Occupational therapists' contributions to fostering older adults' social participation: A scoping review

Abstract

Introduction

To promote active and healthy ageing, it is important to foster social participation. Although well positioned to do so, few community occupational therapists intervene to address social participation, and no review of promising and current practices is available. This study synthesised knowledge on community occupational therapy practices fostering older adults' social participation.

Method

A scoping review involved searches in eight databases using 49 keywords. Studies were selected by two reviewers and content-analysed following PRISMA guidelines.

Results

Of the 32 selected studies, most involved descriptive (n = 11; 34%), randomised controlled trial (n = 9; 28%) or quasi-experimental (n = 7; 22%) designs, and were conducted mainly in the USA (n = 8; 25%), Canada (n = 6; 19%) and Sweden (n = 6; 19%). Twenty promising practices combined multi-component interventions (n = 11; 55%), or involved group (n = 5; 25%) or individual (n = 4; 20%) sessions. Promising practices improved participation in social activities (n = 13; 65%), social interactions (n = 6; 30%), self-rated health (n = 6; 30%) and quality of life (n = 6; 30%), and reduced health-care costs (n = 4; 20%). Facing organisational and systemic barriers, current practices rarely incorporated these possibilities.

Conclusion

Efforts to foster older adults' social participation appear to be cost-effective but need to be further incorporated into practice. Research should engage community stakeholders in implementing these possibilities.

Keywords

Occupational therapy community health services ageing health promotion social isolation

Introduction

With population ageing and the rising prevalence of chronic diseases, it is increasingly important for policymakers to prioritise health promotion and prevention over curative services (World Health Organization (WHO), 1986). To promote active and healthy ageing, health interventions should optimise older adults' participation in society. Defined as the person's involvement in activities providing social interactions with others in society (Levasseur et al., 2010), social participation is a modifiable determinant of health and well-being. According to the Human Development Model – Disability Creation Process (HDM-DCP; Fougeyrollas, 2010), social participation results from bidirectional interactions between personal (age, gender and health) and environmental factors (aspects extrinsic to individuals and generating a reaction from them). Among the factors that could restrict older adults' social participation, disabilities will be experienced by around 42% of adults as they age (Kergoat and Légaré, 2007). These disabilities could be avoided by effective access to prevention and rehabilitation services (WHO, 1986). Although disability has a direct influence on social participation, interventions targeting community environments should also be prioritised, as they have more potential than those targeting personal factors (Amagasa et al., 2017). A lack of social interactions may result in a higher risk of mortality comparable to well-established risk factors for mortality such as tobacco smoking and obesity (Holt-Lunstad et al., 2015), while greater social participation is associated with improved health and well-being and better quality of life (Levasseur et al., 2008).

To foster older adults' social participation, community occupational therapists constitute a pivotal primary health-care resource, as they deliver their services in people's living environments (Lilja and Borell, 2001). In addition to being an essential target of health interventions, social participation is aligned with the concept of health promotion and a holistic vision of occupational therapy. Like other health professionals (Gouvernement du Québec, 2013), occupational therapists are responsible for health promotion and prevention, which includes fostering social participation. In concrete terms, occupational therapy interventions can maintain or improve older adults' functional capacities, adapt activities these adults consider important or meaningful and modify environments to make them more supportive and safe (Townsend and Polatajko, 2013). By creating supportive environments, developing personal skills and building community participation, occupational therapists can actualise their role in health promotion and prevention (WHO, 1986). More specifically, best practices in community occupational therapy may significantly improve health, quality of life, functional autonomy and social participation in older adults (De Coninck et al., 2017). Despite the effectiveness of community occupational therapy, the components and impacts of practices that foster social participation still need to be determined.

Although community occupational therapists are well positioned to foster older adults' social participation, their current practices, which refer to services they provide in real-world settings, rarely incorporate these effective possibilities (Craig, 2012). According to occupational therapists, organisational obstacles restrict social participation interventions in their current practices (Turcotte et al., 2015). As a result, occupational therapists' interventions are limited to ensuring independence and safety at home rather than fostering older adults' social participation. Since most services do not focus on social participation, older adults' most prevalent unmet needs relate to being socially involved, including engaging in leisure, community life or social relationships (Turcotte, Larivière, et al., 2015). Among the reasons for this restriction in social participation interventions, insufficient human and financial resources are often cited (Quick et al., 2010). Organisational factors, however, potentially have more impact on how health-care services respond to users' needs than the quantity or variety of resources (Lamarche et al., 2011). To incorporate promising practices, which can be defined as interventions with sufficient evidence of their effectiveness, it is important to have a better understanding of the factors affecting community occupational therapists' current practices.

Systematic reviews are an essential source of knowledge for occupational therapists regarding current and promising social participation interventions. Few literature reviews have addressed community occupational therapy interventions, and they have rarely been conducted from the viewpoint of older adults' social participation. The effectiveness of occupational therapy with community-dwelling older adults was the subject of a meta-analysis and systematic review (De Coninck et al., 2017). Although older adults' social participation was sometimes mentioned, the majority of studies did not specifically describe occupational therapists' contributions or they involved multi-disciplinary interventions. In addition, interventions mostly consisted of advising on assistive devices and fall prevention; there were no comprehensive descriptions of social participation interventions with older adults. Among other relevant systematic reviews, only one other specifically addressed social participation interventions with community-dwelling older adults, involving occupational therapists or not (Papageorgiou et al., 2016). This review identified some interventions that were found to be effective in promoting participation in education, leisure, work and social participation. However, it used a limited number of keywords and did not assess the gap between occupational therapists' current and promising practices, and studies often did not focus on social participation as the central goal of the intervention. Finally, only one review aimed to describe the current practice of community occupational therapists, which was found to be inconsistent with research (Craig, 2012). As with previous reviews, the studies included did not address specific factors affecting social participation interventions but focused instead on home safety. Despite these reviews, a comprehensive portrait of promising and current community occupational therapy interventions fostering older adults' social participation is still lacking.

To help translate best evidence into community occupational therapy practices and promote older adults' social participation, it is imperative to integrate knowledge regarding current and promising practices, including factors affecting the use of these practices. This scoping review thus aimed to synthesise knowledge about (1) promising and (2) current community occupational therapy practices fostering older adults' social participation, and (3) factors affecting the use of social participation interventions with this population.

Method

A scoping study (Arksey and O'Malley, 2005; Levac et al., 2010) was conducted to synthesise knowledge concerning community occupational therapy fostering older adults' social participation. The framework for scoping studies (Arksey and O'Malley, 2005; Levac et al., 2010) includes collaboration with knowledge users, ranging from identifying the research questions to disseminating the results.

Identifying the research questions

The research team identified three research questions: (1) “What are promising community occupational therapy practices to foster older adults' social participation?”, (2) “What are current community occupational therapy practices with older adults?”, and (3) “Which factors affect social participation interventions?”.

Identifying relevant studies and selecting the studies

Following PRISMA reporting guidelines (Moher et al., 2009) and using 49 keywords, the first author (PLT) searched eight databases (Table 1). Databases and keywords were selected with research team members (ML and AC), respectively experts in older adults' social participation and community occupational therapy, and validated by an information scientist. Extended search strategies included other studies found by a manual search of reference lists and well-known occupational therapy journals, as well as relevant studies proposed by the team members (Figure 1).

Table 1.

Databases searched and keywords used.

	Health-related and management fields
Databases (n = 8)	Health sciences (n = 6): Medline, Cochrane Database of Systematic Reviews, OTDBASE, CINAHL, Scopus, Academic Search Complete Management (n = 2): HealthStar, Business Search Complete
Keywords (n = 49)	1. Health promotion OR prevention OR preventive OR health education OR health literacy OR activity promotion OR health* lifestyle* OR activity participat* OR Community participation OR social participation OR social involvement OR social engagement OR community involvement OR community engagement OR civic participation OR social isolation OR social integration OR social contact* OR social activity* OR social inclusion* OR social interaction* OR solitude OR loneliness OR lonely OR social exclusion* OR leisure AND 2. Occupational therap* OR (rehabilitation AND occupation) AND 3. Community dwelling OR community living OR community health services OR community based OR home care OR homecare AND 4. Elder OR seniors OR old* adult* OR geriatric OR aging OR old* people OR aged OR ageing

Health-related and management fields

Databases (n = 8)

Health sciences (n = 6): Medline, Cochrane Database of Systematic Reviews, OTDBASE, CINAHL, Scopus, Academic Search Complete Management (n = 2): HealthStar, Business Search Complete

Keywords (n = 49)

1. Health promotion OR prevention OR preventive OR health education OR health literacy OR activity promotion OR health* lifestyle* OR activity participat* OR Community participation OR social participation OR social involvement OR social engagement OR community involvement OR community engagement OR civic participation OR social isolation OR social integration OR social contact* OR social activity* OR social inclusion* OR social interaction* OR solitude OR loneliness OR lonely OR social exclusion* OR leisure AND 2. Occupational therap* OR (rehabilitation AND occupation*) AND 3. Community dwelling OR community living OR community health services OR community based OR home care OR homecare AND 4. Elder* OR seniors OR old* adult* OR geriatric OR aging OR old* people OR aged OR ageing

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart of the scoping review process (Moher et al., 2009).

Team meetings were held at the beginning, midpoint and final stages of reviewing the abstracts and full texts to discuss challenges and uncertainties related to the search process. The search strategy was refined if needed. Inclusion and exclusion criteria were discussed at an initial team meeting. Two of the team members (PLT and VR), supervised by the other two (ML and AC), independently screened relevant articles by title and, when available, by abstract. All studies written in French or English that were published between January 1995 and May 2017 and that provided information concerning promising and current community occupational therapy interventions fostering older adults' social participation were retained. The PICO framework (population, intervention, comparisons, outcomes) was used to establish the research purpose, generate eligibility criteria and ensure transparency and reproducibility of the process (Levac et al., 2010). Based on these criteria, two reviewers (PLT and VR) assessed full-text articles. The eligible population consisted of papers on community-dwelling older adults, though not exclusively (i.e. retained if also included older adults). Promising and current practices were included if they described components or characteristics of occupational therapy interventions supporting or promoting the social participation of community-dwelling older adults. All types of qualitative and quantitative designs that verified or described impacts of promising and current practices were considered eligible; the evaluation method was not an inclusion criterion but was considered for analysis. Studies were excluded if they: (1) did not describe occupational therapy in sufficient detail or focused on narrower practices (e.g. only on fall prevention, functional autonomy, mobility at home, gait or physical functions), (2) involved the validation of a measurement instrument and (3) reported expert opinions or conference proceedings (often not providing enough detail).

Charting the data, collating, summarising, reporting, consulting and disseminating results

To extract relevant data from each study and classify the results, a chart was developed according to the definitions of the HDM-DCP (Fougeyrollas, 2010). The first author followed content analysis procedures to identify and synthesise categories by meaning and then classify them into coherent themes. Descriptive statistics (median [Md], interquartile range [IR], mean and standard deviation [SD] for continuous variables, and frequency and percentage for categorical variables) were also used to point to the recurrence and importance of each theme. As such, quantitative themes were indicative only of their magnitude in each domain of the HDM-DCP. After reviewing the completed data extraction tables, the research team discussed and resolved any inconsistencies. Finally, 28 knowledge users, majority female, between 27 and 80 years of age and with different backgrounds (see Appendix), were consulted to discuss and disseminate the preliminary results, identify their implications and ensure their clinical relevance. These stakeholders were purposely and conveniently recruited for their respective viewpoints in a local community health setting in Montréal, Canada. From April to October 2016, the first author conducted four focus groups, one with each group (i.e. five occupational therapists, five older adults, seven community lay workers and four caregivers), followed by seven individual interviews with decision-makers as well as professional and public health representatives. Other ideas and reflections on ways to translate these findings into practice were recorded and content analysed. Through an iterative process and constant comparison with the review findings, the combination of focus groups and individual interviews provided a more in-depth understanding of the data with each type of knowledge user and helped assess gaps in the evidence. The Research Ethics Committee of the Montreal East Island Integrated University Health and Social Services Centre approved this portion of the study.

Results

Of the 1921 papers retrieved through the database searches, 441 were not eligible, based on title and abstract, and 95 were excluded after reading their full texts (Figure 1). Thirty-five met the inclusion criteria, and seven were added via extended search strategies, resulting in a total of 32 studies covered in 42 papers.

Description of selected studies

Published between 1997 and 2016 (Table 2), half of the papers (n = 22; 52%) appeared after 2009, with the most productive years being 2016, 2015, 2014 and 2007 (n = 5, n = 4, n = 4 and n = 4, respectively). Some studies predominantly concerned only older adults (n = 16; 50%), while others also included adults. Studies were mainly conducted in the USA (n = 8; 25%), Canada (n = 6; 19%), Sweden (n = 6; 19%) and Australia (n = 4; 13%; Table 2). Promising practices (n = 20; 61%) were primarily studied using randomised controlled trial (n = 9; 47%) or quasi-experimental (n = 7; 37%) designs, while studies about current practices (n = 13; 39%) were mainly descriptive (n = 11; 85%).

Table 2.

Description of selected studies.

(A) Promising practices of community occupational therapists in social participation (n = 20)
Reference number First author (year) Country	Population/ Sample, Mean age	Design (Study objective)	Setting/ Length/components	Impacts
Name of the intervention
Combined group and individual interventions (n = 11)
1. Clark et al. (2001; 1997) Hay et al. (2002) Jackson et al. (1998) USA Lifestyle Redesign®	Healthy older adults with socioculturally diverse origins, N = 361, 74.4 (67–81.8) years	RCT (three groups): N = 361 Group 1: occupational therapy intervention; Group 2: social activities; Group 3: control (no treatment)	Community/ Nine months, weekly 2-hour group sessions and 9 hours of individual sessions led by two community occupational therapists with up to 10 older adults Methods included didactic presentations, peer exchange, and direct experiences and personal exploration Teaching on importance of the impact of everyday activities on health, time use and energy conservation, transportation utilisation, personal safety at home, community safety, finances, social relationships, cultural awareness, goal-setting, changing routines and habits	↑ quality of social interactions (p < 0.05); ↑ satisfaction with life (p < 0.05); ↑ self-rated health (p = 0.05); ↑ bodily pain (p < 0.05); ↑ physical function (p < 0.01); ↑ activity limitations due to health problems (p < 0.05); ↑ vitality (p < 0.005); ↑ social functioning (p = 0.05); ↑ activity limitations due to emotional problems (p = 0.05); ↑ global mental health (p < 0.05); ↑ maintained over time for quality of social interaction, physical function, role functioning, vitality, social functioning, role emotional and general mental health (p > 0.05) ↑ 4.5% QALY increment (p < 0.001); ↑ costs per QALY (95% CI: US$6747–25,430)
		Economic evaluation (three groups) N = 163 (To evaluate the effectiveness of preventive occupational therapy specifically tailored for multi-ethnic independent-living older adults)
2. Clark et al. (2012) Jackson et al. (2009) Leland et al. (2016) USA Lifestyle Redesign®	Healthy older adults with socioculturally diverse origins, N = 460, 75 (67.2–82.6) years	RCT (two groups): N = 460 Group 1: occupational therapy intervention; Group 2: control (no treatment)	Community/ Six months, weekly 2-hour group sessions and 10 hours of individual sessions led by a community occupational therapist with 8–10 older adults Methods included didactic presentations, peer exchange, and direct experiences and personal exploration Teaching on importance of the impact of everyday activities on health, time use and energy conservation, transportation utilisation, personal safety at home, community safety, finances, social relationships, cultural awareness, goal-setting, changing routines and habits	↓ bodily pain (p < 0.05); ↑ vitality (p < 0.05); ↑ social functioning (p = 0.05); ↑ mental health (p < 0.05); ↑ satisfaction with life (p < 0.05); ↓ depressive symptoms (p < 0.05); ↑ physical well-being (p < 0.05); ↑ night-time sleep (p < 0.05); ↑ 3.8% QALY increment (p < 0.05); ↓ cost per QALY ($US41,218 per unit); No effects found for cognitive functioning
		Economic evaluation (two groups) N = 137 (To evaluate the Lifestyle Redesign® intervention's effectiveness among ethnically diverse elders in community-based settings)
3. Dawson et al. (2014) Canada	Older adults with light cognitive and functional disabilities; N = 19, 66–82 years	Quasi-experimental (two groups)/(To evaluate feasibility and effectiveness of an intervention to maintain executive functions of healthy older adults)	Community (home)/ Eight weeks, 8 hours of group sessions and 9 hours of individual training by a community occupational therapist; Teaching of self-management of symptoms, healthy ageing and occupation-based metacognition techniques	↑ daily functioning (p < 0.05); ↑ participation in physical activities (p < 0.05); ↑ preparation to appointments (p < 0.05); No effect found on executive functions
4. Di Stefano et al. (2009) Australia	Older adults with or without disabilities; N = 137, 51 years+	Quasi-experimental (one group)/(To develop, try out and evaluate a health promotion programme focusing on safe driving of older adults)	Community/ Eight weeks, 45-minute face-to-face delivery plus audience general questions, further 30 minutes post programme allowed for individual questions, delivery aiming to engage participants in active learning, for example inclusion of a quiz, a problem-solving exercise, case scenarios, use of visual aids depicting road/pedestrian scenarios; Teaching on safe mobility, influence of heath and ageing on mobility independence and means of transportation and resources; Topics: common health conditions and their impact on community mobility; road safety issues pertaining to pedestrians, cyclists, use of public transit and motorised scooters; role of occupational therapists in supporting; options for different types of driver assessment and vehicle modifications; resources/organisations available	↑ awareness of risks related to driving and importance of self-declaration (p < 0.05); ↑ knowledge of other means of transportation (p < 0.05); ↑ literacy regarding occupational therapists' role (p < 0.05)
5. Dugow et al. (2012) Germany Independent living programme	Older adults with chronic conditions, N = 10, 70 years+	Quasi-experimental (one group; pretest–post-test); (To examine effects of a programme on self-perception and satisfaction with participation in daily occupations)	Community/ Eight weeks, eight weekly group (presentations, group discussions, written information and demonstrations) and six individual sessions (provision of aids and appliances, energy conservation strategies addressing occupational performance difficulties); Education to maintain self-confidence, motivation and motor abilities; based on the Stanford model of Chronic-Disease Self-Management; Topics: ageing, health and occupation, exercise and ageing, healthy eating, medication management, social entitlements, falls management, personal safety at home, and social participation	↑ global participation in activities (p < 0.05); ↑ self-rated occupational performance (p < 0.001); ↑ satisfaction with participation in activities (p < 0.001); ↑ motor abilities (p < 0.001) ↑ motivation to engage in activities (p < 0.05)
6. Garvey et al. (2015) Ireland OPTIMAL programme	Older adults living with multiple chronic conditions N = 50 65 (50–80) years	Pragmatic feasibility RCT/ (To investigate the effectiveness of an occupational therapy self-management programme to address the challenge of living with multiple chronic conditions)	Community/ Six weeks, weekly 3-hour group sessions led by a community occupational therapist with 10–12 patients, individual goal-setting discussed and revised at each session; Teaching regarding fatigue management; healthy eating; maintaining physical activity (by a physiotherapist); maintaining mental health; managing medications (by a pharmacist) and communicating effectively with health professionals	↑ overall frequency of activity participation (p < 0.01); ↑ occupational performance (p < 0.05); ↑ satisfaction with occupational performance (p < 0.05); ↑ chronic disease self-efficacy (p < 0.05); ↓ disability (p < 0.05); ↑ positive and active engagement in life (p < 0.05)
7. Johansson and Björklund (2016)^a Sweden	Community-dwelling older adults with chronic conditions and disabilities and not receiving home care N = 40 82 (72–91) years	Mixed quasi-experimental design/(To evaluate effectiveness of a four-month occupation based health-promoting programme for improving older adults' health and well-being)	Community/ Four months, weekly 2-hour group sessions with a maximum of four individual home interventions; Educate about and discuss themes such as: occupation, health, and ageing; occupation, time, and energy; occupation and mobility; eating as an occupation; physical activity as an occupation; occupation and mental well-being; occupation and security at home and in the society; occupation and relationships; occupation and economy; and occupation and technical devices	↑ vitality (p = 0.01); ↑ mental health (p < 0.05); ↑ sense of belonging to a group; ↑ self-esteem; ↑ change in occupational behaviours*
8. Larsson et al. (2016) Sweden	Older adults vulnerable to loneliness, N = 30 71.2 (61–89) years	Explorative randomised cross-over design (AB/BA)/(To evaluate the effects of a social Internet-based intervention [SIBAs])	Community/ Three months, between two to five weekly 1.5-hour group sessions with six to eight participants and 1–16 1.5-hour individual home interventions; Establish collaborative relationship and support goal establishment; provide education on how to use chosen SIBAs; inform about blogs, debates, forums and different communities; adapt the working environment (keyboard, seating position, lighting); provide education on how to connect web camera and headphones; support the progress of the individuals' goal achievement; evaluate the participants' progress; re-establish new goals	↓ loneliness (p < 0.001); ↑ satisfaction with social contacts online (p < 0.001); ↑ satisfaction with social contacts offline (p < 0.001); ↑ quality of social interactions (p < 0.05)
9. Mountain et al. (2008)^a UK Lifestyle Matters	Older adults with and without disabilities, N = 28, 78.5 (60–92) years	Quasi-experimental (one group)/(To evaluate feasibility of a health promotion lifestyle intervention with older adults)	Community/ Eight months, weekly group sessions led by two community occupational therapists and two-hour individual session every two months; Topics include: ‘beginnings’, ‘activity and health’, ‘maintaining physical and mental well-being’, ‘activities in the home and community’, ‘safety in and around the home’, ‘managing personal circumstances’, ‘endings’, ‘sleep as an activity’, ‘keeping mentally active’ and ‘memory’	↑ quality of life; ↑ self-efficacy; ↑ general well-being; ↑ participation in meaningful social activities
10. Mulry and Piersol (2014)^a USA Let's Go	Healthy older adults N = 7 62–75 years	Mixed quasi-experimental design (pre–post-test)/(To evaluate feasibility of delivering a community mobility programme in collaboration with the county office on ageing and examine the effects on participation)	Community/ Four weeks, 45-minute weekly group sessions (didactic presentations, peer exchange, direct experience, personal reflection and exploration of alternative transportation options, as well as experiential learning interventions) with four individual follow-up sessions; Topics included educating about the importance of community mobility, its relationship to health and well-being, and awareness of alternative community mobility options, safety, proper mobility aide use, accessing public transit with mobility aides	↑ mobility outdoors (100%); improvements maintained over time (86%); ↑ participation in social activities (86%); improvements maintained over time (100%); ↑ confidence in mobility (71%); ↑ participation in valued community activities (86%); ↑ knowledge of transportation alternatives (100%); ↑ health literacy regarding community mobility (43%)
11. Murphy et al. (2008) USA Activity strategy training	Older adults with chronic pain at lower-limb (arthrosis) N = 54, 75.3 (68–82) years	RCT/(To compare effectiveness of an occupational therapy programme to a health education programme)	Community/ Four weeks, eight biweekly 1.5-hour group sessions led by two community occupational therapists, one home-based individual sessions; two follow-up groups after six months; Group sessions involved education, group discussion and demonstration and practice of techniques to facilitate activity participation; Teaching of chronic pain and symptoms self-management strategies, such as activity pacing, joint protection, body mechanics, and transfer techniques	↑ participation in physical activities (p < 0.05); ↑ reduction of pain; ↑ physical function; No effect on self-efficacy
Group interventions (n = 5)
12. Ciro and Smith (2015)^a USA	Socially marginalised older adults N = 16 62.5 (57–68) years	Mixed method: Phase 1 (QUAL) informed the development of Phase 2 (QUAN)/(To understand how older adults characterise meaningful activity and if short-term intervention could help them overcome barriers to activity engagement)	Community/ Seven weeks, seven 1-hour group sessions led by a community occupational therapist; Educate on definition and power of meaningful activities to influence health, exploration of activities that promote health and identification of solutions to overcome barriers to participation	↑ health literacy regarding the link between meaningful activities and health (p < 0.01); ↑ satisfaction with activities (p < 0.01); ↑ changes in overall activities (p < 0.01)
13. Eklund et al. (2008) Sweden	Older adults having visual impairment N = 229, 78 (66–91) years	RCT/(To compare an activity-based, health-promotion programme with an individual programme, for older adults with visual impairment concerning the effect on the development of dependence in ADL, general health, and self-reported health problems)	Community/ Eight weeks, 20 weekly 2-hour group sessions led by a community occupational therapist with four to six older adults; Providing information and teaching skills based on occupational themes: self-care, meals, communication, orientation and mobility, food preparation, shopping, financial management and cleaning	↑ participation and independence in activities (p < 0.05); ↓ health problems (p < 0.05)
14. Matuska et al. (2003)^a USA Designing a Life of Wellness	Older adults without disabilities N = 65, 85.2 (70–92) years	Quasi-experimental (one group; test–retest)	Community/ Six months, weekly 1.5-hour group sessions led by two community occupational therapists; Teaching on importance of participation in meaningful occupations for better quality of life and strategies to remove personal and environmental barriers that prevent participation; Topics included transportation, ageing, safety and fall prevention, stress, lifestyle balance and communication, and how these issues affected participation in meaningful occupations	↑ vitality (p < 0.05); ↑ social functioning (p < 0.01); ↑ mental health (p < 0.05); ↑ socialisation and participation*
15. O'Toole et al. (2013) Ireland	Adults having multiple chronic diseases N = 16, 66.5 (47–79) years	Pilot study (non-specified design; one group)/(To assess the potential effect of an occupation-based symptom-management program for adults having multiple chronic diseases)	Community/ Six weeks, weekly group sessions led by a community occupational therapist with individual goal-setting and informational booklet; Topics included activity and health, fatigue management, mental well-being, physical activity, medication management and communication with health professionals	↑ frequency of social participation (p < 0.01); including instrumental activities (p < 0.05), leisure/productivity (p < 0.05); ↑ self-rated participation (p < 0.05), satisfaction with participation (p < 0.05) Improvements maintained over time in all variables (p < 0.05)
16. Zingmark et al. (2014; 2016)^b Sweden	Older adults living alone and not receiving home help N = 177 77–82 years	Exploratory RCT/(To evaluate effectiveness and compare cost-effectiveness of three occupational therapy with older adults living at home) (1) Individual group (IG); (2) Activity group (AG); (3) Discussion group (DG); (4) Control group (no intervention)	Community/ AG: eight weekly 1.5-hour group sessions, occupation-focused homework with an activity diary, and activity engagement with five to eight participants; DG: one 2-hour group session with seven to nine participants; Inform about aspect of healthy ageing, such as physical activities, social activities, eating habits and meaningful activities	↑ leisure engagement for DG participants after three months (d = 0.27); ↑ participation in activities for DG participants after 3 (d = 0.31) and 12 months (d = 0.30); ↑ participation in activities for AG participants after 12 months (d = 0.38); ↑ general health for AG and DG participants after three months (p < 0.05); ↑ QALY for AG and DG participants after three months (p < 0.05); ↓ health-care costs for DG participants after 3 and 12 months (p < 0.05); ↓ total costs for DG participants after 3 and 12 months (p < 0.05)
Individual interventions (n = 4)
17. Graff et al. (2006; 2007; 2008) New-Zealand	Older adults with dementia and their caregivers; N = 135, 73–85 years	RCT (two groups)/(To evaluate effectiveness and cost-effectiveness of community occupational therapist intervention with older adults having with dementia and caregivers)	Community/ Five weeks, 10 individual sessions; Teaching of compensatory strategies to adapt activities and home environment; Client-centred and meaningful activities practice	↑ quality of life in dementia (p < 0.001); ↑ global health (p < 0.001); ↓ depressive symptoms in dementia (p < 0.001); ↑ daily functioning and participation in activities (p < 0.001); Improvements maintained over 12 weeks (p < 0.05); ↓ health-care costs (€1748)
18. Logan et al. (2004) UK	Community -dwelling adults who survived a stroke; N = 168, 66–82 years	RCT (two groups)/(To evaluate effectiveness of a community occupational therapist teaching intervention related to mobility, daily participation and well-being)	Community/ Ten months; four individual sessions, total of 230 minutes, brief individual interventions; Teaching, adaptation and orientation in resources and transport services	↑ capacity to participate in outdoor activities as often as wanted at four months (RR = 1.72) and 10 months (RR = 1.74); ↑ amount of outdoor activities at four months (p < 0.01) and 10 months (p < 0.01); ↑ mobility in daily activities, but not statistically significant and no difference at 10 months
19. Walker et al. (2004) Multiple	Adults who survived a stroke; N = 1143, 61–82 years	Meta-analysis of eight RCT held between 1990 and 2001/(To evaluate effectiveness of community occupational therapy interventions with stroke survivors)	Community/ Between five sessions and 6 months, individual sessions; Teaching and adaptations to facilitate participation in daily and leisure activities	↑ quality of life (OR = 1.10; 95% CI: 0.74–1.63); ↓ functional limitations; OR = 0.71 (95% CI: 0.52–0.98); ↑ participation in activities (95% CI: 0.47–2.13); ↑ participation in leisure activities (95% CI: 0.24–2.79)
20. Zingmark et al. (2014)^b Sweden	Older adults living alone and not receiving home help N = 177 77–82 years	Exploratory RCT/(To evaluate effectiveness and compare cost-effectiveness of three occupational therapy interventions with older adults living at home) (1) Individual group (IG); (2) Activity group (AG); (3) Discussion group (DG); (4) Control group (no intervention)	Community/ IG: three to eight individual contacts (telephone, home visits) over a 10-week period; Inform about aspects of healthy ageing, such as physical activities, social activities, eating habits and meaningful activities	↑ leisure engagement for IG participants after 12 months (d = 0.41); ↑ participation in activities for IG participants after 3 (d = 0.29) and 12 months (d = 0.30)

(B) Current practices of community occupational therapists in social participation ( n = 13)
Reference number First author (year) Country	Design	Findings	Discussion
I. Carrier et al. (2015; 2016) Canada	Qualitative (institutional ethnography) among 10 community occupational therapist and secondary key informants (clinicians and managers) about the influence of institutional and systemic environment on community occupational therapists' clinical reasoning	Documents used of referral prioritisation and internal politics contribute to restrict community occupational therapists' interventions to security and functional independence in personal care rather than social participation; Constant concern with productivity and cognitive burden; Limited time with each client and limited follow-ups; Performance indicators and work measures generate deviant clinical behaviours and affect assessments and interventions	Standardised documents can limit client-centred practice and community occupational therapists' values; The restricted current community occupational therapist practice compromises holistic occupational therapy; Organisational factors might compromise health promotion and prevention interventions
II. Craig et al. (2012) USA	Scoping review of home health occupational therapy studies	Not consistent with research; 30% environment adaptations; 23% occupational performance; 12% remediate body structure/ functions; Lack of meaningful activities in practice; Most interventions were exercises and not focused on occupations	Systemic factors limit the proper utilisation and the practice of occupational therapy in home health
III. Filiatrault and Richard (2005) Canada	Theoretical study on health behaviour change theories in health promotion and prevention used by community occupational therapists and clinical examples of current practices	Example of recommendations: home modifications to prevent falls, strategies to reduce caregiver burden, techniques to improve functional independence and prevent accidents, energy conservation principles, exercise programme for long-term diseases; Individual health behaviour theories: health belief model, social cognitive theory, theory of reasoned action, theory of planned behaviour	Community occupational therapists should maximise the effectiveness of their practice by using health-behaviour change theories to promote social participation; Environmental actions (organisation, community, politics) should be prioritised over individual approaches
IV. Furåker et al. (2011) Sweden	Qualitative (journal) with 24 community occupational therapists having a municipal consultant role	Consultant role: discussion, negotiation, information, instruction; Education on transfer techniques and recommendations for home modifications; Time lacking for prevention	Support from system and healthcare managers is needed to allow community occupational therapists to assume their community rehabilitation role
V. Hébert (2001); Hébert et al. (2002) Canada	Survey (quantitative) among 249 community occupational therapists to document their current practice	Important amount of time dedicated to writing clinical notes, then direct interventions with clients; Majority offer interventions focused on independence and home safety; Minority intervene to promote engagement in meaningful activities, new interests and adaptation of activities; Emergency practice to respond to organisational pressure; Practice centred on clients' disabilities and impairments	Occupational therapy theories are rarely integrated to community occupational therapist practice; Loss of holism; Weak consideration for clients' aspirations for optimal quality of life; Restriction to daily activities required to stay at home; Stronger professional identity needed to respond to organisational pressures
VI. Holmberg and Ringsberg (2014) Norway	Qualitative (five focus groups) with 24 community occupational therapists to explore their self-confidence with health promotion	Role models missing in health promotion; Professionals not recognising their own knowledge of health promotion; Health promotion provided only from an individual perspective rather than systemic and societal	Occupational therapists could have a significant contribution to systemic and societal health promotion; Role models must affirm themselves in this field
VII. Lilja et al. (2001) Sweden	Survey on community occupational therapists' current practice (n = 89) with older adults	Provide aids and equipment; Large amount of administrative work, such as documentation, reports, prescriptions and certifications; Limited environmental interventions to promote participation from a societal perspective; Mostly minor home modifications; Improve capacity to realise leisure activities and physical function (treatment); Prevention and evaluation mostly related to personal care; Information, consultation, supervision	Interventions need to develop around community integration from a societal and environmental perspective
VIII. Mitchell and Unsworth (2004) Australia	Survey of 36 community occupational therapists about their current practice	Home visits (100%); Health education (94%); Service promotion (93%); Groupwork (83%); Community development (77%); Physical rehabilitation (50%); Enablers: Diversity of practice and settings, relationships with other agencies, autonomy and responsibilities; Obstacles: funding issues, caseload/staffing levels, pressure and time spent on non-occupational therapy administrative work	Diverse roles and experiences in this field; Limited confidence with administrative tasks but good confidence with client-centred practice; Need to develop follow-up interventions and knowledge regarding possible interventions
IX. Quick et al. (2010) Australia	Survey of 205 community occupational therapists about their current practice	Diversity of clinical and non-clinical tasks; Rare involvement in health promotion, although recognising its importance; Knowledge missing and other clinical tasks being more prioritised than health promotion; Health promotion included education regarding safe environments to prevent unintentional injury in the elderly population and promotion of physical activity; Obstacles: high demand for service, limited funding and time spent on administrative tasks	Important experiences of occupational therapists; Dissatisfaction with service requests, administrative tasks and lack of funding
X. Ramsey (2007) USA	Qualitative observations and interviews with 10 community occupational therapists about their clinical reasoning during home visits	Themes: engagement for holistic community practice; use of diverse and creative clinical skills; client-centred practice; Environmental context of practice; professional identity of occupational therapist; Vocational interventions, including work and community participation; Restricted client-centred practice although valued; Flexibility and adaptability to diverse contexts; Benefits of continued education and professional support	Community practice occurs in different ways according to the setting; Occupational therapists should be involved in community development initiatives
XI. Trentham et al. (2007) Canada	Case study, three community occupational therapists (n = 3) involved in community development initiatives	Few cases of occupational therapists involved in community development; Three approaches: locality development (e.g. neighbourhood safety); social planning (e.g. top-down process such as large-scale population campaigns); and social action (e.g. bottom-up problem resolutions directed at changing power structures); Community vision of occupations; systemic barriers to participation; sustainability of community development projects; balance between individual and population priorities; Resilience of communities as important aspect of practice; Community action programs: age-friendly cities and social isolation reduction; Tension between social action and locality development	Community development practices are health promoting in themselves, as they promote active participation of population; Integrating an occupational perspective to community development is essential
XII. Turcotte et al. (2015) Canada	Secondary analyses of a grounded theory study with 11 community occupational therapists involving 12 observations and 12 interviews	Interventions mainly target personal care and mobility; Limited health promotion interventions (empowerment, client-centred practice, health literacy); Meaningful activities not targeted; Misunderstanding of occupational therapy, older adults' complex needs and restricted time for prevention	Social participation practices not intentionally integrated
XIII. Wood et al. (2013) Australia	Qualitative (narrative) among five occupational therapists in primary health promotion	Obstacles to health promotion include lack of financing, misunderstanding of occupational therapists' role; Facilitators include continued formation, professional identity and experience; Mainly individual services although some provided group interventions fostering social participation and community development	Primary health promotion rarely undertaken; Health promotion often seen as a role apart of traditional occupational therapy

USA: United States of America; UK: United Kingdom; RCT: Randomised Controlled Trial; COT: Community Occupational Therapist; a: Based on Lifestyle Redesign® b: Two types of interventions described in the same study.

Promising practices in social participation

Twenty practices covered in 27 articles identified possible ways to promote older adults' social participation in community occupational therapy (Table 3). Most involved disadvantaged older adults (n = 12; 60%), that is, persons with chronic conditions (n = 10; 50%) and cognitive impairments (n = 2; 10%). The rest were conducted with healthy older adults (n = 8; 40%), including socially isolated (n = 3; 15%), ethnic minorities (n = 1; 5%) and low income (n = 1; 5%) populations (Table 2).

Table 3.

Synthesis of scoping review about promising and current practices fostering older adults' social participation.

(A) Type of interventions, components and impacts of promising practices (n = 20)
Type of interventions	Source [reference number in Table 2]^a	n (%)	Length (weeks)		n (sessions)
Type of interventions	Source [reference number in Table 2]^a	n (%)	Md (IR)	Mean (SD)	Md (IR)	Mean (SD)
Group and individual sessions	[1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11]	11 (55)	8 (1.0)	15 (11.3)	G: 8 (2.5) I: 6 (2.0)	G: 15 (11.3) I: 7 (4.4)
Group sessions	[12, 13, 14, 15, 16]	5 (25)	7 (1.0)	9 (8.7)	G: 8 (2.0)	G: 9 (8.7)
Individual sessions	[17, 18, 19, 20]	4 (20)	17 (8.3)	20 (17.5)	I: 9 (2.0)	I: 12 (8.7)

	Source [reference number in Table 2]^a	n (%)
Components
Social participation and activity (n = 14)
Relationship between meaningful activity and health	[1, 2, 5, 7, 8, 9, 10, 12, 15, 14, 16, 17, 19, 20]	14 (70)
Exercises, mobility and physical activity	[1, 2, 5, 6, 7, 10, 11, 15, 16, 20]	10 (50)
Lifestyle balance and energy conservation	[1, 2, 5, 6, 7, 9, 11, 14, 15]	9 (45)
Community mobility and driving options	[1, 2, 4, 7, 9, 10, 13, 14, 18]	9 (45)
Leisure and meaningful activities	[9, 10, 12, 14, 16, 17, 19, 20]	8 (40)
Communication (including with health professionals)	[1, 2, 6, 8, 13, 14, 15]	7 (35)
Ways to adapt activities	[1, 2, 5, 8, 11, 17]	6 (30)
Healthy eating	[5, 6, 7, 13, 16, 20]	6 (30)
Social relationships	[1, 2, 5, 7, 16]	5 (25)
Medication management	[5, 6, 13, 15]	4 (20)
Budgets and finances	[1, 2, 7, 8, 13]	4 (20)
Shopping	[13]	1 (5)
Home maintenance	[13]	1 (5)
Social Internet-based activities	[8]	1 (5)
Personal factors (n = 6)
Individual goal-setting	[1, 2, 5, 6, 8, 10, 20]	7 (35)
Self-management of symptoms	[3, 5, 9, 11, 12, 13]	6 (30)
Promotion of mental well-being	[6, 7, 9, 15]	4 (20)
Cognitive occupation-based strategies	[3]	1 (5)
Spirituality	[9]	1 (5)
Promotion of physical well-being	[9]	1 (5)
Environmental factors (n = 6)
Physical environment (home) and assistive devices	[1, 2, 5, 7, 8, 10, 17]	7 (35)
Safety at home and fall prevention	[1, 2, 7, 9, 14]	5 (25)
Safety outside and transportation alternatives	[1, 2, 4, 7, 10]	5 (25)
Social environment (caregivers)	[17]	1 (5)
Internet-based technologies	[8]	1 (5)
Role of occupational therapists	[4]	1 (5)
Impacts
Personal factors (n = 14)
↑ self-efficacy and self-esteem	[3, 6, 7, 9, 10, 15]	6 (30)
↑ well-being and self-rated health	[1, 2, 9, 13, 16, 17]	6 (30)
↑ quality of life	[1, 2, 9, 16, 17, 19]	6 (30)
↑ mental health and ↓ depressive symptoms	[1, 2, 7, 14, 17]	5 (25)
↓ physical disability	[1, 5, 6, 11, 19]	5 (25)
↑ vitality	[1, 2, 7, 14]	4 (20)
↓ bodily pain	[1, 2, 11]	3 (15)
↑ motivation to engage in activities	[5, 6]	2 (10)
↑ health literacy regarding link between activity and health	[12, 10]	2 (10)
↑ knowledge of other means of transportation	[4, 10]	2 (10)
↑ awareness of driving risks	[4]	1 (5)
↑ clients' literacy regarding occupational therapists' role	[4]	1 (5)
↓ loneliness	[8]	1 (5)
↑ sense of belonging	[7]	1 (5)
Social participation and activity (n = 10)
↑ participation in leisure and social activities	[1, 2, 3, 6, 7, 11, 12, 15, 16, 18, 19, 20]	13 (65)
↑ overall participation in activities	[3, 5, 6, 7, 12, 13, 16, 17, 19, 20]	10 (50)
↑ satisfaction with participation and life	[1, 2, 5, 6, 8, 12, 15]	7 (35)
↑ social interactions	[1, 7, 8, 9, 14, 15]	6 (30)
Maintain improvements in social participation over time	[1, 10, 17, 18]	4 (20)
↑ social functioning	[1, 2, 14]	3 (15)
↑ social interactions online	[8]	1 (5)
↑ preparation for appointments	[3]	1 (5)
↑ outdoor mobility	[10]	1 (5)
↑ night-time sleep	[2]	1 (5)
Environmental factors (n = 2)
↓ healthcare costs	[1, 2, 16, 17]	4 (20)
↓ total costs (including municipality and health costs)	[16]	1 (5)

(B) Characteristics, barriers and enablers of current practices (n = 13)	Source [reference number in Table 2]^a	n (%)
Characteristics of practice (n = 11)
Making home visits	[I, III, IV, V, VII, VIII, IX, X, XII, XIII]	10 (77)
Not targeting social participation	[I, II, III, V, VII, IX, XI, XII, XIII]	9 (69)
Supervising and providing equipment and aids	[I, II, III, IV, VII, XII]	6 (46)
Being centred around safety and independence	[I, III, IV, V, VII, XII]	6 (46)
Acting as a consultant	[III, IV, VII, VIII, XII]	5 (38)
Doing administrative tasks	[V, VII, VIII, IX, X]	5 (38)
Providing health education related to occupations	[III, VII, VIII, IX, XII]	5 (38)
Prioritising individual over population interventions	[VI, VII, IX, XI, XIII]	5 (38)
Supporting community development and group work	[VIII, IX, XI, XIII]	4 (31)
Having a restricted client-centred practice	[I, V, X, XII]	4 (31)
Having a short-term practice	[V, XII]	2 (15)
Barriers (n = 8)
Organisational pressure and limited time for prevention	[I, III, IV, V, VIII, XII, XIII]	7 (54)
Health policies, institutional culture and procedures	[I, V, VII, VIII, IX, XIII]	6 (46)
Misunderstanding of occupational therapists' role	[VI, IX, X, XII, XIII]	5 (38)
Lack of role models	[VI, IX, X, XI, XIII]	5 (38)
Lack of funding	[VIII, IX, X, XI, XIII]	5 (38)
Increasing needs of older adults and waiting lists	[V, VIII, IX, X, XII]	5 (38)
Professional isolation	[VIII, IX, X, XIII]	4 (31)
Dominant biomedical model	[I, II, IX, V]	4 (31)
Enablers (n = 8)
Systemic vision of community practice and partnerships	[III, VIII, X, XI, XIII]	5 (38)
Strong professional identity	[V, X, XIII]	3 (23)
Creativity and diverse clinical experiences	[V, X, XIII]	3 (23)
Continued training and education	[III, X, XIII]	3 (23)
Professional autonomy and level of responsibilities	[VIII, X]	2 (15)
Peer support and mentoring	[X, XIII]	2 (15)
Use of health behaviour change theories	[III]	1 (8)
Mixed roles (clinical and population practice)	[XIII]	1 (8)

References of studies are found in Table 2; data are presented in order of prevalence.

G: group sessions; I: individual sessions; Md: median; IR: interquartile range; SD: standard deviation.

Types of interventions

Promising practices combined both group and individual interventions (n = 11; 55%), and some involved either group (n = 5; 25%) or individual (n = 4; 20%) interventions (Table 3). Eleven practices combined group and individual sessions. The group component generally involved 45-minute to 3-hour sessions facilitated by two (n = 6; 55%) or one (n = 5; 45%) occupational therapists with 6–16 older adults (Table 3). Given every week or every second week, group sessions ranged over a period of 4–36 weeks. They consisted of didactic presentations, peer exchanges, direct experiences or demonstrations, personal exploration and written information. In the individual component, 1–16 additional meetings were held in the home or community to set personalised goals, provide assistive devices, teach energy conservation strategies and address participation difficulties (Table 3). Five other studies used group interventions led by one (n = 4; 80%) or two (n = 1; 20%) occupational therapists with four to eight participants. The interventions ranged from one 2-hour session to weekly sessions over a 6-month period, included didactic presentations, peer exchanges and direct experiences, and centred on ways to promote engagement in meaningful activities (Table 3). Four studies focused on individual interventions, consisting of one-to-one home-based sessions aimed at teaching compensatory strategies and adaptations to facilitate participation in meaningful activities. Ranging from 3 to 40 meetings (Table 3), individual sessions targeted social (caregivers' support) and physical (home modifications, transportation and public transit use) environments, in addition to personalised occupation-based goal-setting.

Components and impacts of promising social participation practices

Components of promising practices mainly involved ‘social participation and activity’, while impacts were mostly found on ‘personal factors’ and rarely on ‘environmental factors’ (Table 3). Regarding ‘social participation and activity’, most components of promising practices involved education about the positive relationship between meaningful activity and health (n = 14; 70%). Other components incorporated aspects such as exercises, mobility and physical activity (n = 10; 50%), promoting lifestyle balance and energy conservation (n = 9; 45%), as well as community mobility and driving options (n = 9; 45%; Table 3). Practices also aimed to support participation in leisure and meaningful activities (n = 8; 40%) and improve communication skills, including with health professionals (n = 7; 35%). Only five practices directly discussed social relationships (n = 5; 25%), and one addressed social Internet-based activities (n = 1; 5%). Regarding their impacts (Table 3), most promising practices enhanced participation in leisure and social activities (n = 13; 65%) and overall participation in activities (n = 10; 50%). Other practices showed positive effects on satisfaction with participation and life (n = 7; 35%), social interactions (n = 6; 30%) and social functioning (n = 3; 15%), while only one study fostered outdoor mobility (n = 1; 5%) and night-time sleep (n = 1; 5%).

Among the components related to ‘personal factors’ (Table 3), promising practices focused especially on self-management of symptoms (n = 6; 30%), including fostering individual goal-setting (n = 7; 35%) and promoting mental well-being (n = 4; 20%). Other aspects such as spirituality (n = 1; 5%) and promoting physical well-being (n = 1; 5%) were rarely targeted by promising practices. Most impacts of promising practices were related to ‘personal factors’ (Table 3) and included improving self-efficacy and self-esteem (n = 6; 30%), well-being and self-rated health (n = 6; 30%), quality of life (n = 6; 30%) and mental health (n = 5; 25%). Two studies showed that promising practices were effective in increasing literacy about the link between activity and health (n = 2; 10%), while only one reduced loneliness (n = 1; 5%) and increased the sense of belonging (n = 1; 5%).

For ‘environmental factors’ (Table 3), promising practices acted on components that optimised the physical environment (home) and assistive devices (n = 7; 35%), ensured safety at home and fall prevention (n = 5; 25%) or safety outside, and transportation alternatives (n = 5; 25%). Only a few aimed to educate the social environment (n = 1; 5%), which mostly involved family caregivers. Other actions on the social environment, for example to educate about the role of occupational therapists (n = 1; 5%), were rare (Table 3), and none were found that aimed to change attitudes towards people with disabilities or older adults. Regarding the impacts of promising practices on ‘environmental factors’ (Table 3), reducing health-care costs was found in four studies (n = 4; 21%). This cost-effectiveness was demonstrated for combined group and individual interventions (Clark et al., 2012; Hay et al., 2002), group sessions (Zingmark et al., 2016) and individual sessions (Graff et al., 2008). Only one study assessed total costs by considering health-care and municipal costs (n = 1; 5%; Table 3).

Current practices in social participation

Thirteen studies covered in 15 papers described community occupational therapists' current practices that included a social participation perspective (Table 3). Current practices involved making individual home visits (n = 10; 77%), most of which did not target social participation (n = 9; 69%), such as meaningful activities and community integration. Other current interventions related to social participation consisted of supervising and providing equipment and aids (n = 6; 46%), such as mobility scooters or simple home modifications (Table 3). Instead of promoting social participation, current interventions centred on home safety and independence in personal care and mobility (n = 6; 46%) and mainly involved acting as a consultant (n = 5; 38%), which consisted of doing administrative tasks (n = 5; 38%) and having a short-term practice (n = 2; 15%). Although these practices prioritised individual over population interventions (n = 5; 38%), a few occupational therapists supported community development and group work (n = 4; 31%), such as organising group interventions or being involved in community projects, as well as providing health education related to occupations (n = 5; 38%; Table 3).

Barriers to current practices

Current practices faced many organisational and systemic obstacles, including organisational pressure and limited time for prevention (n = 7; 54%; Table 3). Studies also described a culture where ‘clinical work is more important’ as a consequence of health policies, institutional culture and procedures opposing social participation and community integration principles (n = 6; 46%). Considering older adults’ increasing needs and waiting lists (n = 5; 38%), therapists were forced to prioritise and focus on curative care consistent with the dominant biomedical model (n = 4; 31%) shaping their practices (Table 3). Owing to a lack of funding of health promotion initiatives (n = 5; 38%), the occupational therapists’ role in health promotion was misunderstood (n = 5; 38%), due primarily to a lack of role models in health promotion and community development (n = 5; 38%) and professional isolation (n = 4; 31%) in this field.

Enablers of current practices

Despite these obstacles, some enablers fostered occupational therapists' ability to promote older adults' social participation (Table 3). One important facilitator included endorsing a systemic vision of community practice and partnerships (n = 5; 38%), such as involving community organisations or advocacy groups, which act on systemic barriers to social participation and ensure that priorities of the community were considered. Partnerships also allowed occupational therapists to navigate with the individuals into the specific challenges of the health-care system. Having a strong professional identity as an occupational therapist (n = 3; 23%) and some personal skills such as flexibility, creativity and diverse clinical experiences (n = 3; 23%) strengthened their capacity to intervene on social participation (Table 3). This identity could be reinforced by continued training and education (n = 3; 23%) or peer support and mentoring (n = 2; 15%). According to occupational therapists, community practice was associated with greater professional autonomy and more responsibilities (n = 2; 15%), and some thought that mixed roles (clinical and population practice; n = 1; 8%) increased their ability to engage in fostering social participation and balance individual and population interventions (Table 3). Finally, since fostering social participation required modifying older adults' lifestyle, the use of health behaviour change theories (n = 1; 8%) was a strategy supporting the adoption of such practices.

Knowledge users' viewpoints

According to knowledge users, current practices differed greatly from promising practices and were generally not targeting older adults' social participation. Systemic and organisational obstacles, such as performance indicators and an institutional culture that did not consider social participation a health issue, were some of the factors cited as affecting the ability to incorporate these practices. Among the different views emerging from the consultation, incorporating the group component into current practices was considered promising for fostering social participation. Although rarely used in current practices and considered time-consuming, some group interventions were successfully integrated, as mentioned by some knowledge users. To help integrate group interventions, modifying performance indicators to capture their impacts more accurately and value these practices was recommended. Knowledge users also recommended adapting individual interventions by providing personalised assistance to those not reached by group interventions. Providing follow-up and more support to caregivers was also considered important by knowledge users. Other possible practices included delivering community development interventions, such as educating community members on the importance of social participation. Such interventions might include participating in local roundtables to design healthy and age-friendly communities as part of current practices or in another setting, including the public health and municipal sector.

Discussion

This scoping study synthesised promising and current occupational therapy interventions fostering older adults' social participation, as well as factors affecting their use. First, the results of this study provide new comprehensive knowledge regarding 20 promising practices, the majority of which combined both group and individual interventions. Targeting social participation and personal and environmental factors, these practices were found to be effective in improving participation in social activities, self-efficacy and self-confidence, and self-rated health, preventing disabilities and reducing health-care costs. This demonstration adds to a body of literature on the impacts of social participation for active and healthy ageing (Holt-Lunstad et al., 2015). Moreover, this review stresses the importance of activity frequency and its significance for enabling health-promoting changes in older adults' lives, especially through the social interactions they provide (Jackson et al., 1998). Such findings also support the development of the occupational therapists' role in fostering the social participation of community-dwelling older adults and point up their potential contribution in the field of public health. These interventions were, however, carried out in controlled environments, and more studies are needed to implement them in current practices.

Second, this review generated a broad picture of community occupational therapists’ current practices, which emerged from 13 studies. Although many promising practices were identified in this review, findings also showed that current practices were limited to specific roles, such as maintaining functional independence and safety at home, rather than social participation. Despite this limited role, current practices were mainly individual interventions and included providing equipment, educating on how to adapt activities or referring to community groups and, more rarely, group-based and community development interventions. Obstacles to social participation practices mostly involved organisational aspects of the practices, including health policies and procedures that do not value social participation interventions. Similar obstacles were found in a study in primary health care where performance indicators did not accurately capture the broad scope of practice and had unintended consequences on access and health outcomes (Ashcroft, 2014). Enablers of social participation practices included aspects related to the therapists themselves, such as creativity and experience, as well as partnerships with the community. The process underlying some of these enablers was embodied by the concept of ‘strategic use of self’ as proposed by Lauckner et al. (2011). This process consists of strategically shifting and sharing power with individuals so they can participate socially and be involved in their community. To implement promising practices fostering older adults’ social participation, enablers need to be reinforced while obstacles should be diminished.

This review highlighted the possibility of implementing group-based interventions fostering social participation in community occupational therapy. Although group interventions were more prevalent in this review and might have more impacts than individual practices (Zingmark et al., 2016), the specific contribution of each type of intervention still needs to be pinpointed. Similar to other reviews (Dickens et al., 2011; Papageorgiou et al., 2016), group-based interventions were found to be more effective in promoting older adults' social participation than individual home visits. Although this scoping review did not aim to determine the most effective interventions, the majority of promising practices involved a group component, sometimes combined with individual sessions. Such multicomponent interventions might be more successful in promoting older adults' social participation (Dickens et al., 2011). Group interventions could be an interesting avenue for reaching patients on waiting lists more effectively. In fact, adding group interventions to individual sessions was shown to reduce occupational therapy waiting lists in a paediatric rehabilitation programme (Camden et al., 2013). Although there were structural challenges associated with group practices, such as providers' facilitation skills, group dynamics, recruitment and agenda issues, they have the advantage of improving access, quality of care and collaboration with resources. However, since they were conducted in an institutional setting and with a target population that differed greatly from the context of community settings and older adults, further research might be needed to assess the effects of adding group interventions to community occupational therapy for older adults.

A gap was identified between promising and current community occupational therapy practices regarding older adults' social participation. While social participation interventions were found to be cost-effective, they were rarely incorporated in community occupational therapists' current practices. Other studies also revealed this gap between current and evidence-based practices in community settings, which did not focus on social participation interventions (Craig, 2012). According to Grol and Grimshaw (2003), around 30–45% of patients do not currently receive evidence-based health services, and 20–25% of services are not needed or could potentially be harmful. The current focus on in-home activities, functional independence and home safety might bring to adopt a more compensatory approach and lead to an emergency practice context (Hébert et al., 2002), which opposes long-term care principles. Such principles are important, as social and leisure activities cannot be delegated or compensated without losing their benefit. While some individual interventions could foster older adults' social participation, these practices might benefit from being adapted to provide more personalised assistance with social participation, as suggested by knowledge users. One example of this, the Personalised Citizen Assistance for Social Participation (Accompagnement Personnalisé d'Intégration Communautaire), consists of 6 months of community follow-up by a trained citizen who meets weekly with the older adult to assist with social participation (Levasseur et al., 2016). This non-occupational therapy intervention was found to have promising impacts on health and social participation, and the citizens could be facilitated by community occupational therapists.

Few interventions were identified as targeting social aspects of the environment, including attitudes towards people with disabilities and older persons, and they mainly focused on caregivers. Although a few studies targeted marginalised older people, including from ethnic minorities or low-income populations, none were conducted with indigenous older adults, those experiencing or at risk of homelessness or members of sexual minorities. In addition, occupational therapy interventions reducing barriers related to the physical environment, such as those fostering universal access to buildings or transportation, were lacking. Such gaps in the evidence about community occupational therapy are worrisome, as interventions targeting communities and groups have more impact on older adults' health than those targeting only individuals (Amagasa et al., 2017). These interventions embrace principles of community development, a multilayered and community-driven process that promotes the community's ability to participate in occupations, a field in which occupational therapists could be more involved (Lauckner et al., 2011). To help them provide community development interventions and have a sustainable impact on environmental factors, effective knowledge translation strategies for complex health interventions should mainly target organisational and systemic factors. Community-based participatory research is a potential way to support community stakeholders by promoting their engagement in changing their practices, yet it rarely involves occupational therapists (Cockburn and Trentham, 2002).

Strengths and limitations

This study used a rigorous methodological framework for scoping reviews (Arksey and O'Malley, 2005; Levac et al., 2010), including a systematic retrieval of studies on social participation practices in community occupational therapy from numerous multi-disciplinary databases. Quantitative studies were complemented by the results of qualitative studies, which helped explain the gaps between promising and current practices. An effective collaboration with knowledge users (clinicians, managers, older adults, caregivers and community lay workers) from various settings (academic, home-care services, public health and community organisations) ensured an accurate and up-to-date synthesis of the literature (Levac et al., 2010). To our knowledge, this review is the first to include a consultation with knowledge users with the goal of offering a comprehensive understanding of community occupational therapy practices fostering older adults' social participation. As with other scoping reviews (Arksey and O'Malley, 2005), this study did not provide a detailed appraisal of the quality of the evidence, but supports the possibility of conducting a systematic review. Despite this, qualitative methods for analysing documents ensured credibility and strengthened the results (Levac et al., 2010). Information from textbooks and the grey literature may have been missed. Finally, some articles on social participation interventions in community occupational therapy could have been overlooked, as there are many keywords and definitions associated with social participation. Since two reviewers independently screened and selected the papers, these limitations were minimised.

Conclusion

Population ageing and the rising prevalence of chronic diseases require effective practices fostering the social participation of community-dwelling older adults. Community occupational therapy interventions enabling this aspect of active and healthy ageing had never been synthesised previously. The purpose of this scoping review was to synthesise promising and current occupational therapy practices fostering social participation of community-dwelling older adults. Promising practices combined group and individual interventions and also included solely group or individual practices. Components of promising practices mainly targeted social participation, but also personal and environmental factors. Impacts of these practices included improved participation in social and leisure activities, self-efficacy and self-confidence, social interactions, participation in outdoor activities, self-rated health and reduced health-care costs. Current practices, however, rarely incorporated social participation interventions. Except for a few studies, practices mainly focused on ensuring independence and safety at the expense of social participation. Barriers to such practices were institutional culture and health policies that did not focus on social participation, and misunderstanding of the occupational therapists' role in promoting health and social participation. Enablers included having a strong professional identity, creativity and diverse clinical experiences and endorsing a systemic vision of community practice. To inform community stakeholders properly, more knowledge is needed regarding which strategies to employ when incorporating practices fostering older adults' social participation. Finally, the results of the promising practices included in this comprehensive review and synthesis support the development of the community occupational therapists' role in promoting active and healthy ageing for community-dwelling older adults.

Key findings

A gap exists between promising and current occupational therapy practices fostering older adults' social participation.

Group-based and community-based interventions fostering older adults' social participation could be implemented by occupational therapists.

What the study has added

This study adds new comprehensive knowledge about promising and current practices fostering older adults' social participation and supports the development of community occupational therapists' role in this field.

Footnotes

Research ethics

Ethical approval was obtained for the stakeholder consultation by the Research Ethics Committee of the Montreal East Island Integrated University Health and Social Services Centre (CIUSSS-CEMTL-066).

Declaration of conflicting interests

The authors confirm there is no conflict of interest.

Funding

Pier-Luc Turcotte is a Canadian Occupational Therapy Foundation scholarship student. At the moment of the study, Mr Turcotte was a Fonds de la recherche du Québec – Santé (FRQS; #31662) scholarship student, Mélanie Levasseur was a FRQS Junior 1 Researcher (#26815) and Annie Carrier was a Canadian Institutes for Health Research (CIHR; #359665) postdoctoral trainee. Mélanie Levasseur is now a CIHR New Investigator (#360880).

Appendix 1. Characteristics of knowledge users ( n = 28)

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23.

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25.

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26.

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30.

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31.

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33.

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34.

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40.

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43.

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44.

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45.

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46.

Logan

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47.

Matuska

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48.

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49.

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50.

Mountain

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51.

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52.

Murphy

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53.

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54.

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59.

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61.

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65.

Zingmark

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Fisher

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