the project coordinator’s role shifted from research leader to facilitator, consisting of follow-up on tasks identified as priorities. Hence, in the latter stages of the project, community representatives led the project and the occupational therapists played a supportive role.
The CPPF describes a formal ending to the practice relationship once occupational goals have been achieved (Davis et al., 2007); when working at the community level, this stage is often marked by a withdrawal of the occupational therapist’s prominence as others in the community take on leadership roles and strengthen links with existing community resources (Lauckner et al., 2011). This illustrates occupational therapists’ shifting roles when engaging with communities, skilfully moving between leadership and facilitation. Occupational therapists are encouraged to foster both skill sets when working with communities. There are limitations to this age-friendly community consultation that should be noted. Although attempts were made to ensure diverse perspectives were included in focus groups, residents from lower socio-economic status were under-represented. Consequently, the results of this project likely disproportionately represent the views of well, active older adults. With regard to the authors’ reflections, further insights could be gleaned by examining other occupational therapy frameworks in relation to age-friendly community processes and in relation to additional community-level approaches applicable to other populations. Because the authors’ agefriendly process and subsequent reflections focussed on working at the community level with older adults, the conclusions from this small study may not be generalisable to other populations. However, this study and reflections serve to explore the often implicit assumptions of occupational therapy practice frameworks and encourages others to reflect on their own community work. In summary, the CPPF can be made more applicable to community occupational therapy practice when the subtleties of community development work are taken into account. Expanded definitions of the steps in the CPPF, multiple perspectives driving the process, shifting roles of group members and overlapping abilities indicate the greater responsiveness of the age-friendly community consultation process in comparison to the CPPF. Procedural steps found in the age-friendly community process – entry into the project, the dynamics of exiting the process – and the fusion of knowledge from the occupational therapist and the community are less developed in the CPPF.
Conclusion Based on these reflections, the CPPF and age-friendly community consultation processes appeared to provide occupational therapists with a compatible structure for moving beyond individual intervention to creating change at the community level. However, there are important differences in the collaborative nature of their respective processes, which can provide occupational therapists with additional strategies for community partnerships. Occupational therapists working at the community level are engaged in a partnership, where © 2014 Occupational Therapy Australia
382 the occupational therapist is only one of many partners. Consequently, the occupational therapist’s role will shift throughout the project’s duration, with the therapist as part of the process rather than leading it (Lauckner et al., 2011; Restall et al., 2003; Trentham et al., 2007). Although the CPPF intends to be flexible enough to apply to diverse practice settings, explicitly identifying that a different type of relationship exists in community development can assist occupational therapists in negotiating these partnerships. Changing our language from ‘client’ to ‘partner’ to illustrate an equitable relationship can lay the foundation for future work with communities (Lauckner et al.). Through the comparison of age-friendly community processes and the CPPF, we were able to identify sufficient congruency to affirm that we were engaging in occupational therapy practice during this process. A better understanding arose of how the Framework’s applicability to communities can be strengthened through connotative explanation of structure and roles, as well as flexibility of process. Occupational therapists should be encouraged to get involved with community initiatives but at the same time to recognise that their role is more likely to be collaborative. Community work can at times be accomplished appropriately through collaboration rather than leadership; this may produce a greater number of invitations to community discussions and projects in the future.
Acknowledgements A sincere thanks to the research participants who shared their time and perspectives, and the steering committee who demonstrated ongoing commitment to the age-friendliness of Mahone Bay and area. The authors also thank the funders of this project, the Department of Seniors and the Town of Mahone Bay. Dr Brenda Beagan, Dr Elizabeth Townsend and Dr Catherine Backman provided thoughtful reviews of earlier versions of this article that greatly assisted the authors in refining and conveying their ideas.
Funding We gratefully acknowledge funding from the Nova Scotia Department of Seniors and Dalhousie University’s Faculty of Health Professions.
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doi: 10.1111/1440-1630.12147
Feature Article
Examining an occupational perspective in a rural Canadian age-friendly consultation process Heidi M. Lauckner and Robin L. Stadnyk School of Occupational Therapy, Dalhousie University, Halifax, NS, Canada
Background/aim: The age-friendly community movement is a community-level approach to promoting seniors’ health that has yet to be thoroughly examined from an occupational perspective. Through the application of the Canadian Practice Process Framework to an age-friendly consultation process, the authors examined how agefriendly community consultations may provide strategies for occupational therapists to strengthen their work with communities. Methods: A consultation with a rural Canadian community was guided by the Age-Friendly Rural/Remote Communities Initiative. Focus groups were held with 35 older adults to identify age-friendly features of the community. Twenty key informants who provide services to seniors were also interviewed individually. Following the community consultation, we examined the relationship between the age-friendly community consultation process and occupational therapy community development practice processes using the Canadian Practice Process Framework. Results: The steps of the consultation process paralleled the occupational therapy practice process, with occupational issues implicitly identified in the age-friendly consultation. The age-friendly consultation process emphasised the importance of collaborative partnerships and the need for occupational therapists to adopt a facilitative rather than leadership role. Skills that enable occupation were used throughout this age-friendly consultation. Conclusions: The study suggests that the process of this age-friendly community consultation has relevance to occupational therapy theory and practice, and can provide a useful framework for collaborative consultative processes when working with communities.
Heidi M. Lauckner PhD, OT Reg (NS); Assistant Professor. Robin L. Stadnyk PhD, OT Reg (NS); Assistant Professor. Correspondence: Heidi M. Lauckner, School of Occupational Therapy, Dalhousie University, 5869 University Avenue, Forrest Building Room 215, PO Box 15000, Halifax, NS, Canada B3H 4R2. Email: [email protected] Accepted for publication 14 July 2014. © 2014 Occupational Therapy Australia
KEY WORDS community-based occupational therapy practice, age-friendly communities, Canadian Practice Process Framework, community development, application of practice process to community work.
Introduction Through family roles, work, and volunteering, older adults (aged 65+) contribute significantly to the lives of families and friends and add experience and commitment to their communities. Similar to many developed countries, older adults in Canada make up a small percentage of the population (13%), yet account for a disproportionately large percentage of total health-care costs (44%) (Turcotte & Schellenberg, 2007). Given that the number of older adults is expected to double over the next 30 years in countries like Canada and Australia (Australian Government Department of Health and Aging, 2012; Turcotte & Schellenberg, 2007), there is concern about how best to promote the health of older adults, encourage their continued contributions to communities, and reduce their reliance on health-care services. The creation of age-friendly communities is one internationally supported approach to promote older adults’ health (Public Health Agency of Canada (PHAC), 2009; World Health Organisation (WHO), 2007). The policies, services, settings and structures of age-friendly communities are designed to help older adults age actively; that is, to be safe, healthy, and involved (WHO, 2007). The age-friendly community movement arose in 2006 from a partnership between the World Health Organization (WHO) and 33 cities that sought input from older adults, caregivers, and service providers to identify key community features supporting participation, health, and security. Eight features were identified: outdoor spaces and buildings, transportation, housing, respect and social inclusion, social participation, communication and information, civic participation and employment, and community support and health services (PHAC, 2009; WHO, 2007). Inherent in the age-friendly community movement is the recognition that physical and social environments can enable or impede active community engagement.
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Also inherent in this approach is a commitment to bottom-up participation, where older adults’ experiences mark them as experts in the identification of age-friendly community features (WHO).
Age-friendly communities and occupational therapy Age-friendly communities embody concepts such as successful or positive ageing, active ageing (WHO, 2007), liveable communities (Lui, Everingham, Warburton, Cuthil & Bartlett, 2009), health promotion (Letts, Fraser, Finlayson & Walls, 1993), citizen engagement (Letts, 2003) and ageing in place (Chippendale & BearLehman, 2010), which have an effect on many of the ageing adults with whom occupational therapists work (Chippendale & Bear-Lehman; Kaminsky, 2010; O’Sullivan & Hocking, 2006; Siebert, 2007). For their part, in 2011 the Canadian Association of Occupational Therapists (2011) issued a position statement recommending that occupational therapists foster ageing in place at the community level by developing partnerships with older adults and community stakeholders. Age-friendly communities are one way to foster such active ageing and ageing in place at the community level. Despite encouragement to work at the community level (Townsend & Polatajko, 2007), some occupational therapists struggle to apply community development approaches in practice (Lauckner, Pentland & Paterson, 2007; Restall & Ripat, 2008). These struggles are at least in part because the majority of occupational therapy models focus on individual clients and provide limited practical guidance to community-level engagement through partnerships (Lauckner, Krupa & Paterson, 2011; Leclair, 2010). This article examines a community consultation process addressing one Canadian community’s age-friendliness, guided by the Age-Friendly Rural/Remote Communities Initiative (PHAC, 2009). The consultation asked community members to identify community features that were inclusive of older adults and features that were exclusive and needed improvement. Through their involvement in the consultation, the authors (both occupational therapists) acquired experience and reflected upon the occupational therapy process as it unfolded at the community level. Systematic examination of the authors’ learnings in relation to the Canadian Practice Process Framework (CPPF) (Craik, Davis & Polatajko, 2007) fostered a comparative analysis of the processes found in an age-friendly community consultation and occupational therapy practice. Results identified ways to strengthen the applicability of the practice model for occupational therapists working at the community level.
Methods The consultative process aimed to determine how a small rural community in Nova Scotia, Canada, could
become more age-friendly. The provincial Department of Seniors provided funding to support similar projects in many communities and recommended partnering with the local community centre and town government. With the town Mayor’s approval, the second author, who is also a resident of the town, volunteered as the project coordinator. Research Ethics Approval was received for this project from Dalhousie University in April of 2011. Major project decisions were made collaboratively with a steering committee which included the authors, and the consultation process was guided by the steps of the Age-Friendly Rural/Remote Communities Initiative (PHAC, 2009), as outlined in Table 1. During and following the consultative process, the authors engaged in a reflective process that explored the congruence between the age-friendly community consultation process and occupational therapy practice at the community level and the lessons that can be learnt from this consultation process to strengthen the applicability of the CPPF to communities. The focus of this article is on these reflections.
Data collection and analysis Thirty-five (35) older adults from the community participated in focus groups of 5–6 people or individual interviews lasting 1–1.5 hours. In addition, 20 key informants, selected for their knowledge of older adults and community services, were also interviewed. Older adults and key informants were asked questions derived from features identified as relevant to age-friendly communities: outdoor spaces and buildings, transportation, housing, respect and social inclusion, social participation, communication and information, civic participation and employment, and community support and health services (PHAC, 2009; WHO, 2007). Participants were asked to identify community features that promoted participation and those that limited their involvement. The researchers used qualitative content analysis (Sandelowski, 2000) to distil key issues identified by the community members. Key themes were reviewed by steering committee members and presented at a community forum where a group of 30 community members reviewed the findings, prioritised recommendations, and generated potential action plans.
Participants The majority of the 35 older adults involved in this study were between 60 and 79 years of age (69%), female (65%), had lived in the town for more than 10 years (62%), were married and living with a partner (60%), and self-identified as active in their community, in addition to self-identifying as educated, healthy and financially secure. Based on steering committee recommendations, twenty key informants who had expertise about the community and services for older adults were recruited from diverse community sectors. Key informants represented local government, community centres and service organisa© 2014 Occupational Therapy Australia
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TABLE 1: Age-friendly consultation process adapted from the age-friendly rural/remote communities initiative (PHAC, 2009) Age-friendly consultation steps
Description of consultation step within this project
1. Form a steering committee
The steering committee had representatives from eight different community groups including health-care services, businesses, faith communities, service organisations, police, Town Council, the authors and a project assistant who was hired through the grant. The role of steering committee members was to advise the consultation process. The steering committee informed the broader community of this project through a resolution at Town Council, newspaper articles, flyers distributed to faith communities, announcements at a local health fair and radio interviews with steering committee members. Older adults were invited to participate in this project through local advertisements and word of mouth. Because of their familiarity with the community, several steering committee members were involved in the recruitment of participants. Relevant data about the community were gathered by steering committee members from publically available sources and were summarised into a document that profiled the community. Older adults and key informants were asked questions derived from the eight features identified as relevant to age-friendly communities in the documents that guided this consultation process, which the steering committee revised to ensure they suited the community context. The authors, with the assistant of the hired project assistant and student research assistants, completed the content analysis and presented it to the steering committee for review and verification. The steering committee reviewed and discussed preliminary findings as a form of confirming and deepening understanding of the issues raised by the participants. The compiled findings were shared at a community forum with a group of community members, who set priorities and generated potential action plans Different steering committee members led initiatives such as holding a lifetime housing exposition, planning a safety workshop and installing benches. A pamphlet describing. the project findings was mailed out to all community members and a report was generated. Action plans are currently being implemented.
2. Raise awareness about the project 3. Recruit participants
4. Develop a community profile
5. Conduct focus groups and key informant interviews
6. Interpret results
7. Confirm findings with the community
8. Plan future actions with the steering committee
tions, the business sector, health services, faith communities, and residential facilities.
Reflective analysis: Congruence between an age-friendly community consultation and occupational therapy practice The authors examined their age-friendly community consultation process in the light of enabling skills (Townsend et al., 2007) and the CPPF (Craik et al., 2007).
Results Details of the consultation findings can be found in the final report (Lauckner, Stadnyk, Purcell, et al, 2012). Below is a brief summary of the findings from the consultation process.
Context Mahone Bay and area is a small coastal community (population 2658), with a high proportion of older adults who live predominantly in single dwelling homes that they © 2014 Occupational Therapy Australia
own. 24% of the area’s population is age 65 and over (Government of Nova Scotia, 2006), well above the provincial proportion of 15%. Local residents have a lower average individual income than all Nova Scotians. There is a higher proportion of university-educated people in this area (26%) in comparison with the province (22%), but also a higher proportion of people without high school diplomas (25% in the local area; 23% in the province). The area is known as a tourist destination and increasingly as an informal retirement community.
Age-friendly features and barriers Two key features of this community promoting its agefriendliness are its recognition as a small town and its diverse opportunities for participation. Barriers inhibiting its age-friendliness are its inaccessible housing, poor public spaces and transportation, limited health services and businesses, and infrequent sharing of community events and information, particularly for people who do not use the internet. Based on the priorities identified during the community forum, the steering committee has or is implementing measures to improve the walk-
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ability of the town (painting curbs to highlight transitions and adding benches in the town centre), raise awareness of transportation issues, explore housing options and information for older adults, and promote community connection through local radio.
Congruence between an age-friendly community consultation and occupational therapy at the community level Tables 2 and 3 summarise the results of the authors’ reflections and are further explored in the discussion.
Reflections and discussion Reflection on the relationship between age-friendly communities and occupational therapy practice focussed on their congruence and lessons learnt that could strengthen occupational therapy practice at the community level.
The congruence of an age-friendly community consultation with occupational therapy practice at the community level The CPPF involves collaborative and reflective processes engaged in by the occupational therapist and client (an individual, group or community) as they progress towards the client’s occupational goal (Craik et al., 2007). The Framework’s contextual elements con-
sist of society, practice and frame(s) of reference (Craik et al.); these elements encompass a further eight practice processes (see left column of Table 3; for a full description of the CPPF, see Davis, Craik & Polatajko, 2007). Drawing on the CPPF, occupational therapists move through the eight action points to help clients achieve their occupational goals (Davis et al., 2007) by using any combination of their enabling skills – adapting, advocating, coaching, collaborating, consulting, coordinating, designing/building, educating, engaging and specialising (Townsend et al., 2007). Complementing occupational therapy’s focus on enabling skills (Townsend et al.) is the WHO’s affirmation that an essential component of age-friendly settings is ‘enablement’ WHO, (2007, p. 6). The project coordinator drew upon a number of enabling skills, summarised in Table 2, as the project unfolded. The age-friendly community consultation process and occupational therapy community-level practice achieve congruency through complementary processes and transferable skills. Initial reflections on the CPPF and the age-friendly community process indicated some structural alignment: respective processes are situated within a broader context, and systematic processes gather information, collaboratively identify priorities/goals and evaluate outcomes. The Framework explicitly aims to address occupational goals, while the age-friendly community process specifically focuses on the environmental factors
TABLE 2: Key enabling skills (Townsend et al., 2007) used by the occupational therapist during the age-friendly community consultation process Age-friendly community consultation
Enablement skills demonstrated by the occupational therapist
1. Bring together a steering committee 2. Raise awareness about project
● ● ● ●
3. Recruit older adults and service providers to share their perspectives on the age-friendliness of the community 4. Gather information for a Community profile 5. Conduct focus groups and interviews 6. Interpret results 7. Confirm findings with the community 8. Plan actions with the steering committee
● ●
●
●
● ●
9. Evaluate process
●
Advocating for inclusion of particular groups from community Collaborating with Town, community centre, Chair, and community members to raise awareness of project Coordinating meetings, hiring of project assistant, necessary decision-making with steering committee Engaging steering committee to get them excited about the project, ensuring they have a voice Adapting the research and planning process to the local context Coordinating research processes and coordinating activities with project assistant and steering committee members who helped with recruitment Collaborating with and consulting with steering committee members regarding, how results are frames, how to carry out community consultation Collaborating with community on their interpretation of findings and with steering committee on their interpretation of meeting results Collaborating on production of documents by soliciting advice and feedback Coaching steering committee members to identify areas of action and follow-up on them Consulting with steering committee along the way regarding process
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TABLE 3: Key compatibilities between age-friendly communities and the Canadian Practice Process Framework (CPPF) (Davis et al., 2007) CPPF processes
Key compatibilities with age-friendly community (AFC) processes
1. Enter/Initiate 2. Set the stage
●
3. Assess/Evaluate
●
4. 5. 6. 7. 8.
Agree on objectives/plan Implement plan Monitor/modify Evaluate outcomes Conclude/Exit
● ● ● ●
At the onset of the CPPF and AFC processes, there is recognition of the importance of broader contextual factors and the need to negotiate how the interactions will unfold CPPF and AFC processes involve an assessment stage aimed at gathering relevant information about people’s abilities to engage in the activities that are important to them. Enablement skills are apparent in both the CPPF and the AFC processes Both the CPPF and the AFC processes require the objectives and plans to be discussed prior to implementation Both the CPPF and the AFC processes identify plans that enable occupation The CPPF and AFC processes support an evaluative process
that support or limit people’s involvement in their occupations. For example, in this study the age-friendly consultation elicited data about the environmentoccupation connection. Outdoor space accessibility was discussed in terms of walkability, transportation barriers were discussed in terms of the ability to reach a destination, and social inclusion was discussed in terms of knowing about and participating in community events. The similarities between the CPPF and the age-friendly community approach are summarised in Table 3. The age-friendly community consultation process also provided a vehicle through which participants could engage with their communities. For example, the participatory manner of the age-friendly process helped to stimulate community members’ contributions to the planning and implementation of community and health services (Ripat, Redmond & Grabowecky, 2010). This project’s participatory approaches aimed to create change at the community level, and also to sanction people to act collectively, thus creating valuable opportunities for meaningful engagement in collective occupations as part of the process (Leclair, 2010; Ripat et al.; Trentham, Cockburn & Shin, 2007). Regular meetings, collective decision-making processes and shared planning of a housing exposition – all of which occurred during the project – can be regarded as collective occupations. As with other community development projects facilitated by occupational therapists, the age-friendly community process can thus provide a system for engaging in occupation both as the ‘end’ and the ‘means’ of the process (Trentham et al.).
Lessons learnt from the age-friendly community process in relation to the Canadian Practice Process Framework Although the CPPF emphasised the occupational therapist’s contribution to and leadership during the age© 2014 Occupational Therapy Australia
friendly community consultation, this assumption did not accurately capture Robin’s experience as project coordinator. For instance, the Framework recognises a formal referral or contract sequence – which is the occupational therapist’s ‘call to action’ or first point of contact with the client – during the initial phases of the process. In this project, the call to action was directed by the funder jointly to the authors and the community members; the authors and the community representatives initiated the project together. Moreover, due to Robin’s connection with the community, no formal referral was made. Therefore, when applying the occupational practice process to community work, it is important to remember that the call to action may arise from the community through an invitation to partner in a project. Multiple points of entry exist in the age-friendly community consultation process: prior informal relationships, project initiation with partners, and information-sharing throughout the broad community. At the community level, previous community involvement, and informal relationships in particular, can foster partnerships and promote various ways of working together, enhancing the CPPF’s description of how the occupational practice process begins. The CPPF describes the occupational therapist during the assessment stage as using his/her frames of reference to analyse and interpret findings. This was realised with the community development models (Lauckner et al., 2011; Scharlach, 2009) that largely informed this project, and a locality development approach (Scharlach) that yielded active involvement by local institutions via the steering committee. However, offering more complexity to the findings are the age-friendly community consultation process’s intentionally collaborative mechanisms that integrate the community’s frame of reference: a steering committee, community profile development, and data collection
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from older community members. Guided by a community’s values, these collaborative partnerships illustrate how occupational therapists can resist the urge to establish a conventional client-therapist relationship (Lauckner et al.) and work with community members as colleagues instead. When goals are collaboratively identified and a plan is implemented, the CPPF emphasises ‘occupational therapy expertise’ for successful complex enablement (Davis et al., 2007, p. 258); in this project, the agefriendly community consultation process emphasised the expertise of the community. The nature of the agefriendly process guidelines for collaborative data collection and decision-making required that the project coordinator ensure that steering committee members did in fact steer the process. This required thoughtful facilitation interwoven with enablement skills that often occurred behind the scenes, such as efforts to collaborate with steering committee members between meetings. Enablement is recognised as a largely unseen process that risks being taken for granted or undervalued (Townsend et al., 2007), although ‘invisible enablement may actually be an indicator of success’ (Townsend et al., p. 114). The project coordinator’s enablement skills assisted in keeping the group focussed and goal-oriented, and provided concrete, achievable steps that allowed the project to progress. Thus, application of expertise in a community development context such as an age-friendly community consultation may be more subtle than the language of the CPPF implies. When applying the Framework to communities, it may be useful to look for and acknowledge implicit enablement skills. The CPPF implies that the occupational therapist is essential to the process and is usually in a leadership position. In contrast, in the age-friendly community consultation process, the occupational therapists were two of many contributors to the process, and leadership was shared. The steering committee was a vital component to promoting inclusive participation throughout the process. By including representatives from key decision-making bodies (e.g. Town Council) and informal community leaders (e.g. members of the community centre and the local faith communities), the steering committee was well placed to make informed decisions about how to best conduct the consultation and address the identified priorities. Although initial leadership around research processes was provided by the occupational therapists, the committee members’ intimate community knowledge offered ongoing guidance on how to apply research approaches appropriately to their community. Once the research was completed, the project coordinator’s role shifted from research leader to facilitator, consisting of follow-up on tasks identified as priorities. Hence, in the latter stages of the project, community representatives led the project and the occupational therapists played a supportive role.
The CPPF describes a formal ending to the practice relationship once occupational goals have been achieved (Davis et al., 2007); when working at the community level, this stage is often marked by a withdrawal of the occupational therapist’s prominence as others in the community take on leadership roles and strengthen links with existing community resources (Lauckner et al., 2011). This illustrates occupational therapists’ shifting roles when engaging with communities, skilfully moving between leadership and facilitation. Occupational therapists are encouraged to foster both skill sets when working with communities. There are limitations to this age-friendly community consultation that should be noted. Although attempts were made to ensure diverse perspectives were included in focus groups, residents from lower socio-economic status were under-represented. Consequently, the results of this project likely disproportionately represent the views of well, active older adults. With regard to the authors’ reflections, further insights could be gleaned by examining other occupational therapy frameworks in relation to age-friendly community processes and in relation to additional community-level approaches applicable to other populations. Because the authors’ agefriendly process and subsequent reflections focussed on working at the community level with older adults, the conclusions from this small study may not be generalisable to other populations. However, this study and reflections serve to explore the often implicit assumptions of occupational therapy practice frameworks and encourages others to reflect on their own community work. In summary, the CPPF can be made more applicable to community occupational therapy practice when the subtleties of community development work are taken into account. Expanded definitions of the steps in the CPPF, multiple perspectives driving the process, shifting roles of group members and overlapping abilities indicate the greater responsiveness of the age-friendly community consultation process in comparison to the CPPF. Procedural steps found in the age-friendly community process – entry into the project, the dynamics of exiting the process – and the fusion of knowledge from the occupational therapist and the community are less developed in the CPPF.
Conclusion Based on these reflections, the CPPF and age-friendly community consultation processes appeared to provide occupational therapists with a compatible structure for moving beyond individual intervention to creating change at the community level. However, there are important differences in the collaborative nature of their respective processes, which can provide occupational therapists with additional strategies for community partnerships. Occupational therapists working at the community level are engaged in a partnership, where © 2014 Occupational Therapy Australia
382 the occupational therapist is only one of many partners. Consequently, the occupational therapist’s role will shift throughout the project’s duration, with the therapist as part of the process rather than leading it (Lauckner et al., 2011; Restall et al., 2003; Trentham et al., 2007). Although the CPPF intends to be flexible enough to apply to diverse practice settings, explicitly identifying that a different type of relationship exists in community development can assist occupational therapists in negotiating these partnerships. Changing our language from ‘client’ to ‘partner’ to illustrate an equitable relationship can lay the foundation for future work with communities (Lauckner et al.). Through the comparison of age-friendly community processes and the CPPF, we were able to identify sufficient congruency to affirm that we were engaging in occupational therapy practice during this process. A better understanding arose of how the Framework’s applicability to communities can be strengthened through connotative explanation of structure and roles, as well as flexibility of process. Occupational therapists should be encouraged to get involved with community initiatives but at the same time to recognise that their role is more likely to be collaborative. Community work can at times be accomplished appropriately through collaboration rather than leadership; this may produce a greater number of invitations to community discussions and projects in the future.
Acknowledgements A sincere thanks to the research participants who shared their time and perspectives, and the steering committee who demonstrated ongoing commitment to the age-friendliness of Mahone Bay and area. The authors also thank the funders of this project, the Department of Seniors and the Town of Mahone Bay. Dr Brenda Beagan, Dr Elizabeth Townsend and Dr Catherine Backman provided thoughtful reviews of earlier versions of this article that greatly assisted the authors in refining and conveying their ideas.
Funding We gratefully acknowledge funding from the Nova Scotia Department of Seniors and Dalhousie University’s Faculty of Health Professions.
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