What is the Rationale for PREP?
Using this skills-based approach, therapists work with the client (and his/her parent or caregiver when appropriate) to identify aspects of the environment and the activity that either support or hinder participation. Together, a plan to minimize and/or remove barriers within the environment and build on supports is developed and implemented so that the client can participate in the activities of his/her choice.
Participation, defined as “involvement in life situations” or “engagement in daily activities”, is recognized by the World Health Organization (WHO) as one of the important outcomes of rehabilitation intervention (WHO, 2001). Taking part in recreational activities (e.g., playing team sports, joining community groups or going out for coffee) enables individuals to gain skills and competency, achieve physical and mental health, and develop a sense of meaning and purpose in life (Anaby, Miller, Eng, Jarus & Noreau, 2009; Anaby et al., 2011; Eccles, Barber, Stone & Hunt, 2003; Larson & Verma, 1999). Participation in leisure activities is beneficial across the life span, particularly for adolescents because it helps them build a strong connection to their community and expand their social roles, in turn, facilitating their readiness for adulthood (Gorter, Stewart & Woodbury-Smith, 2011).
Despite the importance of participation and its positive impact on health outcomes, the participation of individuals with disabilities is restricted in comparison to their peers without disabilities (Engel-Yeger, Jarus, Anaby & Law, 2009; King, Law, Hurley, Petrenchik & Schwellnus, 2010; Law, Anaby, Dematteo & Hanna, 2011). For example, a North American study found that 37% of children and youth with disabilities never took part in organized physical activities in the community, as compared to only 10% among their typically-developing peers (Bedell et al., 2013). Additionally, two Canadian studies found that participation among older adults is reduced with increasing age and disability, especially with respect to personal care, housing, mobility, community life, and leisure activities (Desrosiers et al., 2009; Turcotte et al., 2015).
Environmental factors have been found to have a major impact on one’s ability to participate (Anaby et al., 2013; Anaby et al., 2014; Law, Petrenchik, King & Hurley, 2007; Vaughan, LaValley, AlHeresh & Keysor, 2015). Different aspects of the environment are recognized as potential supports or barriers to participation (Law et al., 2007; Welsh et al., 2006), including:
- physical (e.g., built environment, accessibility, districts of residency)
- social (e.g., social support and peer support)
- attitudinal (e.g., perceptions towards disability and recreation)
- familial (e.g., family functioning)
- institutional (e.g., policies and availability of programs)
The impact of the environment on the participation of people with health conditions is often greater than the impact on people without health conditions. To illustrate, Bedell et al. (2013) found that 36% of parents of children and youth with disabilities reported no access to, or a lack of availability of programs and services, in comparison to only 3% of children without disabilities. This barrier to participation may be heightened if individuals are not able to access information or are unfamiliar with available resources and policies (Anaby et al., 2013; McManus et al., 2006).
Emerging Intervention Approaches
The relationship between the environment and one’s ability to participate has prompted researchers and clinicians to consider environment-focused approaches. One such approach, known as “context therapy” (Darrah et al., 2011), focuses on modifying environmental conditions and activity demands to foster participation. Context therapy has been proven effective for young children with cerebral palsy (Law, Darrah, et al., 2011) and was graded as one of the interventions with the best evidence available for children and youth with cerebral palsy (Novak et al., 2013), yet it is not typically used in current clinical practice (Anaby et al., 2016; Palisano, et al., 2012).
Coaching is another intervention approach that has begun receiving attention in rehabilitation. While there are many different coaching approaches, most are based on similar theories or frameworks, including client- or family-centred practice, occupation-centred practice, and adult learning theory (Kessler & Graham, 2015). One example of a coaching approach developed and used by occupational therapists is “Occupational Performance Coaching” (Graham, Roger & Ziviani, 2009). When using this coaching approach, occupational therapists use specific language and questions to encourage parents to think about their child’s participation and develop their own solutions to address the challenges their child faces. Studies examining the effectiveness of coaching with parents of young children with disabilities have demonstrated preliminary, positive effects on children’s goal performance (Dunn, Cox, Foster, Mische-Lawson & Tanquary, 2012; Graham, Rodger & Ziviani, 2010; Novak, 2014). Similar findings are also evident among adults recovering from a stroke (Kessler, 2015).
Given the growing evidence regarding the association between the environment and participation (Anaby et al., 2013; Anaby et al., 2014) and emerging evidence to support the use of coaching approaches, we conducted a study to examine an environment-based intervention to improve leisure participation of youth with physical disabilities. An occupational therapist worked with each youth and his/her family to set three leisure goals. A coaching approach was used to collaboratively identify and implement strategies to remove environmental barriers. We found that the use of environmental interventions successfully improved the performance and satisfaction of participation in meaningful, community-based leisure activities for youth with physical disabilities in both Ontario (Law, Anaby, Imms, Teplicky & Turner, 2015) and Quebec (Anaby, Law, Majnemer & Feldman, 2015). Findings from a bigger study analyzing about 80 goals set by 28 youth with physical disabilities indicated a clinically relevant and statistically significant treatment effect on the COPM performance scale (Anaby, Law, Feldman, Majnemer, Avery, 2018). Moreover, improvements in performance were maintained during follow-up (week 20). Following the PREP, youth also engaged in more study-related activities, spent more time with friends and less in digital media activities (Anaby et al., 2019). Finally, the PREP was positively perceived by both parents (Anaby, Mercerat & Tremblay, 2017) and occupational therapists (Anaby, Law, Teplicky & Turner, 2015). These studies illustrate ways in which therapists can work with people with disabilities to enhance participation in self-selected leisure goals and potentially develop their capabilities for problem-solving strategies to overcome environmental barriers they face in daily life.
This website is based on our learning from the studies reported above and ongoing research. It describes an approach to practice that focuses on changing the environment to enhance participation. This protocol is client/family-centred and incorporates a coaching approach that enhances clients’ own ability to identify and implement environmental modifications.