Social participation of seniors: Applying the Framework of Occupational Justice for healthy ageing and a new approach to policymaking

ABSTRACT

Background: Social participation is associated with positive health outcomes for seniors. However, not all seniors may be able to achieve a satisfactory level of participation. Purpose: This study aimed to analyze the social participation of seniors within the Framework of Occupational Justice (FOJ) to promote an occupational perspective to policymaking. Methods: This study employed a deductive and inductive thematic content analysis of seniors’ responses from focus group data that looked at seniors’ experiences with social participation in Montreal, Canada. Twelve focus groups for a total of 111 participants from diverse backgrounds were analyzed. Results: The analysis revealed structural and contextual factors that can enable or prevent social participation. Potential enablers to social participation include the presence of individual community support workers, the design and accessibility of the physical environment, and programs tailored to seniors’ needs. Underlying occupational determinants identified as barriers are related to cultural values and policies tied to ageism. Inductive reasoning also yielded new, neutral, occupational outcomes for the FOJ. Conclusion: When applying the FOJ to a diverse population, there is the possibility of a spectrum of occupational outcomes, which shifts the perspective from the polarity of rights and injustices currently presented in the FOJ. In terms of social policy, social participation is viewed as a right and that public policy can work towards promoting this right.

背景：社会参与与老年人的正面健康结果相关。然而，并非所有老年人都能达到令人满意的参与水平。目的：本研究旨在分析老年人在生活活动正义框架 (FOJ) 内的社会参与，以促进生活活动为角度的决策。方法：本研究对加拿大蒙特利尔老年人社会参与经历的焦点小组资料中的老年人的反应进行了演绎和归纳主题内容分析。对来自不同背景的共 111 名参与者的 12 个焦点小组进行了分析。结果：该分析揭示了可以促成或阻止社会参与的结构和背景因素。社会参与的潜在推动因素包括社区支持人员的存在、物理环境的设计和可达性，以及针对老年人的需求量身定制的项目。被确定为障碍的潜在生活活动决定因素与与年龄歧视相关的文化价值观和政策有关。归纳推理也为 FOJ 产生了新的、中性的、生活活动的结果。结论：当将 FOJ 应用于不同的人群时，可能会出现一系列不同的生活活动结果，这转变了当前 FOJ 中呈现的权利两极化和不公正的视角。在社会政策方面，社会参与被视为一项权利，公共政策可以促进这一权利。

Antecedentes: La participación social de las personas mayores redunda en resultados positivos para su salud. Sin embargo, no todos los adultos mayores pueden lograr niveles de participación satisfactorios. Propósito: El presente estudio se propuso analizar la participación social de personas mayores dentro del Marco de Justicia Ocupacional (FOJ), con el propósito de promover el uso de una perspectiva ocupacional en la elaboración de políticas. Método: Partiendo de las respuestas proporcionadas por personas mayores, el estudio efectuó un análisis de contenido temático deductivo e inductivo, empleando información recabada durante la realización de varios grupos focales que examinaron las experiencias de adultos mayores involucrados en actividades de participación social en Montreal, Canadá. En este sentido, se analizaron 12 grupos de discusión en los que participaron 111 personas de diversos orígenes. Resultados: El análisis dio cuenta de la existencia de factores estructurales y contextuales que pueden facilitar o inhibir la participación social. Entre los posibles facilitadores de la misma figuran la presencia de trabajadores de apoyo a la comunidad, el diseño y la accesibilidad del entorno físico, además de los programas adaptados a las necesidades de los mayores. A su vez, los determinantes ocupacionales subyacentes identificados como barreras están relacionados con valores culturales y políticas vinculados a la discriminación por razón de la edad. Asimismo, el razonamiento inductivo arrojó nuevos resultados ocupacionales neutrales para el FOJ. Conclusión: Al aplicar el FOJ a una población diversa, existe la posibilidad de que surja un espectro de resultados ocupacionales, lo que cambia la perspectiva de la polaridad de derechos e injusticias presente actualmente en el FOJ. En términos de política social, se considera que la participación social es un derecho y que la política pública puede orientarse de manera de promover este derecho.

KEYWORDS:

• Occupational science
• Participation
• Seniors
• Older people
• Ageing
• Human rights

Social participation, an important area of occupation, refers to people’s involvement and interaction with others in their local communities, neighbourhood, and wider society (Levasseur et al., 2008). Social participation results from these reciprocal interactions between personal and environmental factors (Fougeyrollas, 2010). Having social connections, support, and engagement are all encompassed by social participation (Bruggencate et al., 2017). A large body of research demonstrates the benefits of promoting seniors’ social participation, as it decreases cardiovascular morbidity (Valtorta et al., 2016), slows cognitive decline (Zunzunegui et al., 2003), decreases hospital visits and front-line professional consultations (Cruwys et al., 2018), reduces depressive symptoms (Abu-Rayya, 2006), and increases reported quality of life (Levasseur et al., 2008). Social participation is positively associated with decreased mortality (Wilkins, 2003), disability (Lund et al., 2010), and depression (Glass et al., 2006). A meta-analytic review also found that individuals with adequate social relationships have a 50% greater likelihood of survival compared to those with poor or insufficient social relationships (Holt-Lunstad et al., 2010). This effect is greater than quitting smoking as well as many other well-known risk factors for mortality, such as the influence of obesity and level of physical activity. Social participation is, therefore, viewed as a major determinant of health, as well as one of the pillars of healthy ageing (World Health Organization, 2015).

Despite this established connection between social participation and health, data from the 2008–2009 Canadian Community Health Survey - Healthy Aging (CCHS-HA) has shown that one in four persons over the age of 65 in Canada reported that they would have liked to have participated in more social occupations in the previous year and one in five felt a lack of companionship, left out, or isolated from others (Gilmour, 2015). A secondary analysis of the data from the CCHS-HA supported the idea that the average frequency of participation in seniors could be higher, especially when personal and environmental barriers are removed (Naud et al., 2019). This study also highlighted that the social participation of seniors is changeable, and it can be further increased with the appropriate interventions.

Occupational Justice Theory and Framework

Occupational justice is a theory stemming from occupational science. It is defined as equity and fairness for individuals, groups, and communities regarding resources and opportunities for their engagement in diverse, healthy, and meaningful occupations (Nhunzvi et al., 2019). It supports the principles of fairness, equity, and empowerment to create opportunities for participation in occupations for the promotion of health and quality of life (Stadnyk et al., 2010). Theorists of occupational justice believe that people have the right to engage in varied occupations of their choice to meet their needs and develop their potential (Durocher et al., 2014). The relevance of occupational justice to the social participation of seniors can, therefore, be traced to its emphasis on the social determinants of health and social inclusion as outcomes (Nhunzvi et al., 2019).

The Framework of Occupational Justice (FOJ), depicted in Figure 1, was developed by occupational justice theorists Stadnyk et al. (2010) to enable the definition of an issue that prevents a person’s occupational engagement. The FOJ describes how structural and contextual factors interrelate to determine occupational justice outcomes (Chichaya et al., 2018). The FOJ indicates that policies underlie occupational determinants because occupation is contextual; thus, policies form part of the structural factors that shape the context in which justices and injustices are formed (Chichaya et al., 2018).

Figure 1. A Framework of Occupational Justice. Adapted from Stadnyk, R. L. (2007). A framework of occupational justice: Occupational determinants, instruments, contexts, and outcomes. In E. A. Townsend and H. J. Polatajko. (2013), Enabling occupation II: Advancing an occupational therapy vision for health, well-being, and justice through occupation (p. 81). CAOT Publications ACE. Adapted from Townsend, E. A. & Wilcock A. A. (2004). In C. H. Christiansen & E. A. Townsend. Introduction to occupation: The art and science of living (p. 251). Prentice Hall. Adapted with permission from the CAOT Publications ACE.

To frame a situation in occupational justice terms means to identify an outcome as either a right or an injustice (Wolf et al., 2010). When individuals have access to adequate supports and resources, they experience occupational outcomes identified as occupational rights, termed as meaning, participation, choice, and balance (Townsend & Wilcock, 2004). When people systematically face an unfavourable context or structural barriers, they experience occupational outcomes known as occupational injustices, labelled as imbalance, marginalization, alienation, and deprivation (Townsend & Wilcock, 2004). Occupational imbalance occurs when an individual is either under-stimulated and has too little to do, or inversely, the individual may be involved in too many occupations that have been imposed on them (Wolf et al., 2010). Occupational marginalization arises when individuals lack the power to exercise occupational choice, as can occur when persons are stigmatized by age, sex, race, illness, or disability (Townsend & Wilcock, 2004). Occupational deprivation is the result of individuals being denied the opportunity and resources to participate in occupations. Occupational alienation occurs when people are required to participate in occupations that lack meaning to them or are done with little to no recognition or reward (Wolf et al., 2010).

To date, the FOJ has primarily been applied to populations for which potential occupational discrimination has been largely documented, such as prisoners, substance users, or ethnic minority groups (Benjamin-Thomas & Laliberte Rudman, 2018). With seniors, the FOJ or the occupational justice theory has generally been applied to those living in care homes (Andrew & Wilson, 2013; Causey-Upton, 2015; Morgan-Brown et al., 2017; O’Sullivan & Hocking, 2013), or as it relates to a specific topic, such as technology use (Kottorp et al., 2016), or for a specific population (Brown, 2008; Lim & Stapleton, 2016; Orellano-Colón et al., 2015). However, the FOJ offers a promising perspective to analyze the barriers and inequalities of participation in a diverse population of community-dwelling seniors, potentially resulting in the creation of policies aimed at reducing existing inequities in health. The development of a better understanding of the occupational justice and social participation needs of seniors will support policy and social service development.

Objectives

The main objective of this study was to analyze the social participation of seniors within the FOJ to promote the use of an occupational lens in policymaking. A secondary objective was to shed new light on the application of the FOJ with perspectives gathered from a larger, more diverse segment of the general senior population.

Methodology

This was a secondary analysis of focus group data that looked at seniors’ experiences with social participation in an urban context (Lemieux et al., 2018). The perspectives on social participation and its influencing factors captured in these focus groups were reviewed through the theoretical lens of the FOJ, with a focus on the factors that positively or negatively influenced social participation in seniors. In terms of researchers’ reflexivity, the primary author viewed the data from the stance of her background professional training in occupational therapy and interest in promoting seniors’ social participation. The co-author, being from both occupational therapy and public health backgrounds, adopted an analytical intention of documenting social inequalities in participation as a health determinant.

Participants

In total, 15 focus groups were conducted with 6-14 participants per group, all residents of Montreal, Canada (Lemieux et al., 2018). Participants were recruited via convenience sampling through community organizations and community workers, although an effort was made to reach out to more vulnerable, harder-to-reach seniors. Participants needed to be at least 55 years old or older, have a minimal form of social participation, and be able to communicate their thoughts on the subject in either French or English (except for a group of Latino immigrants, where two interpreters were present). A diverse representation was also sought out, as 44% of Montreal seniors were born outside Canada (Direction régional de santé publique de Montréal [DRSP], 2019). Only 12 of the 15 original focus groups were available for analysis due to the timing of the focus groups and the timing of the primary author’s presence within the organization for the data analysis. Within these 12 groups, there were 77 women and 34 men. The age range of the participants was from 56 to 98 years of age, with three groups composed of 75-year-olds and over. Only one group specifically explored the experience of immigrant seniors, and 27 out of the 111 participants were born outside of the country (24%), which left foreign-born people under-represented in the sample. Three of the groups were held in low-rental housing units, four of the groups were held in private senior’s residences, and five were held in a community space. This strategy was designed to target different cultural and living conditions that might influence older adults’ perceptions and needs regarding social participation. Homogeneous focus groups can also facilitate openness among the participants during discussions (Sim, 1998). The characteristics of each focus group are depicted in Table 1.

Table 1. Group Characteristics.

Number of Participants	Age Range	Number of Immigrants	Number of Men	Location of Group
10	72-87	0	5	Private seniors’ residence
9	61-97	0	4	Private seniors’ residence
11	75-98	3	1	Private seniors’ residence
10	75-90	4	0	Private seniors’ residence
10	57-85	4	4	Low-income housing
6	67-76	3	0	Low-income housing
8	56-83	0	0	Low-income housing
9	62-83	0	9	Community centre
10	61-78	0	2	Local community health centre
7	80-94	4	1	Local community health centre
13	62-85	7	4	Community centre
8	66-74	2	4	Community centre

Data collection

In the original study, ethical approval was granted by the Comité d’éthique de la recherche-Dépendence-Inégalités sociales et Santé publique (CÉR-DIS) and written participant consent had been obtained before the focus groups took place. For this study, the Human Research Ethics Board of the University of Victoria granted ethical approval and confidentiality agreements were signed with the CÉR-DIS prior to secondary analysis. The focus groups were semi-structured and invited seniors to reflect on their social participation. A community worker and a member of the research team facilitated the focus groups. Group participants were asked to comment on five open-ended questions about their experience of social participation: 1) What are your social activities or involvement in your community?, 2) What do you get out of it?, 3) What promotes your participation in these activities?, 4) What makes them more difficult or made you quit?, 5) Have you ever felt treated differently because of your age?. For the purposes of the original study, these questions were based on pre-established categories derived from existing literature (Raymond et al., 2012). They, therefore, did not have an occupational focus. Finally, socio-demographic data were also collected. The focus groups lasted around 3 hours on average, including a lunch break. To permit the seniors to discuss their ideas freely, the focus groups were not recorded; rather, two note-takers were present to capture the participants’ ideas and transcribe verbatim when possible. The note-takers wrote directly in an electronic observation grid. The group facilitator and lead researcher in the original study were present for all the focus groups. This researcher validated the transcript information with the note takers before finalizing the focus group reports.

Data analysis

The analysis was conducted with the data in its original language (English or French), as both the authors identify as bi-lingual. It was performed using the definitions provided by the FOJ; thus, coding was mainly deductive (Miles et al., 2014). However, emergent new themes were accepted, and the need to do so became apparent during the data analysis process, therefore also including an inductive approach (Boyatzis, 1998). This was done using an iterative process that allowed the authors to explore and identify any element that could be relevant to the FOJ (Neale, 2016). This approach of combining both deductive and inductive analysis complemented the research aim by allowing the principles of the FOJ to be integral to the process of deductive thematic analysis, while allowing for new themes to emerge directly from the data using inductive coding for a greater understanding of the implications of using the FOJ with a diverse population (Fereday & Muir-Cochrane, 2006).

As described by Elo and Kyngas (2008), content analysis is a method that systematically outlines any explicit meaning (termed as a code) throughout a qualitative data set. Codes and sub-codes that depict the same phenomenon are then grouped into categories, referred to as themes. Similar themes can later be regrouped again into overarching themes. Thus, the focus group data were analyzed by labelling segments of the data with codes indicating the observable meaning within the categories of occupational outcomes. A segment was first coded as an injustice or a right when a person explicitly voiced a situation where the outcome could be labelled as positive (right) or negative (injustice). Each outcome was also coded with its respective combination of structural and/or contextual factors when provided, with further reflexive analysis being noted in memos as it was being indexed. As an example, a participant mentioned not doing much and finding it difficult to get out into the community after having moved into a private seniors’ residential facility where no access to public or private transport was offered and that her old friends rarely visited her at the residence. The segment was coded as occupational deprivation, with the lack of occupational instruments or programs (transportation) as an associated structural factor and spatial contexts (remote location) as a contextual factor. The final coding tree is illustrated in Figure 2.

Figure 2. Coding Tree.

The authors completed the analysis in three rounds. In the first round, they discussed and established a common understanding of the conceptual definitions associated with each occupational outcome. The focus group reports were analyzed using a qualitative analysis software tool (QDA Miner, Lite version). To ensure credibility, dependability, and confirmability (Laperrière, 1997), the principal author reviewed all 12 focus group reports and the co-author reviewed a sub-section of these groups for later triangulation.

The second round of analysis consisted of peer debriefing between the two authors to discuss and resolve discrepancies in the coding. This was done with the focus groups that were reviewed by both authors. The debriefing also revealed some overlapping reflective interpretations of the sub-codes when they were applied to the four definitions of occupational injustice. Codes with multiple interpretations were discussed until a consensus was reached on the most appropriate sub-code definition.

During the second round of data analysis, debriefing between authors revealed that the majority of discrepancies in coding occurred when an occupational outcome was expressed but not outwardly characterized positively or negatively, yet certain personal, contextual, or structural factors were noted to be facilitating or hindering that outcome. These nuanced outcomes initially led to the new code “neither a right nor an injustice”; this code was further broken down into the sub-codes of occupational loss, tipping point, mismatch, and forced transition. These codes depicted situations where someone expressed a significant occupational change due to something happening outside of his or her control, but that did not match the definition of injustice or right, or it did not elicit a feeling of empowerment or prejudice. This resulted in a final coding tree that combining both inductive and deductive approaches, as outlined in Figure 2.

In the third round of data analysis, a thematic analysis was undertaken to identify the overarching themes that emerged from the coded content. The thematic analysis allowed for the creation of four central themes relating to each dyad of occupational outcomes, as described in Table 2, and further elaborated on in the discussion. These central themes also became the basis for the policy flow chart, in Figure 3.

Figure 3. Policy Flow Chart of Social Participation and Occupational Justice.

Table 2. Thematic Content Analysis in Accordance with the Four Definitions of Occupational Rights and Injustices.

	Selected Codes	Themes	Central theme
Occupational deprivation and participation
Occupational injustice	Issues related to personal and physical security in their home environment or neighbourhood Wait lists or regulations for occupations Loss of space/occupation/person/committee Gossip Transportation (i.e. cost, length of the journey) Poor accessibility Poor understanding of technology Lack of access to information Cost of occupations Pressure from family or friends to abandon an occupation (e.g., driving) or move Fear (i.e., of falling)	Issues exist with availability and affordability of occupations Issues exist related to low socioeconomic status Lack of skills to participate	Importance of analyzing the context before introducing occupation
Occupational right	Resilient, open, and positive mentality of individual/group/management of residence Presence of a person or pet that links an individual with other people or an occupation Low cost of an occupation Ability to use technology to maintain contact with family and friends Delegation of household tasks Environments that facilitate connection Modification of how the person participates in a given occupation	Psychological response can positively influence participation Environmental enablers promote participation Equal opportunity for participants to participate
Occupational alienation and meaning
Occupational injustice	Feeling pressure from society to age in accordance with positive ageing Judgment from others Gentrification Difficulty identifying with the need to learn how to use technology Little interest in the types of occupations offered	Underlying cultural values negatively influence participation Range of occupations offered does not reflect the needs and interests of seniors	Need to acknowledge the diversity amongst older adults and understand how this diversity influences participation
Occupational right	Recognition for efforts in a given occupation The maintenance of strong bonds between family and friends Feeling an attachment to their community/dwelling Participant expresses the significance of a given occupation to them	Positive social participation is experienced Expressing feelings of competence and accomplishment Sense a feeling of belonging
Occupational marginalization and choice
Occupational injustice	Being excluded from occupations as a result of physical disability or use of technical aid Made to feel unwelcome during volunteer occupations by paid employees or management Ageism in the workplace Unable to do occupations as before if not adept at using technology Isolation when moving to a seniors’ residence Not invited to participate due to sexual preference	Inaccessible environments limit access to community occupations for participants with physical disabilities Ageism and other stigmatizing attitudes undermine a participant’s social participation	Revisit the concepts of what it means to age successfully, to reduce ageist perceptions of older adults
Occupational right	Making a conscious decision to put their needs and desires first Activity schedules that are coherent with seniors’ schedule	Perceptions and attitudes of participants favour occupations of preference Timing of schedules interfere with seniors’ participation
Occupational imbalance and balance
Occupational injustice	Difficulty participating in occupations due to caregiving for partner or grandchildren Lack of opportunity in occupations in place of residence	Social participation not seen as a priority	Social participation needs to be viewed as a determinant of health and as a right to which all persons should have access to
Occupational right	Ability to continue paid employment with a flexible schedule	Favorable condition to promote continued employment

Results

Although the group discussions on social participation were not originally intended to explore occupational rights and injustices, several seniors did express occupational outcomes. Throughout the discussions, it was possible to first identify the occupational outcomes, and subsequently the combinations of structural and contextual factors that enabled participants’ rights or hindered participation and contributed to the formation of injustices, as suggested by Wolf et al. (2010). For this reason, results are categorized by occupational outcomes. For the participants of this study, the most common structural factors were policies and underlying values, community supports, recreational facilities, housing, transportation, technology use, and accessibility; and the most cited contextual factors related to employment, social networks and supports, and an individual’s psychological response. Table 2 also summarizes the structural and contextual factors that led to the formation of a right or an injustice (labelled as “code” in the heading), as well as the multiple themes and central themes that emerged from these factors. The quotes presented in this section were translated into English by the primary author and reviewed by the co-author for accuracy.

Occupational injustices

Deprivation

Occupational deprivation was coded when participants brought up circumstances that stood outside of their control and caused them to limit their social participation. This included concerns about personal security; loss of a physical space, a community worker, or an occupation that allowed for social participation; the cost and time involved with transportation; and poor access to information, amongst others. For example, several groups cited the loss of or the prohibition to create residents’ committees at their private seniors’ residential facility when explaining why they have reduced opportunities to participate in social occupations. One woman who lived in a private seniors’ residence explained, “There was once a residents’ committee here, but the administration wouldn’t listen to them, so everyone on the committee ended up quitting. Even now, it is generally understood that the administration does not want another residents’ committee.”

Accessing or having to utilize technology was also a source of deprivation. For example, those who were able to use computers or cell phones often required human assistance to troubleshoot and those who did not have this assistance, or who could not access this type of technology altogether, felt deprived of being able to communicate with others. One participant from a men’s group said, “No internet, no computer, no cellphone; I would need extra resources to have access to a computer.” Participants also expressed that the information about opportunities for participation was difficult to access offline. Another participant from the men’s group mentioned, “I tried to find the information on where I could go swimming in my neighbourhood online, but when I couldn’t find it there, or elsewhere, I just didn’t go.”

Alienation

Segments were coded as alienation when a senior mentioned feeling a sense of meaninglessness or emptiness resulting from a lack of resources and opportunities to experience meaningful occupations. Alienation may also occur with forced participation, or when people perceive an outside pressure to participate despite having the will or capacity to do so, resulting in a feeling of failure or powerlessness. This included: the replacement of the unique character and social identity of a neighbourhood (e.g., indirect displacement) due to gentrification (Versey et al., 2019); or, pressure from society to participate in certain types of occupations over others. One participant expressed: “You feel a pressure to continue to live busy and productive lives. You would think that we should all be jogging, even at 75 years of age!” when explaining how she felt that she did not live up to society’s standards of ‘successful ageing’.

Marginalization

Occupational marginalization sub-codes were noted to be mainly as a result of participants feeling excluded due to physical limitations or the use of a mobility aid. This could be seen in the attitudes of others (e.g., being told not to take up too much room on the sidewalk when driving a four-wheeled scooter), physical barriers (e.g., community spaces not accessible for those who use an assistive device), and policies (e.g., a fall prevention group that prohibits those with walkers from joining). Also, participants who had moved into private seniors’ residential facilities noticed that their friends were reluctant to visit due to the notion that “only the very elderly” live in these places and that their friends did not want to be associated with this image. One participant, who lived in a private seniors’ residence said:

What am I doing here? It isolates me. My friends don’t want to come to visit me, they don’t want to be amongst older people … people from the outside pass judgment on the residence without knowing what’s going on.

Imbalance

An occupational imbalance was coded when participants mentioned being unoccupied, under-occupied, or over-occupied in their lives and that this imbalance was attributable to structural or contextual factors outside of their control. These codes largely stemmed from the role of caregiving, whether it was for a family member who required assistance as a result of an illness or taking care of grandchildren. It should be noted that not all caregiving roles were coded as an imbalance, only when the participant mentioned it prevented them from accessing other desired occupations and that they felt that this role had been imposed on them because of a lack of public resources to care for their relative.

Occupational rights

Participation

The occupational right of participation was coded when factors were in place for participants to thrive in occupations of interest to them, such as gateway resources that enabled a person to participate. These gateway resources could be a community worker, a social mediator, or a neighbour acting as a link with others or with social occupations. Other elements that were linked to participation were the presence of “meeting spots” in the person’s living environment or their community, or the low-cost and ease of access to a particular occupation. For example, in one focus group held at a low-income housing unit, several participants mentioned that the local community worker helped them get out of their isolation and reconnect with others. One person explained: “She [a seniors’ outreach worker] made a positive difference in my life. A sense of trust is established, and you end up accepting her suggestions or invitations to outings.” In another example, in the focus group comprised of men, one of the participants said:

I have a coffee shop right next to my house and I go there every morning to hang out and see other people. I think that there should be a ‘community worker’ who helps people to introduce themselves to others and meet other people.

Meaning

Codes that exposed meaning in occupations were selected most often when participants expressed a sense of gratitude or recognition when they participated. Meaning was also found when strong family or friendship bonds were created as a result of an occupation or when participants felt an attachment to their community or living environment. To explain why he volunteers, a participant said: “A volunteer’s salary is recognition. This helps to keep you motivated. When your feedback is positively received [by the managers of the residence], you want to continue.”

Choice

The occupational right of choice was often voiced when participants mentioned that in recent years, they had gone through a personal reflection and had “decided to take care of myself” or “realized what is important for me.” In many of these cases, however, the person expressed having an existing supportive social network that allowed them to decide what was important to them in terms of social participation. Seniors mentioned that having activities that had schedules adapted to their needs increased their likelihood of consciously making a choice.

Balance

An occupational balance was coded when participants expressed having the possibility of engaging in diverse occupations that promoted well-being and productivity. There were fewer outcomes of occupational balance in the focus group reports, and it was primarily noted in seniors who were able to continue working. Despite there being few participants who continued to engage in paid employment, those who did so were able to manage their schedule in freelance-type work, thus being able to adapt to varying degrees of energy and allowing for rest periods. Another example was when a participant mentioned being able to delegate certain household tasks, like cleaning, to external sources, allowing them to preserve their energy levels for more meaningful occupations. This participant mentioned, “As I age, I have more trouble sleeping, which means I have less energy during the day. I decided to pay for a cleaner so I can use the energy I have for social activities.”

Neither an injustice nor a right: New occupational outcomes

As described in the data analysis section, and outlined in Figure 2, several neutral occupational outcomes were noted during analysis, which led to the creation of a new code and 5 sub-codes in the coding tree that were not originally present based on the current FOJ. A ‘forced transition’ was coded when a person experienced a change in their life that was not planned or wanted that impacted their daily occupations, yet there was no sentiment of an injustice attached to the event. For example, forced transitions were reported when people had to give up driving or had to give away a pet that helped them go out and connect to other people. A “tipping point” was coded when a participant reported an occupational challenge because of a contextual or structural factor but did not explicitly link it to an outcome. For example, several participants mentioned having unpleasant experiences while taking public transit (e.g., not being given priority for a seat or getting rude comments from the bus driver). While these experiences made taking public transit more difficult and could impact social participation, they did not mention limiting their outings or having to change their activities as a result.

An “occupational loss” was described as the person having to give up an occupation due to circumstances outside of their control, but it did not generate a feeling of injustice or frustration from the participant. In one group, a participant mentioned that when two of her best friends passed away, she did not feel like doing the outings she used to do with them alone. A “mismatch” was coded when the abilities of the participant no longer met the demands of the occupation, such as giving up a particular sport following an illness. To our knowledge, this is the first study to define occupational outcomes in terms other than a right or an injustice. These findings, which led to the creation of new occupational outcome codes, demonstrate that being exposed to the same structural or contextual factors may lead to different outcomes between individuals.

Discussion

This study demonstrates that the FOJ can be applied to document occupational outcomes, as well as the barriers and enablers of social participation in seniors. It also highlights that, when the FOJ is applied to a more diverse population, occupational outcomes are not as clearly divided into rights and injustices. This nuance may become important when planning interventions, especially those considered “universal”. More importantly, however, is that all rights and injustices documented through the experiences of seniors’ social participation were linked to a structural component: public policies, social norms and values, political or economic context, or distribution of public resources in terms of occupational instruments or programs. These findings shed light on the importance of not only incorporating an occupational justice lens in policy development, but also the need to use occupational justice to re-think the cultural values around ageing.

A tool for policymakers

Based on this study’s findings, Figure 3 introduces a flow chart that synthesizes the identified themes, as outlined in Table 2, of occupational justice as outcomes of policy implementation that may affect opportunities for social participation for seniors. This policy flow chart could serve as a tool for policymakers and key stakeholders (e.g., public health managers, community organizations, etc.) to link barriers in resource implementation to occupational injustices that infringe on a senior’s social participation. The proposed policy tool also takes into account the interrelatedness of the structural and contextual factors, which equally influence occupational outcomes. The structural and contextual factors are the resources associated with being a facilitator or a barrier to social participation, based on the results of the focus groups. As such, the resources are not exhaustive but are the ones most frequently mentioned by the study participants. Each subcategory then highlights the occupational outcomes that are possible depending on how occupational justice is incorporated into the policy implementation process. One can consider occupational justice is upheld when the proposed policy: 1) does a proper analysis of the related structural and contextual factors before implementation (occupational participation versus deprivation); 2) acknowledges the diversity amongst seniors’ social participation needs (occupational meaning versus alienation); 3) questions pre-conceived notions of successful ageing (occupational choice versus marginalization); and, 4) promotes social participation as a right to which all seniors should have access to (occupational balance versus imbalance).

Preventing deprivation: Conducting an environmental scan

The results of this study suggest that occupational deprivation can occur when the needs of the target population, as well as the structural and contextual factors that can affect how these needs are met, have not been properly taken into consideration, resulting in barriers to accessing certain occupations for more vulnerable seniors. Interventions that are planned without a proper analysis may cause a lack of consideration for the link between occupations, social participation, and health (Moll et al., 2013). Therefore, an environmental scan of existing norms and societal values, resources, community assets and challenges, as well as collective and individual social capital that can impact on social participation should be analyzed before designing and implementing any policy. Interventions based on an occupational justice perspective must be conscious as to whether improving the occupational participation of one group of people does not inhibit the participation of another (Bailliard, 2016). Proper analysis of existing resources and programs or instruments geared towards social participation will ensure that they afford equitable access to all groups of the senior population.

Preventing alienation: Acknowledging diversity

Occupational alienation can be observed when policies or services targeting a certain population are developed without carefully considering the preferred modalities of social participation of the target audience. This disparity can lead stakeholders to support policies that do not take into account the need to ensure equity in opportunity for social participation for all citizens. Excessive simplification of an occupational injustice can lead to a simplified assessment of the issue and an ineffective intervention (Bailliard, 2016). To address this, Zur and Laliberte Rudman (2013) recommended integrating participatory community-based methodologies to effectively address inequities and occupational injustices. The use of both top-down and bottom-up perspectives in consultations are encouraged, as there may be differences between policymakers and the community as to the occupational needs of the population (Chichaya et al., 2018). The inclusion of citizens in the public policy process could help to address several injustices and build trust and a sense of belonging and solidarity within a particular community (Horghagen et al., 2018).

These sentiments echo the description of the occupational right of meaning, where occupations are experienced as significant and enriching. To promote social participation, Laliberte Rudman (2006) reminded us that seniors are not a homogeneous group. There are differences in gender, culture, social class, health, preferences, and occupational needs (Urbanowski et al., 2013). It is, therefore, necessary to recognize this diversity to offer a wider range of occupational opportunities (Canadian Association of Occupational Therapy [CAOT], 2011). In terms of public policy, there is a need to encourage greater recognition of diverse occupations and assume collective responsibility to create and secure a more occupationally just future (Whiteford, 2014).

Preventing marginalization: Combatting ageism

Occupational marginalization of seniors will manifest when policies are rooted in ageism. Seniors are marginalized and discriminated against when negative stereotypes, prejudices, and biases about older people are perpetuated, which contribute to infringements on their basic human rights associated with dignity, participation, health, and security (Cox & Pardasani, 2017). Challenging ageism requires questioning the notions of what it means to age as society deems acceptable. Although there has been an explicit effort towards instilling a more positive perspective on ageing, the pitfall is to provide one sole perspective and associate it with a narrow spectrum of what “positive, successful ageing” is. A positive discourse on ageing includes a dissociation between ageing and disease, a focus on the postponement of old age, a focus on individual responsibility to maintain good health, and a focus on being active (Laliberte Rudman, 2006).

Despite its good intentions, this positive view of ageing has the potential to create inequities, as it favours certain profiles of seniors more than others. In discourses on positive ageing, the promotion of occupations that require financial resources, good health, and a certain level of literacy excludes many types of occupations and is likely to reinforce the inequalities in the occupational opportunities of the elderly. These discourses on ageing may justify the withdrawal of the state in programs for the elderly and the maintenance of social structures contributing to poverty and disability among them (Laliberte Rudman, 2006). For example, seniors with limited financial resources, who are often older, single or widowed women, have fewer opportunities to move towards this positive ageing “gold standard” that focuses on participation in a wide variety of social, cultural, physical, or leisure occupation that require a certain level of financial independence (Townsend, 2015). Marginalization is also reflected in the “digital divide” where differences in access to information and communication technologies limit seniors’ participation in society (Abbey & Hyde 2009). Moreover, Sawchuk (2013) stated that the pressure to use digital technologies to maintain connections and fully participate in current Canadian culture—a process she referred to as “mediatization”—privileges educated social elites and reduces opportunities for others.

Preventing imbalance: Social participation as a human right

An occupational imbalance was present when certain types of social participation were viewed as secondary to other occupations, thereby deeming them inferior in an un-written “hierarchy” and negating its benefits to health, quality of life, and well-being. Promoting the value of social participation and underscoring it as a matter of justice taps into the realm of human rights. However, this would require having clear standards and regulations to prove when these needs have not been met, which can lead to a proper impact assessment. On the international stage, the United Nations is proposing a Convention on the Rights of Older Persons and remarks that current action plans “have not been sufficient to promote full and effective participation by and opportunities for older persons in economic, social, cultural and political life” (United Nations, 2013, p. 2). Further research that links occupational justice theory with issues of social participation needs to examine how human rights standards and indicators could be used to advocate for better equity in opportunity. Moreover, the inclusion of occupational justice terminology of “rights” and “injustices” would allow for the advancement of this rights-based approach, as well as for collaboration with rights-based practices advanced by other scholars and the UN (Hammell, 2015).

Limitations

The limitations of this study include the secondary data used for the thematic content analysis. The data were gathered from a study whose primary purpose was to gather lived experiences of seniors’ social participation. Thus, it was not constructed with the FOJ in mind, thereby reducing the occupational focus of the research questions and consequently the participants’ responses. Also, the decision of the researchers to not audio record the focus group meetings was meant to allow the participants greater freedom in their responses; however, this may result in reduced quality of the data as bias may be introduced with manual notetaking. Moreover, despite efforts from the investigators of the original study, focus groups were not as diverse as the general senior population in the city where the study was located. Older adults with different social participation needs, including men and ethnic minorities, were underrepresented. The cultural and socio-political factors that the participants have lived will have influenced their perceptions of their experiences, and thus how the researchers interpreted themes of occupational justice and injustice from them.

Conclusion

This study explored how the FOJ could be applied to a diverse population and to provide guidance for social policy to promote seniors’ social participation. For the participants of the focus groups, potential barriers that had a direct impact on their social participation included a lack of health and community supports, a loss of recreational facilities, issues with the time and money involved with transportation, difficulties with various modes of communication and media. The presence of a community support worker, the design and accessibility of neighbourhoods, and the scheduling of recreational occupations that suited their needs were perceived as enablers. Participants also hinted at indirect structural factors as barriers to social participation, such as cultural values around ageing and ageist values underlying policy and program development.

This novel application of the FOJ encourages a paradigm that promotes the implementation of practices and policies that enable participation in meaningful occupations. This study promotes the use of the framework in public health and social policy so that these professionals can take a critical approach to facilitators and barriers to social participation. In doing so, social participation will be viewed as a right for all persons, especially seniors. This human rights perspective provides the mandate to fulfill the human need for occupation with social policy acting as the means for attaining participation.

Data Availability Statement

The data that support the findings of this study are available from the second author, upon reasonable request.

Acknowledgements

We honour and thank the Kanien’kehà:ka (Mohawk) and the Anishinabeg (Algonquin) peoples as the traditional inhabitants of the lands of Tiohtiá:ke, Montreal, where this research was conducted.

The authors thank the participants for their time and insights provided on their experiences with social participation. The principal author expresses her sincere gratitude to Dr. Nigel Livingston and Dr. Nathan Lachowsky in the School of Public Health and Social Policy of the University of Victoria, and Dr. Marika Demers in the Department of Occupational Therapy at McGill University for providing valuable input with the writing of this manuscript.