Understanding Policy Influences on Health and Occupation Through the Use of the Life Course Health Development (LCHD) Framework

Principles of Life Course Health Development

“Lifecourse-informed models of health introduce a new way of thinking about how health and disease develop across the life span, fundamentally challenging existing simple biomedical, and more recent multiple risk factor[,] models” (Russ et al., 2014, p. 498). Life course theory emerged from the epidemiologic study of health disparities and social determinants of health. A life course perspective links life adversity, particularly risks early in life, with long-term effects on health, such as adult chronic disease (Hertzman, 1994; Kuh & Hardy, 2002; Marmot et al., 1978), and it is based on the premise that complex biological and social factors affect health development in different ways, and with varied impacts, at critical periods of development.

Halfon and Forrest (2018) explained that “health development integrates the concepts of health and developmental processes into a unified whole” (p. 26). As a dynamic, emergent process, health development is the outcome of transactions among people’s internal bodily systems and external environments and diverse contexts: genetic, physical, social, family, psychological, health care systems, and culture or policy (Halfon & Forrest, 2018; Halfon & Hochstein, 2002; Halfon et al., 2014). Halfon and Forrest also proposed principles of LCHD that seek to further explain the complex, adaptive process of health development. We provide descriptions of these principles in Table 1 and build on previous examples (Kim et al., 2018; Larson et al., 2018) of the application of these principles to disparities in health by demonstrating how they guide analysis of policy influences on occupation. We believe that understanding the LCHD principles as they relate to occupation will open new doors for occupational therapy practitioners, scientists, and scholars to consider policy when analyzing participation and performance. The example we describe next illustrates how policy may not address all gaps in accessing healthy occupations and thus contributes to disparities in health development.

Lack of Paid Family Medical Leave: Influences on Occupation and Health

Family leave from work, especially if paid, is an essential benefit for parents who want to establish a positive early relationship with their infant and foster the best start for LCHD (Zero to Three, 2018). This benefit allows parents to take time off work for situations that include the birth or adoption of a child for bonding as well as for responsibilities such as taking an infant to well-baby visits. Family leave also provides an extended opportunity to establish breastfeeding and is associated with improved maternal health outcomes (Chuang et al., 2010; Jacknowitz, 2008; Jou et al., 2018; Mandal et al., 2010; McCarter-Spaulding & Horowitz, 2007; Skafida, 2012). However, the United States is one of three countries worldwide that has not implemented a national paid family leave policy; Papua New Guinea and Suriname are the other two (WORLD Policy Analysis Center, 2019).

In the United States, unpaid family leave is currently available through the Family and Medical Leave Act of 1993 (FMLA; Pub. L. 103-3) for certain employees of companies with 50 or more employees (U.S. Department of Labor, n.d.). FMLA provides 12 weeks of unpaid, job-protected leave each year for qualified medical or family reasons, including caring for newborn or other children. The law allows states and employers to establish family leave policies that are more expansive than the FMLA; however, only a few states have done so (Domonoske, 2016; Zero to Three, 2018). Moreover, the majority of working parents are not covered under the existing FMLA because of the size of their employers, and many parents who would return to paid work after the birth of a child are not financially able to take unpaid leave, even if it is available (Zero to Three, 2018).

The LCHD principles of timing, plasticity, and thriving are particularly applicable to understanding how this policy situation negatively affects individual and family occupations and health and subsequently contributes to occupational injustices and health disparities. Using these principles we aim to illustrate how application of a framework such as LCHD helps inform analysis of policy influences on occupation:

Bringing these principles together, we theorize that health development enables certain outcomes such as quality of life, wellness, and well-being and that occupational engagement is a key mediator, or determinant, of health (Pitonyak et al., 2015). Therefore, the lack of optimal paid family leave—a policy gap—is a contextual factor that inhibits access to desired family occupations, such as bonding (social participation) and breastfeeding (feeding, eating, and child rearing) that are critical for development and well-being. Through optimal paid family medical leave, the United States could align protective or health-promoting policy with this sensitive period of health development.

Increasing Understanding of Policy Influences on Occupation

Policy, whether intended to foster health, education, or other social outcomes, often has broad influences and consequences once implemented. These consequences affect diverse social groups in ways that may contribute to disparities in health and participation rather than diminishing them (Gerlach, 2015; Rudman, 2013). Gerlach (2015) proposed that “socially responsive and equity-oriented occupational therapy theorizing and practices must be responsive to the multilayered, contextual, and structural nature of people’s lived experiences of intersecting forms of marginalization and their agency and resistance” (p. 251). A fundamental belief of occupational therapy is that health is determined by the quality of everyday living and the ability to participate in occupations that give meaning and purpose and are required to fulfill societal roles and foster personal ones. As such, the LCHD framework may be a useful tool for occupational therapy practitioners and scholars to use in deeper analysis of how policy can limit access to desired occupations, and thus to health, and move occupational therapy toward Gerlach’s call for social responsiveness and equity-oriented practice.

Although occupational therapy practitioners consider contextual influences on occupation, the impact of policy is not a traditional component of thinking during the occupational therapy process (Mroz et al., 2015; Pitonyak et al., 2015). It is timely for the field of occupational therapy to broaden its understanding of policy as both a social determinant and a contextual factor. Occupational therapy considers the person in context, and context includes policy and its impact on occupation. Health is an asset and a resource for life; occupations are a means to health and well-being (Gupta & Taff, 2015). Fostering a deeper understanding of policy influences on access and opportunities to engage in occupation among practitioners in the United States is one way to move toward socially responsive and equity-oriented occupational therapy.

Occupational therapy scholars have discussed how thinking about social determinants of occupation, such as policy, needs to be included in the occupational therapy process—particularly to actualize client-centered care (Bailliard, 2013; Gupta & Taff, 2015; Hocking, 2017; Mroz et al., 2015; Pitonyak et al., 2015; Rudman, 2013; Townsend & Wilcock, 2004; Whalley Hammell & Iwama, 2012). With occupational therapy practitioners’ understanding of habits, routines, and participation, they can bring a deeper understanding of the lived experience of policy; therefore, practitioners have a role and unique perspective to help policymakers understand the impacts of policy, or its gaps. Moreover, they have the role of constructing occupational therapy interventions or programs to address habits, routines, and participation to enable people to overcome negative impacts of policy.

Although occupational therapy practice in the United States requires engagement with policy, this engagement primarily pertains to service delivery, reimbursement, and scope of practice. In this article, we have made a case for the profession’s consideration of context to go beyond a view of individual factors and to understand that clients’ everyday living conditions are affected by multiple systems, including policy. Issues of social determinants and systems that address these determinants will benefit from the inclusion of an occupational perspective and its contribution to creating conditions that develop productive and well-adjusted citizens.

Whalley Hammell and Iwama (2012) stated, “If occupational therapists are to take seriously their espoused commitment to enabling access to participation in occupation, the inequitable conditions of people’s lives will need to be addressed” (p. 385). People have the right to engage in meaningful occupation that contributes to well-being (Whalley Hammell & Iwama, 2012). Durocher et al. (2014) argued that access to meaningful occupation is a human right. Last, Townsend and Wilcock (2004) decreed that full participation in society requires means. Policy, or its gaps—such as failure to expand access to paid family medical leave—contribute to health inequities by limiting possibilities for participation in daily life. The conditions of everyday living encompass broader social determinants of health. Tackling health disparities and meeting the societal needs of the day warrant that practitioners “walk their talk” by enhancing their understanding of contexts at multiple levels as defined by the LCHD framework and bringing their unique understanding of occupation as a social determinant to the changing approach to health.