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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

Paradigm Shift: From the Medical Model to the Community Model Public Health, Community Health, and Occupational Therapy By Hui-Fen Mao 2012/9/20 1. What is paradigm? - An example, pattern, or model -

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Conceptual framework that allows for explanation and investigation of phenomena. “ universally recognized scientific achievements that for a time provide model problems and solutions to a community of practitioners” (Tomas S. Kuhn, 1970, in “ The Structure of Scientific Revolutions”)

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“ consensus-determined matrix of the most fundamental beliefs or assumptions of a field”

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“ cultural core of the discipline” and “provides professional identity”

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Two essential characteristics: 1) a sufficiently unprecedented scientific achievement that draws a large number of constituents from competing areas of inquiry, 2) adequately open ended enough to allow for the exploration of solutions to a variety of problems.

2. What can discipline-specific paradigm determine for a profession? - How professionals view their phenomenon of interest? - What puzzles, problems, or questions practitioners will seek out in their work? - What solution will emerge? - What goals will be set for the direction of the profession?

3. Describe the positive and negative aspects of having a well-developed paradigm. -

“paradigm effect”: paradigm act as filters of perception

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

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When utilized appropriately, it distributes or provides information into meaningful and useful guidelines for practice.

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The danger is that their potential for limiting problem solving and innovation by constraining thinking and perception.

4. There are 4 stages of paradigm shifts. 1. Pre-paradigm: Competing schools of thought confronting the same range of phenomena

2. Paradigm : Consensus as to the nature of the phenomenon, problems to be addressed, and methods of solution

4.Crisis resolution through reorganization of the discipline under a new paradigm

External Factors: Social and epistemologic al demands on the discipline

3.Crisis: Rejection of the old paradigm

5. *Do you think there are paradigm shifts occurring in occupational therapy? Paradigm Shifts in OT 1) 18th and 19th centuries: moral treatment 2) 1900~1940--Paradigm of Occupation Crisis (1950) 3) 1960s—Mechanistic Paradigm: more scientific, reductionism (Kinesiology, neurophysiological, and psychoanalytic approaches, exercise, talk groups, treatment technique, modality‌.) Crisis (1970) 2


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

4) 1980-1990s—Emerging paradigm, to understand the complexity of human behavior-- system’s perceptive

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

6. What are the characteristics of the emerging (顯現 ) paradigm in OT? 

Occupational performance results from the dynamic interaction between the person, the environmental context, and the occupations in which the person engages. A more complex perspective on factors that impact occupational performance

All systems and components of systems are organized by levels and operate according to the laws of hierarchy (rather than cause-andeffect relationship)=> Dynamical systems theory: self-organizing processes

Input (Open system)=> Throughput=> Output, the interaction of the system with it environment is refined and guided by the feedback process

A broader range of potential solutions to occupational performance

7. The definition of public health: (Green and Anderson, 1982) The science and art of preventing disease, prolonging life, and promoting health and well-being through organized community effort for the sanitation (衛生設備) of the environment, the control of communicable infections, the organization of medical and nursing services for the early diagnosis and prevention of disease, the education of the individual in personal health, and the development of the social machinery to assure everyone a standard of living adequate for the maintenance or improvement of health. 8. Five phases of the “modern era” of public health: 1) Miasma(毒氣、沼氣) phase (1850-1880): garbage collection, public sanitation, street cleaning, food handling, personal hygiene education 2) Disease control or health protection phase (1880-1920): Organisms causes disease and the science of bacteriology/ inoculations against diseases such as rabies (狂犬) and typhoid fever(傷寒), quarantine (隔離)to prevent the spread of communicable illnesses

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

3) Health resources or medical phase (1920-1960): financial resources in construction of hospital, the development of health profession, the biomedical research (OT in medical model expanded significantly) 4) Social engineering phase (1960-1975): Medicare and Medicaid legislation in 1967 make health care services available to all citizens. Social concerns addressed at the federal level (housing, education, and poverty) 5) Health promotion phase (1975-present): recognition that health problems are attributable to an individual’s lifestyle and behavior (leading causes of morbidity, mortality, and disability—heart disease, cancer, stroke, HIV, and accidents), health promotion efforts—combine social and environmental supports with strategies for health education and behavior changes to prevent disease and disability 9. Health-Care Delivery for Persons with Disabilities 1) Institutionalization 2) Deinstitutionalization and community develop (1975~to late 1980): “homelike settings, professionals are still the planners of service and retained authority/ Guiding principles—developmental theory, to develop skills and behaviors) 3) The era of community membership: focus on community supports to facilitate integration, autonomy, quality of life, and independence / Guiding principles—the adaptation of the environment to meet the individual’s needs, rather than education of the individual to adapt to the environment. Dysfunction is a dynamic interplay between an individual’s limitations and resources and the demands and constraints of the environment. (Systems approach: Social and environmental constraints than inherent in the physical disability) 10. The Vocational Rehabilitation (1980~)—2 models of practice 1) Clinical model of vocational rehabilitation: PWD are unemployed, need to be assessed, counseled,, and treated to make him or her more employable/ to modify or restructure the psychological and vocational skills and behaviors. 2) Ecological or environmental model of vocational rehabilitation: numerous environmental, social,, and economic forces affect the PWD/ to modify all aspects of environment (physical, social,, and political) 5


2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

11. Compare and contrast the paradigm shifts in OT with those of public health and vocational rehabilitation. 12. What are the basic components and/ or characteristics of a community practice paradigm in OT? 1) Broader perspectives: Client (vs. Patient), Intervention (vs. Treatment), Funding (vs. reimbursement) 2) “Client”-centered approach to practice: promote participation, exchange information, client decision-making, and respect for choice, focus on the issues which are most important to the person or family 3) The collaborative process to enable the client to identify occupational performance problems, engage in problem solving. * OT’s role—facilitator, educator, and mentor in the process (* Table 2-1: Contrasting Paradigms) 13. Discuss the usefulness of system theory to community practice. (p.31) How to assess the client in the community? (Box 2-1)

=================================================== Public Health, Community Health, and Occupational Therapy 1. What is “Public Health”? “The process of mobilizing local, state, national, and international resources to ensure the conditions in which people can be health.” 4 strategies: 1) Promoting health and preventing disease 2) Improving medical care 3) Promoting health-enhancing behaviors

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

4) Controlling the environment * defined in terms of aims and goals, rather than grounded in a specific of knowledge=> many disciplines involved 2. Terms in Epidemiology * Epidemiology – the study of the distribution, frequencies, and determinants of disease, injury, and disability./ use health statistics, including measures of incidence and prevalence, to estimate disease, injury, and disability in a variety of population groups; analyze the health trends; plan and evaluate public health initiatives; and make informed health policy decisions * Incidence refers to the number of new cases within a specified time frame (a year) * Prevalence refers to the total number of cases at one point in time. => What is the purpose of preventive intervention? To reduce ________ => List the strategies to the duration of illness. ________________ => What is the most effective approach to reduce overall prevalence? * Public health intervention: to modify all types of risk factors and strengthen resiliency or protective factors to enhance the overall health and well-being of population. - To decrease “risk factors”: -- precursors that increase an individual’s or population’s vulnerability to developing a disease…(physical, behavior, or genetic, social, economic, political, and environmental) - To increase “resiliency (反彈) factors” -- precursors that increase an individual’s or population’s resistance to developing a disease… * “Health Promotion”—any planned combination of educational, political, regulatory, environmental, and organizational supports for action and conditions of living conductive to the health of individuals, groups, or communities.

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

* “Prevention”—anticipatory action taken to reduce the possibility of an event or condition from occurring or developing, or to minimize the damage that may result from the event or condition if it does not occur “Primary prevention”—focuses on healthy individuals who potentially could be at risk for a particular health problem/ to prevent the disease (example) “Secondary prevention”—focuses on the detection and treatment of disease early on in its preclinical or clinical stages/ to slow the disease process, attempt to cure or control (example) “ Tertiary prevention”—used in the advanced stages of disease (already ill), to limit disability and other complications/ to restore as much functionality as possible, and to prevent further damage (example) 3. Describe the differences between public health and medical approaches to health and disease. Discuss the implications of these two approaches with respect to OT practice. (p.39) 4. What is “community health”? *”Community”—Noninstitutional aggregations of people linked together for common goals or other purposes * “Health”—the blending of a person’s physical, emotional, social, intellectual, and spiritual resources so that he or she can master the developmental tasks necessary to enjoy a satisfying and productive life. * “ Community Health”— the physical, emotional, social, intellectual, and spiritual well-being of a group of people who are linked together in some way 5. What are included in “community-based approach” to enhance “ community health”? 1) Educational intervention 2) Social intervention (economic, political, legal, organization change) 3) Environmental supports

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

4) The health behavior of a community: actions of any person who may influence health behaviors,, resources or services ( police maker, ill persons, professionals,, employers,…..) 6. Describe the history of the development of national health goals and objectives and potential roles for OT practitioners within the Healthy People framework. 1) “Healthy People” proposed by the Department of Health, Education and Welfare (Now the Dep. of Health and Human Services) in 1979. - to identify national health goals and discuss health promotion and disease prevention in the US, and efficiently and effective use of the health-care resource - morbidity and mortality can be attributed to four primary elements: 1) Inadequacies in the existing health-care system 2) Behavioral factors or unhealthy lifestyles: the leading cause of death for adolescents and young adults 3) Environmental hazards 4) Human biological factors * Five major health goals according to life span (infants, children, adolescents and young adults, adults, and older adults) 2) In 1980, “ Objectives for the Nation” -- a total of 226 specific goals A mid course review in 1986 3) “ Healthy People 2000” in 1990: Focus is to improve the QOL, and people’s sense of well-being (rather than just reduction of mortality rate) - Increase the span of healthy life for Americans - Reduce health disparities among Americans (people with low income, disabilities, in minority groups) - Achieve access to preventive health services for all Americans (social and environmental factors)

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2012 autumn -- 429 U0210 Topics in Community-based Practice of Occupational Therapy

4) “ Healthy People 2010” in 2000: due to advances in preventive therapies, vaccines and pharmaceuticals, assistive technologies, and computerized systems. * 28 Focus areas (Box 3-1), 467 goals 5) “ Healthy People 2020”

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