Occupation and the Risk Message Recipient
Summary and Keywords
Responding to health messages about environmental risks and risky behaviors requires adjustments to what individuals do: how they organize and perform occupations, and their understanding of what occupations mean—for themselves and others. Encouraging people to make a change means influencing what they want to do, the possibilities open to them, and societal support and demand for healthful ways of life. Bringing an occupational perspective to the design of risk messages will generate new insights into the complexities of everyday occupations, revealing the dynamic territory into which health messages are targeted. Occupation, or everyday doing, is described as the means by which people experience their very nature, become what they have the potential to be, and sustain a sense of belonging in family, community and society. To influence what people do, designers of health messages are encouraged to consider what engages people in occupations and keeps them engaged; the identity and cultural meanings expressed through occupation; the exhilaration of challenge and risk; the satisfactions of competence and flow experiences that keep people engaged in what they are doing; whether or not people are fit and prepared for the occupations they embark on and what happens when they are not; and the pull of habits and routines, which hold existing patterns of occupation in place. Equally, health message designers need to engage with the occupational science literature, which recognizes how people are shaped toward particular occupations and occupational identities by social policy, institutional practices, and media messages. That means questioning the rhetoric that occupations are freely chosen, rather than shaped and patterned by the historical, sociocultural, political, and geographic context. Simultaneously, health message designers need to recognize that individuals incorporate specific occupations and occupational patterns into their lifestyle and sense of self, believing they have a measure of control over what they do while rationalizing failure to make health-supporting changes.
Occupation as the Context for Health Messages
In designing health messages, strategic efforts often neglect to consider occupation. Telling farmers to avoid the sun during peak hours of the day in order to reduce skin cancer risk, for example, is bound to fail because it ignores the realities of their work. When contoured within the context of occupation, however, such messages might be designed to guide farmers to adapt to risk by wearing long-sleeve shirts and hats. To assist in the design of health messages that target change in the parameters or performance of occupation, a taxonomy of influences on human occupation is outlined below. It spans considerations relating to what people do, why they do it, and their level of preparedness for the things they plan to do. In the context of risk reduction, understanding why people continue to do things—even when they experience negative health effects—is imperative. That requires insights into the influences on people’s opportunities and choices about doing, their experience of disruptions to doing, and what happens when people set out to change what they do, from an occupational perspective. Underpinning this taxonomy is the proposal that each person’s occupations, the things they do, express and create who they are—their “being,” including how risk averse they are. Occupation is also framed as the basis for “becoming” who they will be in the future, including how alert and responsive they will be to health messages. Finally, doing is seen to be the basis for “belonging” within people’s multiple social contexts, with its implications of accepting or standing against existing norms of being safety conscious or not (Wilcock & Hocking, 2015). Doing, being, becoming, and belonging, taken together in context, thus explain a great deal about the health risks people encounter, how the risks are perceived, and how responsive they will be to health messages.
The occupational perspective is drawn from occupational science, a new field of study that was originally envisioned to be foundational knowledge that would inform occupational therapy (Yerxa et al., 1989). Within health services, occupational therapy is most often provided as an individualized rehabilitation program supporting people to better manage the occupations they want, need, or are required to do at home, work, school, or in the community. Group-based programs have targeted diverse health needs by redesigning people’s lifestyles to increase activity levels and to promote a sense of well-being. Such approaches have been applied to older adults (Clark et al., 2012), people on long-term sick leave (Erlandsson, 2013), people with spinal cord injury who are at risk of pressure sores (Fogelberg, Powell, & Clark, 2016), and people who are obese or have obese children (Orban, Ellegård, Thoren-Jerneck, & Erlandsson, 2012). Occupational science is now increasingly given practical application in population health arenas, for example through initiatives aiming to make schools more supportive environments for children to spend time in (Bazyk, 2007), and by informing the work of urban designers (Thompson & Kent, 2014). Applying an occupational perspective to public health was pioneered in Australia in the late 1990s (Wilcock, 1998), and is presented here to provide a fresh perspective to designers of health messages intended to change what people do or the manner in which they do it. Suggestions for the application of an occupational perspective to the design of health messages should be considered in this light.
Occupation is generally understood to refer to paid or voluntary work activities. However, activities outside of the working day also pose health and safety risks. Consider, for example, trips and slips in the course of taking a bath, accidents caused by texting while driving, and injuries sustained while playing sports. Accordingly, the broader perspective of occupation proposed by occupational scientists is adopted here. In occupational science, occupation is defined as encompassing all human activities that occupy time, space, and attention (Boyt Schell, Gillen, & Scaffa, 2014), as opposed to momentary actions, such as blinking or scratching. From an occupational science perspective, risky behaviors like smoking and drinking are not in themselves considered to be occupations. Their occupational nature is revealed, however, if the meanings, contexts, and pattern of people’s actions are considered. Thus, the process of going outside to join other smokers, lighting and smoking a cigarette, extinguishing it, and returning inside to do something else would be considered one form of the occupation of smoking a cigarette (Nelson, 1988).
Occupation spans mundane tasks, such as brushing one’s teeth, and extraordinary feats like climbing Everest. It thus includes chores and errands, tasks, assignments and projects, duties, exercises, jobs, endeavors, undertakings, ventures, leisure activities, labor, and even enforced labor and servitude. Expressed differently, occupation includes everything people want, need, and are expected to do in their day-to-day lives (Fisher, 1998). Some occupations are a habitual part of daily life, occurring in the same place and in much the same way, day after day. Others are weekly, monthly, seasonal, annual, occasional, or once in a lifetime experiences. Whatever their frequency, occupations are learned rather than innate, which suggests that people progress from becoming aware that others do something, to being a novice at doing it, to competent, proficient, or even expert levels of performance (Kielhofner, 2008). Acknowledging that people learn how to do occupations also points to the fact that performance is not standardized across different individuals, cultures, places, and times. Rather, some occupations are structured within fairly inflexible parameters (e.g., withdrawing money from an ATM) while others, such as dance, have extraordinary variability (Graham, 2002). All occupations change over time in response to technological advances, market forces, the availability of resources, and societal and cultural shifts (Hocking, 2013).
Participating in an occupation might require minimal attention or intense concentration, be draining or invigorating (Kielhofner, 2008). Occupations are often described as meaningful or purposeful, and self-initiated. Participating in occupation is viewed as a means of both meeting biological needs, such as locating or preparing food, and responding to environmental demands, such as constructing a shelter from the weather or having the requisite skills to gain employment (Hocking, 2001). Additionally, occupations are subjectively anticipated, experienced, and remembered (Kielhofner, 2008). Doing things might elicit the spectrum of human emotions: joy, challenge, boredom, frustration, fatigue, or threat. This diversity of experience further adds to the variability of engaging in an occupation, across diverse people but also the same person across different times, circumstances, and life stages. Thus, occupations are both unique to each person, and culturally recognizable, understood, and, in many cases, regulated (American Occupational Therapy Association, 2014).
The Relationship of Occupation to Health and Well-Being
To address known health risks by modifying what people do and how they do it, an understanding of the relationship of people’s occupations and their health is essential. That relationship has long been recognized, with “chimney sweep’s cancer” identified in 1775 (Waldron, 1983) and the protection cowpox conferred on milkmaids providing a vital clue to the development of a smallpox vaccine in 1796 (Baxby, 1999). It is fair to assume that all occupations affect human health and well-being to some extent, by maintaining, fortifying, or injuring body structures and functions. The International Classification of Functioning, Disability and Health (ICF; World Health Organization, 2001) provides a useful conceptual model that explains that relationship (see Figure 1). The elements of the ICF are health conditions, bodily structures (e.g., bones and nerve pathways), and body functions (e.g., cognitive, physiological, and reproductive functions). Activity and participation encompass everything people do, with or without assistance. Personal factors (genetic makeup, age, gender, individual response to stressors, etc.) and environmental factors (social determinants of health, pollution, etc.) are identified as moderating influences. The purpose of the model is to show how health conditions interlink with all of the other elements.
Of note, all of the relationships depicted in the ICF are bidirectional. That is, just as impairments to body structures and functions might have a disabling effect on participation, the occupations people participate in might damage body structures and functions (causing physical injury, sleep disturbances, chronic anxiety, etc.). For example, arthritis of the knee indicates damage to joint cartilage and pain, with predictable reduction in the distance a person walks. Conversely, walking long distances with heavy loads, as sub-Saharan African women do to fetch water, is associated with musculoskeletal injuries (Barrett, 1997). Equally, participation undertaken at the right intensity might aid physical, psychological, emotional, and spiritual healing. Depending on personal and environmental factors and any preexisting health conditions, participating in occupations can thus be protective or cause and exacerbate health conditions.
While it is useful to appreciate that the relationship of health and participation is bidirectional and moderated by personal and environmental factors, an occupational perspective reveals just how complicated the relationship can be. For instance, greater risk of harm might be associated with being a beginner, thus not having developed the skill and capacity to safely accomplish the task (Kielhofner, 2008). Conversely, harm might be associated with being highly experienced, as in the cumulative musculoskeletal damage of decades of physical labor. Frequency and intensity of performance might be implicated, as in stress fractures and overuse syndromes (Guptill, 2012). A lifetime of exposure to general health messages alerts us that risks might lie in the occupation itself (driving at high speed), the person (a distracted driver), the tools and materials involved (a car without airbags), or the environment (an icy road). Risks might translate into harm very quickly (falling off a ladder) or be delayed by decades (removing asbestos from a building). Equally, risks might manifest in the interaction of factors, such as a weak person lifting a heavy load or a person with fair skin working outdoors. The risks associated with an occupation might be imperceptible or obvious (the glow and heat radiating from a kiln being fired), unanticipated or known (other people hunting in the same wilderness area), or announced or unnoticed (changing weather pattern while hiking). An occupation might be risky for some but not for others (consider height restrictions on theme park rides). Additionally, personal capacities for performance, and thus the risks involved, might be over- or underestimated, and actual harm might be attributed to bad luck rather than careless disregard of health messages.
Further complicating the picture, some occupations known to be hazardous to health, in the long term, can provide short-term benefits for other aspects of well-being. For example, in addition to delivering a catalogue of carcinogenic substances and a nicotine hit that sustains addiction, smoking a cigarette might mark the transition from one occupation to another, thus reinforcing a sense of accomplishment. Smoking a cigarette might equally allow a few moments of quiet time or be undertaken in the company of others. In many contexts, smoking a cigarette requires people to go out into the natural environment, which can be health enhancing, or provide a reward for completing something unpleasant (Luck & Beagan, 2015). To more fully explore the health risks associated with the human, material, environmental, and temporal aspects of occupation, and how those risks relate to people’s experiences, the next section presents a taxonomy of considerations about what, why, how, and whether people do things in response to health messages. The discussion is informed by an occupational science perspective.
A Taxonomy of Occupation and Health Risk Prevention
People Become What They Do
The adage that “you become what you do” holds an important truth, particularly when considering the things people do often, intensely, or over a long period of time (Wilcock & Hocking, 2015). Becoming what you do is a literal truth: Olympian weight lifters develop a different physique than sprinters do, and sprinters are different from swimmers. Wine tasters develop a more discerning palate. Philosophers learn to think deeply. There is ample evidence that, in addition to its effects on physique, becoming increasingly healthy or unhealthy also depends on what people do, as much as what they do not do. According to the World Health Organization (2016), engaging in adequate physical activity, on a regular basis, confers a raft of health benefits. Physical activity, essentially how much people move in the course of working, walking, biking, household chores, playing, and exercising:
• Is a key determinant of weight control.
• Improves bone and functional health.
• Reduces the risk of heart disease, stroke, diabetes, various forms of cancer, depression, and injuries from falls (World Health Organization, 2016).
There is now additional evidence that, for older adults at least, occupations with physical and cognitive components, such as dancing, reading, playing musical instruments, or board games, stave off the onset of dementia (Verghese et al., 2003). Participating in meaningful social occupations that maintain close relationships also confers protective benefits, including increased lifespan, lower incidence of disability and depression, and better cognitive and self-rated health. For example, a 2008/2009 cross-sectional study of 16,369 Canadian seniors found that those who participated in fewer social activities reported poorer overall health, greater loneliness, and less satisfaction with life. Although the mechanisms by which social participation supports health are not well understood, positive social interactions, practical assistance, emotional and informational support, and feeling loved and wanted seem to make a difference (Gilmour, 2015). However, as the World Health Organization (2016) identified, finding effective ways to increase levels of engagement in occupations that require people to move, process information, and maintain friendships and other social ties is a societal problem that demands population-based and culturally relevant action. The challenge for designers of health messages, therefore, might be how to support whole populations to become not just health conscious, but alert and responsive to information about what to do and what to avoid doing. Perhaps, as a bottom line, acting on health messages must readily fit in with people’s established ways of doing things and pose few threats to their social connectedness.
Drivers of Human Occupation
Viewed from an occupational perspective, designing health messages intended to affect what people do and how they do it will likely require attention to the drivers of human occupation. At the most basic level, people are driven to participate by needs, the most pressing of which is survival. The quest for meaning is another potent driver, as are sense of self and identity, achieving a sense of belonging, and human development. For humans, survival entails:
• meeting bodily needs of sustenance, shelter, safety, and self-care.
• acquiring the social structures, technologies, and skills needed to fend off predators and cope with the environment.
• developing and exercising personal capacities.
Needs, according to Wilcock (1993), are experienced in three ways, all of which are implicit to sustaining health. An immediate need might be felt as discomfort after a problem occurs, such as thirst, depression, or fear, which calls for action to assuage it. Needs also function to protect us and prevent potential problems, prompting a surge of energy to explore, plan, seek to understand something, listen, express oneself, or find company. Finally, people need to use their capacities, and doing so is rewarded by experiencing a sense of purpose, satisfaction, pleasure, or fulfillment.
Through doing, people develop a sense of who they are (their being), what they are capable of, and what they prefer doing. This existential sense of self is typically described in terms of spirituality, creativity, and having a sense of purpose in life, as exemplified in Victor Frankl’s (1946/2006) account of surviving captivity in a Nazi concentration camp. Being is perhaps most acutely experienced through particular kinds of doing, as in religious observances, engaging with nature, and acts of self-expression. A sense of self might be heightened by creating material products imbued with the expertise, care, and spirit of their maker, but worn down by the daily grind of necessary and required occupations (Wilcock & Hocking, 2015).
In addition to the existential meanings of doing, many occupations have a more pragmatic purpose or function, such as earning a living, keeping the house tidy, or repairing the road. That does not mean that otherwise mundane occupations, even those undertaken on a daily basis, are not rich with meaning. For instance, in addition to nutritional concerns, cooking a meal for the family is replete with gender norms (de Vault, 1991), religious and cultural meanings (Sered, 1988), and memories (Lupton, 1994). Consuming a meal can be the highlight of the day for older adults living in residential care (Bundgaard, 2005), reinforce ethnic identity (Torp, Berggren, & Erlandsson, 2013), or express a wife’s love for her husband (Sidenvall, Nydahl, & Fjellström, 2000). People’s purpose in participating in occupations, then, is shaped by their cultural and social context, and personal responsibilities and concerns. Those might include establishing a home, rearing children, or caring for other people, pets, livestock, or plants. Depending on their priorities and opportunities, people’s purpose might center on self-care or self-expression, enjoyment, trying something out, passing the time, and avoiding doing something. The purposes of occupations are as diverse as educational, relational, or inflicting punishment. On a given occasion, the purpose of participating in an occupation might be simply to become more skilled or proficient at performing it, as in the hours of practice put in by musicians and athletes, for example. Further, occupations might be about acceptance, as in the spiritual occupations of African Canadian women that help protect them from the negative impact of racism (Beagan & Etowa, 2011); they might be aimed at resisting the dominant culture, as in rap music and hip-hop culture (Pyatak & Muccitelli, 2011); or they may be consciously chosen for environmental reasons (Hocking & Kroksmark, 2013).
Identity is another occupational driver that, like meaning, is continually interpreted, constructed, and reconstructed as individuals interact with their environment. Many of those interactions are occupational, supporting the assertion that our occupations shape who we might become, our future and possible selves (Kielhofner, 2008). Participation in occupation is an expression of the skills individuals have mastered, the materials with which they have an affinity, their spiritual commitments, and, for weavers at least, an embodied sense of rhythm and process (Riley, 2008). People express their individuality through their occupations, and, accordingly, make occupational choices and carry out occupations in a manner that both maintains a personally acceptable and satisfying identity and projects the identity they want others to perceive. Additionally, occupations that are shared with others, such as singing in a choir (Jacob, Guptill, & Sumsion, 2009), and those that connect individuals to traditional vocations and crafts (Riley, 2008) confer a collective sense of self.
Identity, however, is not entirely self-authored. Research suggests that people’s occupations are influenced by their background, thereby situating them in a particular place and time (Kielhofner, 2008). Identity is also shaped and even produced by occupations that earn social approval, as well as those that are ascribed and prescribed (Phelan & Kinsella, 2009), which serves as a reminder that social factors can restrict occupational potential and thus identity development and expression over a lifetime (Asaba & Wicks, 2010). The identity ascribed to people is not always welcomed or beneficial. In this regard, it is instructive to learn that people with disabilities have been found to actively manage their occupations to be socially valued and to avoid stigma (Rudman, 2002). Prescribed identities can also be contested, such as when wheelchair users defy social ideologies of disability by claiming an identity as youthful, able, desirable, and daring (Asaba & Jackson, 2011).
Allied to identity is the human need to belong. It is strongly felt, encompassing a sense of connection and being accepted, cared about, and wanted. To belong is not to be alone, but to be recognized as one of the family, a friend, a group member, or a citizen. However, belonging is “always provisional and in process” (Mee, 2009, p. 844), implying that connections must be maintained and the boundaries of acceptability must be respected. Belonging relates to doing in the sense that being accepted into a group often involves doing something, an initiation rite of some form, and maintaining group membership often involves taking up opportunities to do things together, thus cementing belonging over time. A sense of belonging is significantly associated with well-being, as demonstrated by statistics showing that people who are well connected to their local community report good or excellent health (Statistics Canada, 2010) and live longer than those who are socially isolated (Umberson & Montez, 2010). Those facts relate to having people to do things with, giving and receiving practical support, and merely knowing that there are people to call on for assistance if needed. The sense that one belongs is further strengthened by participation in occupations that connect us to particular places, traditions, ethnic origins, and a home country (Wilcock & Hocking, 2015).
Human development is another driver of occupation. Where psychologists historically framed development as a biologically determined process that unfolds over time, it is now recognized that parenting practices shape when milestones are reached and what babies and infants attend to. As they attend, children are challenged to join in. Even very young infants have been shown to perceive other people’s actions as intentional; that is, the people around them are involved in doing things. Consequently, their capacities to participate in occupation work together, eliciting higher levels of functioning that enable them to achieve the goal of doing things (Humphry, 2016). That process is supported by infants’ innate capacity, from birth, to imitate others (Ehrlich & Ornstein, 2010), a capacity explained by the existence of mirror neurons, which fire when individuals carry out goal-related actions and also when watching other people doing something (Pfeifer, Iacoboni, Mazziotta, & Dapretto, 2008). Considered together, the drivers of occupation suggest that health messages may be more effective if the message is perceived to align with what people need, to support or enhance a valued identity, to convey the sense of being part of a community of people, and to align with the directions in which people wish to develop.
Preparedness for Occupation
Being prepared implies both getting ready to do something and that something is expected to happen. Preparation might involve assembling tools and materials, gaining the requisite skills and knowledge, and setting time aside. As well, getting ready to start might require entering and perhaps modifying the environment where the occupation will take place, and being mentally and physically fit for what will be done. Knowledge of academic preparation for professional work, skills training for technical tasks, and athletics training are well described in the educational and sports literature. However, people do not typically prepare for occupations that “come naturally,” such as the tasks associated with parenting and, arguably, cannot prepare for occupations they have little knowledge of. Following the logic that “people become what they do,” in many cases people’s prior occupational history adequately prepares them for new ventures. Alternately, concepts like “work hardening” suggest that people quite rapidly develop the necessary strength, stamina, or concentration. In some cases, however, the demands of the task exceed an individual’s capacity. For instance, while there are multiple factors that put mothers at risk of musculoskeletal injury when lifting infants in the home, they are particularly at risk if:
• They are not physically fit.
• Their child is heavy but not yet walking.
• They do most or all of the lifting.
• Some tasks require lifting the child up high (e.g., to clear a high chair), down to floor level (e.g., into a bath), or away from their body (e.g., into a car seat) (Vincent & Hocking, 2013).
Many people provide information about parenting; midwives, developmental psychologists, early childhood educators, and producers of nutritional and other products. However, the concept of physically preparing for the workload, or adapting ergonomic principles of lifting to a precious squirming infant, have received little attention. For designers of health messages, therefore, the biggest challenge might be how to get information to people who do not know they will need it, perhaps in the midst of multiple competing messages that draw their attention away from themselves.
Continuing an Occupation
Health risks can also become apparent when people engage in occupations repeatedly or for sustained periods despite negative consequences. Two explanatory concepts are offered; habituation and experiential. Habituation refers to people’s tendency to form routines, defined as regular patterns of behavior, and habitual ways of thinking and doing things. Habits and routines provide a sense of stability, continuity and predictability. They reduce the cognitive load that would otherwise be required to attend to every occupation and decide what to do next (Kielhofner, 2008). Habitual ways of doing things are acquired through interaction with physical and social features of the environment and, once established, can make it easier for groups of people to coordinate their actions (Fritz, 2014). Famously, habits resist change. People tend to continue to do what they have usually done despite radical change in circumstances and early, even blatant, indications that their actions are harming their health. For instance, despite the risk of developing pressure ulcers, some people with spinal cord injuries resist changing the habits that make that outcome likely (Fogelberg et al., 2016).
Counterbalancing the habitual, experiences such as flow, challenge and risk also support continued engagement in occupation. Flow refers to the experience of becoming immersed in what you are doing, to the extent that everything else is forgotten and time seems to fly by. It is characterized by intrinsic rewards, intense concentration, loss of self-consciousness, and a sense of being in control of the situation. There is a balance between skill levels and the demands of the task; it is neither too hard nor too easy. Flow experiences have positive health impacts, are more commonly associated with work than leisure, and are described as optimal, peak or desired states of being (Csikszentmihalyi, 2008). Nonetheless, entering a state of flow has been associated with exacerbation of musculoskeletal injuries amongst musicians, who get “lost” in the music, playing without pause and failing to notice intensifying pain (Guptill, 2012).
Like flow, challenge and risk also appear to stimulate prolonged engagement in occupations. Skateboarding, for example, accounted for almost 282,000 injuries requiring medical attention in the United States in 2002. Skateboarders, however, accept injury as one of the attributes of their sport and exhilarate in the sense of freedom it provides, continue to push themselves to perform at their best, and proudly take on the identity of a “skater” (Haines, Smith, & Baxter, 2010). In light of these habitual and experiential reasons to continue to participate, and likely resistance to changes perceived to require effort, or to dilute or distract people from the experience, designers of health messages might be wise to work with, rather than against, continuing participation.
Choices and Opportunities for Occupation
In western societies, there is a widely held assumption that people chose what to do, what to study, what type of work to pursue, and whether to play a sport, join a club, or watch television. For designers of risk messages, clarity about whether advice should be presented as an individual choice, a societal goal, or an institutionalized requirement is likely to be an important consideration. Choice is typically framed as a rational decision-making process, informed by personal motivations and values, previous experiences of participating, and goals for the future. Choices might be tempered by the availability of resources, and age and gender differences are acknowledged (Kielhofner, 2008). From birth, however, the assumption of freely chosen occupations is not entirely true. Parents organize family occupations, based on their own interests and values, with the intention that children learn about the family’s ethnic origins, religion, and hobbies (Segal, 1999). They also actively constrain children’s occupational choices, in order to keep them safe, to a much greater extent than their own choices were closed down when they were children (Niehues, Bundy, Broom, & Tranter, 2016).
Parents’ occupational choices are also constrained. The division of responsibilities in families with traditional gender roles reflects established cultural patterns, rather than active choice. The concept of a “second shift,” meaning the household chores women complete outside of their paid employment, is well supported by population time-use studies and has proven remarkably consistent over decades, despite marked increases in women’s working hours (Bittman, 2000) and the resultant role strain. That this division of labor is not actively chosen by women is supported by observational findings that “paternal assistance is characterized by the father’s abdication of responsibility for the children when the mother is present” (Primeau, 2000, p. 26).
Organizational processes also enter into people’s daily lives. For instance, unemployment benefit claimants invest time and effort into complying with the regulations and expectations of their case managers (Prodinger & Turner, 2013). At a societal level, people’s occupational choices are subtly shaped by pervasive media messages, which present idealized images of the occupational possibilities open to certain classes of people. Retirees, for example, are positioned as maintaining a busy lifestyle that keeps them youthful and actively contributing to the economy, either through employment or consuming products and leisure opportunities. Analysis reveals the neoliberal agenda underpinning the self-reliance retirees are depicted as having, and which covertly distances the state from responsibility for social problems like elders’ living in poverty and the escalating health needs of an aging population (Rudman, 2005).
The broadly framed risk discourses now pervasive throughout western societies are also shaping whether and how people engage in occupation, as we are urged to avoid, manage, and minimize the risk of injury and illness. Accordingly, accidents are being reframed as preventable injuries and are attributed to individual failure to envision the risks involved or to adequately mange those risks. In this social climate, people are expected to approach risk as rational and responsible citizens (Dennhardt & Rudman, 2012).
There are certainly examples of people taking up the risk discourse. As noted above, many parents actively restrict children’s activities because of the perceived risks of being unsupervised (Niehues, Bundy, Broom, & Tranter, 2016) and skateboarders report accepting the risks inherent in their sport. Nonetheless, they ameliorate those risks by wearing protective helmets and knee pads (Haines, Smith, & Baxter, 2010). Children are also responsive to warnings about unsafe behaviors. For instance, 10- to 12-year-olds reported moderating their online activities in response to parental warnings about unsuitable websites, making online purchases, and posting personal information (Silcock, Hocking, & Payne, 2013). Even while some people take action to reduce the risks they face, others continue to engage in occupations despite knowing the physical, neurological, and legal risks. Risky occupations include binge drinking (Jennings & Cronin-Davis, 2016), tagging (Russell, 2008), and the consumption of illicit drugs (Helbig & McKay, 2003).
Historical events also cast a shadow over present occupational choices. Youths growing up in communities forcibly established during South Africa’s apartheid era, for instance, ultimately take up occupations they had previously criticized in their elders. Their poor education, lack of employment opportunities, and lack of exposure to real alternatives leave them little choice (Galvaan, 2015). Similarly, colonization disrupted indigenous peoples’ traditional occupations and disenfranchised their land rights. The ongoing impact affects not just socioeconomic status, educational attainment, and health, but also the choices they make in relation to both participating in occupations of the majority culture and participating in their traditional occupations and vocations (Frank, 2011). Clearly, the extent to which people really have choice and the factors that influence their choices are complex and contested issues. Given that, health message designers must carefully consider how their recommendations are framed and the consistency of such messages with any competing choices.
Disruptions to Occupation
Disruptions to people’s regular occupations represent points in time when people might be more disposed to adopt or drop the actions and precautions associated with protecting their health. Disruptions include predictable transitions to a new life stage, such as becoming a first-time parent (Horne, Corr, & Earle, 2005) or retiring (Jonsson, Borell, & Sadlo, 2000). Examples of less predictable changes, or changes with less predictable consequences, include emigrating (Nayar, Hocking, & Giddings, 2012), internal displacement (McElroy, Muyinda, Atim, Spittal, & Backman, 2012), completing a tour of duty with the armed forces (Cogan, 2016), and weight-loss surgery (Wilson, 2010).
Referring to a change as a disruption suggests that it is dramatic and sudden. However, the impact of some disruptions might become evident only over years or generations. Installing new technologies is one example. In families where television becomes an ever-present part of everyday life, shared family occupations can shift to incorporate it. That might mean meals eaten in front of the TV, conversations squelched while individuals are “watching” or centering on familiar characters, other occupations being scheduled around favorite programs, and outdoor occupations falling by the wayside. Perhaps less noticed are the disruption to children’s play, with traditional games that expressed and conformed to family, ethnic, and religious values and expectations being replaced by “play” shaped by the universalizing culture of western TV programs. This rupture can be so pronounced that parents and grandparents don’t recognize children’s playful engagement with TV characters, commentary on the storyline, singing along to jingles, imitation of moves on music videos, and entering competitions promoted on TV as play activities (Ramugondo, 2012).
Any and all disruptions to occupational routines and settings require an adaptive response, which implies making multiple adjustments. Considering the disruptions in people’s lives from an occupational perspective might assist designers of health messages to gain insights on:
• People who need to be targeted (e.g., new immigrants, school graduates, or new employees).
• When health messages need to be given or later reinforced (e.g., along with new technologies or in the lead-up to retirement or return to civilian life).
• How risk avoidance advice might be delivered (e.g., with redundancy packages or following a disaster).
• Possible vectors to get information to people at risk (e.g., via disaster relief teams or in parenting literature).
Of particular note are the health risks of populations deprived of meaningful occupations or subjected to prolonged idleness, such as asylum seekers who are denied the right to work, or prisoners. Asylum seekers in Australia, for instance, experience escalating confusion, distress, depression, and hopelessness (Crawford, Turpin, Nayar, Steel, & Durand, 2016). Prisoners report watching the clock, and disconnection from the few activities on offer—AA meetings, mass, and repetitive assembly line activities in the workshop, none of which helps them make realistic plans for life outside prison (Falardeau, Morin, & Bellemare, 2015). With encompassing health risks and in the context of such restrictive environments, it is hard to imagine what health advice might be tendered or how it might be framed.
Moving Toward Healthful Occupations
Taking up health risk messages often requires addition or modification of a series of actions within an established way of doing things, such as placing the sunscreen where you will see it and be reminded to apply it, taking it with you, monitoring how much is left. As this example illustrates, convenience and environmental cues (seeing the bottle of sunscreen) support repeat performance. Deployment of such strategies has been noted in relation to older people’s medication-management practices, so that they become unobtrusively embedded in their daily routines. Thus, supplies are placed where they will be ready to hand when needed (ointments in the bathroom if application requires undressing, pills in the kitchen if taken with meals, or carried around if needed during the day). To confirm whether medications had been applied or swallowed, a system of moving the container might be used, such as from the table to the top of the fridge and back again next morning (Bytheway, 2001).
Some health-enhancing strategies, like becoming more physically active, require more comprehensive lifestyle changes. Three keys to the success of the Well Elderly Study, a randomized controlled trial of an occupation-focused intervention to improve the health status of low-income seniors living in downtown Los Angeles, were re-engagement with previously valued occupations outside their homes, social support, and practice—actually going to places and experiencing that they were capable of, and derived pleasure from, renewing their involvement (Clark et al., 2012). Finally, taking up some health risk messages is tremendously challenging, and feels like “restructuring your whole life” (Luck & Beagan, 2015). Developing a nonsmoker identity, for instance, might be stimulated by forthright rejection of being an addict and might be supported by framing previous failed attempts as building skills and competence at quitting. Smoking cessation frees smokers from “a lot of shame” and “a lot of sneaking around” (Luck & Beagan, 2015, p. 187) but also means losing the time spent with smoking buddies and the structure smoking gives to the day. That demands the creation of new routines—new ways of taking personal or contemplative breaks during the day, finding replacement occupations and strategies to cope with stress, and facing a sense of abandonment by smoking friends. Success, however, means no longer being preoccupied with the need to smoke, gaining a substantial amount of time previously spent smoking, feeling powerful for having beaten the addiction, and, for some, capitalizing on that self-perception to trigger a cascade of dietary and physical activity changes as well.
While understanding the experience of hard-won transitions to healthful occupation is instructive, so, too, is how people explain engagement in occupations that knowingly defy health messages. One young binge drinker incorporated that aspect of his occupations into his identity, just as smokers do, with specific occupations facilitating drinking (e.g., festival attendance) and weekends when “we don’t particularly do anything” slowing down his intake (Jennings & Cronin-Davis, 2016, p. 248). Believing binge drinking to be “a quintessential part of British life” (p. 248) supported drinking in this manner, as did the perception that it was relaxing, helped with socializing, led to forgetting worries, and focused his brain on having fun. Binge drinking was further supported by a short-term view of the health consequences (dehydration and fatigue) and the belief that his lack of family responsibilities and relative youth insulated both other people and his liver from serious harm. He now viewed the determined drunkenness and loss of control he had sought at an earlier age to be obnoxious, describing how it made him more outgoing but also prone to shouting and “leery” behavior (p. 249). However, believing he now knew the indicators of going “too far” (p. 249), he deferred any thought of pulling back to the future.
Discussion of the Literature
Occupational science introduces a new perspective from which to consider the design of risk messages. The literature spans insights into the human capacities that enable people to perform ordinary and extraordinary activities, the form those occupations take, and how that varies across place and time. It is also concerned with what is achieved by participating in occupations—their function for both individuals and society, and the meanings embedded in and experienced through occupation. As such, occupational science provides insights into what people do, how they come to be doing those things, and why they continue. Important meanings attached to doing even mundane occupations are revealed, including how meanings vary across individuals and groups. There is an additional focus on how occupation is organized, and how choices are shaped by sociopolitical processes. There is emphasis on the complexity of occupation, but how that complexity is overlooked because people are engaged in occupations in every waking moment and over their lifespan. A central theme is how human occupation affects health and well-being and, conversely, how having a health condition affects people’s patterns and experiences of occupation.
Occupational science is informed by transactionalism, which takes the perspective that people are inseparable from their environment and through interaction, both people and environments are altered. Issues of human rights are being increasingly incorporated, with attention drawn to inequitable access to occupation for different groups in society. That work has spawned work with immigrants, refugees, asylum seekers, undocumented workers, homeless people, and other disadvantaged populations, with issues of occupational deprivation and other injustices described. Overall, the literature is dominated by small-scale qualitative studies, but research informed by ethnographic and critical perspectives is challenging the field to attend to groups that are most at risk of poor health outcomes that can be attributed to their impeded access or pattern of occupation. The body of knowledge being developed will provide useful insights to designers of risk messages targeting individual behavior change, as well as those aimed at specific populations or participation in particular occupations, whether pursued in the course of work, education, sport, leisure, or home life.
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