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Activity and occupation.
- Matthew L Molineux (24 August 1999)
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In support of meaningful occupation for the elderly
- Karen Rebeiro (26 August 1999)
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Social and productive activities as predictors of survival among elderly Americans
- Gerson T Lesser (5 October 1999)
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Social, productive and fitness activities have been confused
- Chris Riddoch (16 October 1999)
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Matthew L Molineux, Lecturer, Discipline of Occupational Therapy College of Ripon & York St John
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Editor It was with great interest that I read the paper by Glass et al (1) which examined the relationship between activity and survival in older Americans. This paper makes a significant contribution to our understanding of how health effects, and is effected by, engagement in purposeful, meaningful activity, or what occupational therapists term occupation. Although the occupational therapy profession was founded on a belief in this relationship, it is only in relatively recent times that this has been examined more critically. This paper contributes to the growing body of research based knowledge which can now help us better understand the relationship between occupation and health. A similar project was undertaken by Iwarsson et al (2) who used existing data from a 25 year longitudinal investigation of elderly people in Sweden. In this study significant differences in survival were found between women who were more active and less active. In a more rigorous project using a randomised design Clark et al (3) compared groups of elderly people living in Los Angeles. One group received an activity programme led by occupational therapists, one an activity programme led by non-occupational therapists, and one control group. Interestingly they found there to be no significant differences between the control group and the group who received the non-occupational therapy programme. The occupational therapy intervention, however, was found to have significant benefits “... across various health, function, and quality of life domains.” (p1324) Of note in the current study (1) is the finding that social and productive activities were just as effective in reducing the risk of mortality as fitness activities. As the authors suggest this is likely due to a wide range of mechanisms and as such, provides further evidence of the complex nature of occupations. Indeed Rudman et al (4) found that elderly Canadians considered activity as being any form of mental, social and / or physical types of doing. The findings also suggested that sense of control was an important mediator of the heath benefits of engagement in occupation. For these reasons a full understanding of the relationship between occupation and health can only be achieved by considering occupations from many perspectives; transcendental, symbolic-evaluative, sociocultural, information processing, biological and physical (5). It is exciting and encouraging that other disciplines are investigating the occupational nature of humans, and I look forward to future research in this area. Yours faithfully Matthew Molineux, Lecturer, Discipline of Occupational Therapy, College of Ripon & York St John, Lord Mayor’s Walk, York, YO31 7EX. Doctoral student, Department of Occupational Therapy, The University of Queensland, Australia. m.molineux@ucrysj.ac.uk References 1 Glass TA, de Leon CM, Marottoli RA, Berkman LF. Population based study of social and productive activities as predictors of survival among elderly Americans. BMJ 1999;319:478-83 2 Iwarsson S, Isacsson A, Persson D, Schersten B. Occupation and survival: A 25-year follow-up study of an ageing population. American Journal of Occupational Therapy 1998;52:65-70 3 Clark, F, Azen A, Zemke R, Jackson J, Carlson M, Mandel D, Hay J, Josephson K, Cherry B, Hessel C, Palmer J, Lipson L. Occupational therapy for independent-living older adults. JAMA 1997;278:1321-6 4 Rudman D, Cook J, Polatajko H. Understanding the potential of occupation: A qualitative exploration of seniors’ perspectives on activity. American Journal of Occupational Therapy 1997;51:640-50 5 Clark F, Parham D, Carlson M, Frank G, Jackson J, Pierce D, Wolfe R, Zemke R. Occupational science: academic innovation in the service of occupational therapy's future. American Journal of Occupational Therapy 1991; 45: 300-10 |
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Karen Rebeiro, Clinical Resarcher - Occupational Therapy Network North
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To the Editor: Congratulations to Thomas Glass and associates for their article, "Population based study of social and productive activities as predictors of survival among elderly Americans" [BMJ 1999; 319: 478-483 (August 21)]. The discussion in particular highlights what occupational therapists have long known and incorporated in their clinical practice, but unfortunately, have been less than rigorous in conducting clinical research studies and widely disseminating the findings. Occupational therapists in Canada define the activities surveyed in the study (social, productive and physical fitness activities] within the broad rubric of human occupation. According to the Canadian Association of Occupational Therapists, (1997), occupation is defined as, "everything people do to occupy themselves, including looking after themselves (self- care), enjoying life (leisure), and contributing to the social and economic fabric of their communities (productivity)" (p.3). It was not surprizing to read that the seniors in your study lived longer when their level of participation in occupation was sustained. I would suggest that their perceived quality of life was also higher than those seniors less involved, but I recognize that this was not a dependent variable measured. I thought that it might be appropriate to inform the readership that there is in fact, a small, but growing # of studies conducted by occupational therapists which support the findings in this study. Specifically, D. Laliberte conducted a qualitative study of the meaning seniors attach to activity and found the most significant meanings to be associated with social contact/support, quality of life, health benefits and self-image [ LaLiberte, D. (1995). An exploration of the meaning seniors attach to activity. Unpublished master's thesis. The Univeristy of Western Ontario, London, ON, Canada. Another study which specifically looked at the benefits of occupation [or activity] versus counselling and other types of intervention at a senior's complex found a significant correlation between the occupation- based intervention and a multitude of other variables . This article is by Clarke, F. et al and can be obtained through the American Journal of Occupational Therapy. Finally, a variety of research studies that I have personally conducted, but with mental health clients, found similar results in that those with higher levels of participation in personally meaningful and socially valued occupations, enjoyed higher perceived quality of life, sense of well-being and had a positive self-image and social identity: [Opportunity, not prescription: An exploratory study of the experience of occupational engagement. CJOT, October, 1999; Voluntarism as occupation. CJOT, December, 1998; The labyrinth of community mental health: In search of meaningful occupation. Psychiatric Rehabilitation Journal, Fall Issue, 1999.] The latter article speaks to the many systemic barriers within the community which constrain participation for persons with serious mental illness. I would imagine, the social issues and public policy issues would be similar for seniors - - especially when our health care system remains almost exclusively personal -problems focused versus addressing the many social issues faced with people everyday. In closing, I congratulate you and your colleagues on your article. On behalf of occupational therapists, thank you for providing evidence which supports our mission and clinical endeavours. Most sincerely, Karen L. Rebeiro, M.Sc.O.T., B.Sc.O.T.(c) Clinical Researcher Network North 680 Kirkwood Drive Sudbury, ON P3E 1X3 email: karen@nisa.on.ca |
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Gerson T Lesser
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To the Editor: Glass and co-workers (1) add critically important information to the field of gerontology and enlarge our scope for assessing and caring for older people. The authors note the possibility "...that activity levels measured at baseline were actually measuring health status...", and attempted to examine this in subsequent analyses by eliminating deaths in the first 5 years of follow-up. However, they do not adequately deal with the probability that "those who can, do, and those who cannot, don't do". Since individuals self-select for the observed social and productive activities, any factors pertinent to self- selection, such as well-being or self-health appreciation, obviously may be involved in the outcome (survival). There have been a number of longitudinal community cohort studies that observed mortality following a self-health evaluation (2,3,4); some followed the cohort well beyond 5 years (2,3) and some adjusted the self-appraisal further with a concurrent medical appraisal (2). Almost without exception, global self-rated health was found to be a significant predictor of mortality. It may be noted that the differences of mortality rates in the elderly between those with highest and lowest health self-evaluations proved to be about 20-35%, equal to or greater than the "protective" mortality reductions both for social/productive activities and for increased physical activity. Does this perhaps suggest that some common underlying factor, not readily measured by surveys (e.g., subtle perceptions of energy level, absence of major pre-clinical health problems), may prompt one to evaluate self- health positively and also to participate in more social/productive or greater physical activity? The findings of Glass and co-workers are fascinating and should prompt broader research into these relatively neglected areas that may be critically important in longevity. However, it is too soon to fully endorse a premise that enhancing social/productive activities in otherwise unmotivated, relatively inactive elderly persons would extend life. As practitioners, most of us have supported productive activities of our elder patients. Without better confirmation for cause-effect, I am not sure we are yet in a position to press all the indolent elderly to become "actively involved" as a health measure; such intervention could be harmful rather than salutary. References: 1. Glass TA, Mendes deLeon C, Marottoli RA, Berkman LF. Population based study of social and productive activities as predictors of survival among elderly Americans. BMJ 1999;319:478-483. 2. Inchingolo GM. Self-perception of health and survival. A 10-year follow-up among Italians aged over sixty. Minerva Medica. 1997;88:15-23. 3. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health & Soc Behavior 1997;38:21- 37. 4. van Doorn C, Kasl, SV. Can parental longevity and self-rated life expectancy predict mortality among older persons? Results from an Australian cohort. J Gerontol 1998;53B:S28-S34. Gerson T. Lesser, M.D. I have no competing or financial interest in any aspect of this or related topics. |
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Chris Riddoch, Senior Lecturer, Exercise and Health Science University of Bristol
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Glass et al, (1) have concluded that in elderly people "social and productive activities that involve little or no enhancement of fitness lower the risk of all-cause mortality as much as fitness activities do", and that "activity may confer survival benefits through psychosocial pathways". However, the study design incorporates a common misconception that unfortunately pervades many physical activity studies. Neither high levels of cardiorespiratory fitness, nor participation in vigorous activities that promote cardiorespiratory fitness, are necessary to decrease morbidity and mortality. The key health-related variable is the volume, rather than the frequency, intensity or duration of the activity. Whether the activity is planned (as in sport), or incidental (as in gardening), is obviously immaterial. The body does not care whether the physical activity is undertaken as sport, exercise, hobbies, translocation, or household chores. In this study, the majority of activities categorised as 'social' and 'productive' can involve significant levels of incidental physical activity. Of the 11 activities mentioned, only 'day or overnight trips' and 'playing cards, games, bingo' are likely to be completely sedentary. There is very high risk that this analysis is seriously confounded by the presence of health enhancing physical activities in all three categories. The authors are obviously aware of this, as they have omitted 'shopping' and gardening 'from one of the analyses. However, we cannot discount the possibility that ALL the activities categorised as 'productive' (gardening, preparing meals, shopping, unpaid work, paid work, and other employment) might incorporate significant amounts of physical activity. Significant risk reduction is achieved at a level of 150 kcal/kg/day of activity energy expenditure (2). This level is embodied in current health- related physical activity guidelines (3,4) which recommend 30 minutes of brisk walking per day. Sufficient energy expenditure can be just as easily accrued through incidental physical activity as by predetermined sports and exercise activity. While the distribution of TOTAL physical activity between the three groups in this study remains uncertain the findings, although interesting, must be highly questionable. Future health-focussed studies incorporating physical activity should appreciate that there are many potential pathways to achieving health-related physical activity targets, and should not be distracted by notions of sport, fitness, and fitness training. 1. Glass TA, de Leon CM, Marottoli RA, Berkman LF. Population based study of social and productive activities as predictors of survival among elderly Americans. BMJ 1999;319:478-83. 2. Paffenbarger RS, Hyde RT, Wing AL, Hsieh C. Physical activity, all- cause mortality, and longevity of college alumni. N Engl J Med 1986;314:605-13. 3. Department of Health. Strategy statement on physical activity. London: Department of Health, 1996. 4. Department of Health and Human services. Physical activity and Health: a report of the Surgeon General. Pittsburgh, PA: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health promotion, 1996. Chris Riddoch: Senior Lecturer, Exercise and Health Science
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