Occupational Therapy Interventions Supporting Social Participation and Leisure Engagement for Community- Dwelling Older Adults: A Systematic Review Stacy Smallfield, Whitney Lucas Molitor Stacy Smallfield, DrOT, OTR/L, BCG, FAOTA, is Associate Professor of Occupational Therapy and Medicine and Assistant Director, Occupational Therapy Entry-Level Professional Programs, Washington University School of Medicine, St. Louis, MO; stacy.smallfi[email protected]Whitney Lucas Molitor, OTD, OTR/L, BCG, is Assistant Professor, Department of Occupational Therapy, University of South Dakota, Vermillion. This systematic review examines the evidence for the effectiveness of interventions within the scope of oc- cupational therapy that address leisure engagement and social participation among community-dwelling older adults. Eleven Level I, 1 Level II, 1 Level III, and 1 Level IV studies met inclusion criteria. Included articles addressed two themes: interventions supporting social participation and interventions supporting leisure engagement. Strong evidence supports leisure education interventions to enhance leisure engage- ment, and moderate evidence supports chronic disease self-management programs to support leisure en- gagement. Mixed evidence exists for community-based group interventions and electronic gaming to support social participation. Routine use of leisure education and chronic disease self-management programs to enhance leisure engagement and selective use of community-based groups and electronic gaming to support social participation are recommended. Smallfield, S., & Lucas Molitor, W. (2018). Occupational therapy interventions supporting social participation and leisure engagement for community-dwelling older adults: A systematic review. American Journal of Occupational Therapy, 72, 7204190020. https://doi.org/10.5014/ajot.2018.030627 W ithin 30 yr, the population of older adults residing in the United States is expected to reach nearly 84 million (Ortman, Velkoff, & Hogan, 2014). Researchers estimate that 35% of U.S. adults over age 45 are lonely (Wilson & Moulton, 2010). As a population, older adults may experience greater social isolation because they are more likely to live alone, have a chronic illness, lose a significant other, experience transportation or mobility difficulties, have low income, and experience declines in muscle strength (Kharicha et al., 2007; Nicholson, 2009; Wilson & Moulton, 2010). Older adults who experience loneliness or social isolation have an increased risk of other physical and mental health issues, such as disease, falls, depression, poor nutrition, rehospitalization, cognitive decline, heavy alcohol consumption, high systolic blood pressure, infection, and mortality (Coyle & Dugan, 2012; Lillyman & Land, 2007; Nicholson, 2009; Wilson & Moulton, 2010). Loneliness and social isolation can undermine well-being by leading to feelings of stress and can influence physical, emotional, and psychological health (Coyle & Dugan, 2012; Shankar, McMunn, Banks, & Steptoe, 2011; Wilson & Moulton, 2010). Because health and wellness risks are associated with social isolation and loneliness in older adults, mitigating these health risks may im- prove not only mental health but also physical health and quality of life (QOL) in this population. Maintaining social participation and leisure engagement throughout the lifespan is important for enhanced well-being and health (Chang, Wray, & Lin, 2014; Doble & Santha, 2008). Because leisure pursuits often stem from en- gagement in meaningful occupations identified earlier in life, ensuring that 7204190020p1 July/August 2018, Volume 72, Number 4
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Occupational Therapy Interventions Supporting SocialParticipation and Leisure Engagement for Community-Dwelling Older Adults: A Systematic Review
Stacy Smallfield, Whitney Lucas Molitor
Stacy Smallfield, DrOT, OTR/L, BCG, FAOTA, is
Associate Professor of Occupational Therapy and
Medicine and Assistant Director, Occupational Therapy
1 article provided Level II evidence (Bell et al., 2011), and
1 article provided Level III evidence (Matuska, Giles-Heinz,
Flinn, Neighbor, & Bass-Haugen, 2003). Three main in-
tervention approaches—community-based group interven-
tions, community mentoring, and electronic gaming—were
identified.
Community-Based Group Interventions. Four studies
used a community-based group model of intervention
either as part of a multicomponent intervention or as a
single-component intervention (Creswell et al., 2012;
Matuska et al., 2003; Ollonqvist et al., 2008; Routasalo
et al., 2009). Group sessions were usually held weekly,
7204190020p3 July/August 2018, Volume 72, Number 4
and programs lasted from 8 wk to 6 mo. In a Level III
study, Matuska et al. (2003) found that group sessions
run by occupational therapists resulted in increased social
and community participation and significant differences
in posttest scores on social functioning. However, in a
Level I study, Routasalo et al. (2009) studied the effect of
3-mo psychosocial groups on the outcomes of loneliness
and social networking. Participants were assigned on the
basis of interest to one of three weekly groups: art or
other creative activities, group exercise and discussions,
or therapeutic writing and group therapy. Intervention
participants reported significant increases in number of
new friends but nonsignificant differences in loneliness or
social networking compared with control participants.
Creswell et al. (2012, Level I) studied an 8-wk stress
reduction program and found a significant decline in
loneliness. Finally, Ollonqvist et al. (2008, Level I) ex-
amined the effectiveness of intensive multidisciplinary
group rehabilitation for frail older adults but found no
significant difference between groups on the outcome of
loneliness. In combination, the 3 Level I studies and 1
Level III study provide mixed evidence for the use of
community-based group interventions to improve social
participation among community-dwelling older adults.
Community Mentoring. One study used a community
mentoring model of intervention (Dickens et al., 2011,
Level I). Older adults received up to 12 wk of mentoring
in self-confidence and engagement in personally mean-
ingful social activities. However, no improvements in the
outcomes of social activity or social support resulted from
the mentoring relationships. Thus, this study provides
moderate evidence against the use of a community
mentorship approach to promote social activity and
support.
Iden
tific
atio
nSc
reen
ing
Elig
ibili
tyIn
clud
ed
Records identified throughdatabase search
(N = 1,895)
Additional records identifiedthrough hand searching
(n = 265)
Records screened(n = 1,868)
Records excluded(n = 288)
Records included in systematicreview
(n = 14)
Full-text records assessed foreligibility(n = 302)
Records after duplicatesremoved
(n = 1,603)
Social participation (n = 7) Leisure engagement (n = 7)
Figure 1. Flow diagram for studies included in the systematic review.Figure format from “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, & D. G.Altman; PRISMA Group, 2009, PLoS Med, 6(6), e1000097. https://doi.org/10.1371/journal.pmed.1000097
The American Journal of Occupational Therapy 7204190020p4
on occupational engagement with a group activity in-
tervention, a discussion group intervention, and no in-
tervention. All groups declined in participation over time;
however, leisure participation declined slightly less among
intervention group participants, with the one-to-one in-
tervention group showing the highest rate of continued
leisure engagement. In general, although the dosage and
content of the programs varied, strong evidence supports
use of leisure education programs in occupational therapy
interventions targeting engagement in leisure activities for
community-dwelling older adults.
Self-Management of Chronic Disease. Garvey et al.
(2015, Level I) reported on the use of a 6-wk chronic
disease self-management program to enhance leisure
participation among older adults with multiple chronic
conditions. Goal setting, self-management of chronic
conditions, and peer support were introduced in weekly
meetings that had an occupational therapy emphasis.
This intervention led to an increase in activity frequency
compared with a control group and improved self-
perception of activity performance and satisfaction. This
study provides moderate evidence supporting the use of
chronic disease self-management programs to address the
outcome of leisure activity engagement.
Assistive Devices. One Level IV study examined
assistive device use in relation to leisure participation
among community-dwelling older adults with physi-
cal disabilities that limited home-based leisure activities
(Schweitzer et al., 1999). Participants’ home setup, assis-
tive device use, and barriers to leisure participation were
reviewed in structured interviews. Then, an appropriate
assistive device was provided to each participant to en-
courage participation in a personally meaningful leisure
activity. Provision of assistive devices led to an increased
likelihood of attempting leisure pursuits. Because only one
low-level study addressed this subtheme, insufficient evi-
dence supports the use of assistive devices to increase
home-based leisure engagement for community-dwelling
older adults.
Discussion
This systematic review examined the effectiveness of in-
terventions within the scope of occupational therapy to
promote leisure engagement and social participation
7204190020p5 July/August 2018, Volume 72, Number 4
among community-dwelling older adults. Results provide
strong evidence for the use of leisure education programs
and moderate evidence for the use of chronic disease self-
management programs to enhance leisure engagement of
community-dwelling older adults with chronic health
conditions. These interventions should be offered rou-
tinely to clients in this population who present with de-
creased participation in leisure activities. Additionally,
mixed evidence was found for community-based group
interventions and electronic gaming interventions to
improve social participation outcomes; therefore, occu-
pational therapy practitioners should consider these in-
terventions on a case-by-case basis.
Implications for OccupationalTherapy Education
The role of occupational therapy in community-based
practice is expected to rise to meet the challenge of caring
for the growing number of older adults in an ever-changing
health care environment (Lamb & Metzler, 2014). Pre-
paring future occupational therapy practitioners to meet the
needs of older adults living in the community, including
social participation and leisure engagement, should be a
focus of occupational therapy educational programs. Cur-
ricula should include the following:
• Education regarding the relationship between leisure
and social participation and physical, cognitive, and
emotional health and well-being
• Education about health conditions and contextual factors
that influence participation in social and leisure activities
• Training in the use of formal and informal assessments
of leisure and social participation
• Knowledge and skill training in the delivery of effec-
tive interventions for social and leisure participation,
including leisure education and electronic gaming.
Implications for OccupationalTherapy Research
Occupational therapy has the potential to play a significant
role in supporting social participation and leisure en-
gagement among community-dwelling older adults. Oc-
cupational therapy researchers need to continue to develop
and examine interventions for enhancing these occupa-
tions. Further research regarding interventions that im-
prove social and leisure participation will be critical to
supporting occupational therapy practitioners in this area
of practice. Recommendations for strengthening research
in this area include the following:
• Use of occupational therapy practitioners as study
interventionists
• Improvement in the consistency of interventions in-
cluded in multicomponent interventions
• Evaluation of intervention dosages (frequency and du-
ration of intervention) needed for efficacy
• Increased consistency in outcome measures used to
demonstrate intervention effectiveness
• Review of differences in leisure engagement and social
participation among older adults residing in assisted
living facilities versus those living at home.
Increased quantity and quality of evidence-based inter-
ventions that promote social participation and leisure en-
gagement will guide practitioners in providing best practice
to community-dwelling older adults.
Implications for OccupationalTherapy Practice
On the basis of the results of this review, the following
interventions are recommended as part of routine occu-
pational therapy services to community-dwelling older
adults at risk of a decline in social participation and leisure
engagement:
• Leisure education programs to enhance leisure
participation
• Chronic disease self-management programs to im-
prove leisure participation among those with chronic
conditions.
The following interventions should be offered selec-
tively on the basis of individual client characteristics and
intervention context:
• Community-based group interventions to support so-
cial participation
• Electronic gaming to enhance social participation.
The following intervention requires further research:
• Assistive devices to promote home-based leisure par-
ticipation for clients with physical disabilities.
Limitations
Although a growing body of literature supports inter-
ventions within the scope of occupational therapy practice
to promote social participation and leisure engagement in
community-dwelling older adults, the available research
has several limitations. First, the majority of outcome
measures used to collect information on social partici-
pation and leisure engagement were self-report measures,
which introduce recall bias. Second, interventions, in-
tervention dosages, and outcome tools varied across studies,
limiting the extent to which the data could be synthesized.
The American Journal of Occupational Therapy 7204190020p6
Third, several included RCTs had small sample sizes. Last,
several subthemes did not have enough studies to provide
sufficient evidence. Finally, although the interventions de-
scribed were within the scope of occupational therapy
practice, in the majority of studies, the interventionists were
not occupational therapy practitioners. Future research
addressing these gaps will strengthen the evidence sup-
porting interventions in this area of practice.
Conclusion
Older adults may experience increased social isolation
because of the natural losses that occur in this phase of life.
Those who experience loneliness and social isolation have
an increased risk of other physical and mental health is-
sues. Interventions that support social participation and
leisure engagement may mitigate social isolation and
loneliness and improve well-being. Strong evidence sup-
ports leisure education programs and moderate evidence
supports chronic disease self-management programs to
enhance leisure engagement. Mixed evidence exists for
community-based group programs and electronic gaming
interventions to promote social participation.
Occupational therapy practitioners know the value of
engaging in meaningful activity in all stages of life and
understand the effect of social participation and leisure
engagement on older adults’ health and well-being.
Practitioners working with community-dwelling older
adults are strongly encouraged to integrate effective in-
terventions for social and leisure occupations into routine
care for this population. s
Acknowledgments
We thank Deborah Lieberman, Marian Arbesman, and
Beth Hunter for their guidance and support on this
project. We also acknowledge Kaitlin LaPlant, who assisted
with minor editing. An earlier version of this article was
presented at the 2017 AOTA Conference & Expo in
Philadelphia.
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Supplemental Table 1. Search Terms for the Systematic Review of Interventions Supporting Social Participation and Leisure Engagementfor Community-Dwelling Older Adults
Category Key Search Terms
Population aged (80 and over), aged (includes ages 80 and over and frail elderly), aging, elderly, geriatrics, gerontology, late life, older adults,oldest old, pensioner, seniors, 651, young old
Rehabilitation information occupational therapy, rehabilitation, recreation therapy
activity participation, civic engagement, civic participation, computer application, computer tablet, computer tablet technology,computer use, clubs, community service, crafts, creative aging, elder hostel, family relations, friends, friendships, games, hobbies,hobby, interpersonal relations, leisure, leisure activities, leisure exploration, leisure participation, mobile application, mobiledevice, mobile phone, neighbor relations, peer, personal support, reading, recreation, relationships, retirement, retirementplanning, retirement preparation, road scholar, senior center, senior games, senior groups, smartphone use, social activity, socialadjustment, social capital, social environment, social interaction, social isolation, socialization, socializing, social participation,social skills, social support, sports, tablet technology, third age, travel, vital aging, vitality
Study and trial designs appraisal, best practices, case control, case report, case series, clinical guidelines, clinical trial, cohort, comparative study,consensus development conferences, controlled clinical trial, critique, cross over, cross-sectional, double-blind, epidemiology,evaluation study, evidence-based, evidence synthesis, feasibility study, follow-up, health technology assessment, intervention,longitudinal, main outcome measure, meta-analysis, multicenter study, observational study, outcome and process assessment,pilot, practice guidelines, prospective, random allocation, randomized controlled trials, retrospective, sampling, scientific integrityreview, single subject design, standard of care, systematic literature review, systematic review, treatment outcome, validationstudy
Suggested citation: Smallfield, S., & Lucas Molitor, W. (2018). Occupational therapy interventions supporting social participation and leisure engagement forcommunity-dwelling older adults: A systematic review (Suppl. Table 1). American Journal of Occupational Therapy, 72, 7204190020. https://doi.org/10.5014/ajot.2018.030627
The American Journal of Occupational Therapy, July/August 2018, Volume 72, Number 4 1
Supplemental Table 3. Risk-of-Bias Analysis for Included Studies on Interventions Supporting Social Participation and LeisureEngagement for Community-Dwelling Older Adults
Suggested citation: Smallfield, S., & Lucas Molitor, W. (2018). Occupational therapy interventions supporting social participation and leisure engagement forcommunity-dwelling older adults: A systematic review (Suppl. Table 3). American Journal of Occupational Therapy, 72, 7204190020. https://doi.org/10.5014/ajot.2018.030627
The American Journal of Occupational Therapy, July/August 2018, Volume 72, Number 4 7
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