Order 1425430: occupational therapy

Elnaz Alimi

1. Which theory bases would you use to guide your project and future work in this area? Please discuss both a) an occupational therapy model(s), as well as b) related knowledge theory bases you would prioritize from outside the field of OT that you think are important to use to guide interactions with this population.

2. Given these theory bases from #1, how would you define and conceptualize occupational engagement and social participation with this population?

3. How would you assess needs and evaluate outcomes related to these two concepts with immigrants and refugees? E.g., which assessment tools would you use and why?

4. How would you adapt your assessment and intervention process so it is a) accessible to people with diverse disabilities in this population, while also being b) culturally relevant to people from within this social group?

1. Theories and Models

This project will be guided by both occupational based model Person-Environment- Person-Participation known as PEOP and other related knowledge theory bases related to immigration studies. All of these theories are explained as following. The detailed explanations about these theories are eliminated and the main features of them that are align with this project are illustrated.

1.1. Person-Environment-Occupation-Performance (PEOP) Model

The Person-Environment-Occupation-Performance (PEOP) Model was generated in 1985 and published in 1991. Development of this model was a response to need for more occupational based models over the paradigm shift. (Christiansen & Baum, 1991, 1997; Christiansen et al., 2005). It is envisioned that although there are some similarities with other models, yet different from other models in terms of its focus on occupational performance and participation, as well as using a top-down approach (Christiansen et al., 2005). The PEOP model is defined as a system model that looks at the function in the systems as a whole and considers the interaction over its components. Occupational performance has been received close attention in the PEOP model and contains three main components: (1) characteristics of the person (including physiological, psychological, motor, sensory/perceptual, cognitive, or spiritual), (2) characteristics of the environment (including cultural, social support, social determinants, and social capital, physical and natural environments, health education and public policy, assistive technology), and (3) characteristics of the activity, task, or role. The most recent edition is developed to provide therapists to identify the client’s enablers and barriers to occupational performance, and might be employed both individual and organizational/community based (Christiansen et al., 2005). PEOP pays close attention to the importance of occupational competency in order to attain occupational participation. Occupational participation in PEOP is wider compared to occupational performance as it embeds the ability to engage in preferred lifestyle choices to participate in meaningful and purposeful roles and activities (Christiansen et al., 2005). Occupational performance and participation are considered as main focus of this model by placing these concepts strategically in the center of the model.

Performing occupations, people interact with their environment. Thus, there are reciprocal interactions; a people’s goals and intentions influence their occupational performance, and the action affects their environment and their personal characteristics at the same time. The reciprocal interaction between the person and environmental characteristics influences occupational performance positively or negatively. When there is an appropriate person-environment overlap in supporting the desired occupation, success in occupational performance eventually results to participation and well-being [two outcomes that this project is looking for]. In addition, the PEOP model is a client-centered model in which clients are supposed to set goals actively and participate in planning that promotes occupational performance. Guiding practice by PEOP model requires a collaborative and engaging relationship between the client and practitioner. Practitioners captures the issues and options presented by the client’s needs and goals by asking the appropriate questions to elicit client’s narrative. The model identifies factors in the personal performance capabilities/constraints and the environmental performance enabler/barriers that are central to the occupational performance, which in turns lead to development of a realistic and sequenced intervention plan (Wong and fisher, 2015).

1.2. Related Knowledge Theories: Immigrants Studies Theories

1.2.1. The Trajectory Approach

The idea of a trajectory means that we perceive factors or contributors related to immigrant health to operate together as a dynamic system over course of time developing a relationship between a population and the health-related system. The term ‘‘health-related system,’’ in this approach, looks at the combination of health services with the economic, community, social and cultural supports necessary for their effective delivery. Figure 1 is an illustration of an immigrant/refugee health trajectory, moving from relatively good health status at first arrival to decreasing (and then slightly increasing) status over time as a function of marginalization from health and supporting resources, inspired by diverse contributing factors [10].

Fig. 1 Concept of immigrant/refugee health trajectory

Factors contributing to Health Disparities among Immigrant and Refugee Populations

Poverty and limited resources: 21 percent of children who are living in immigrant families live in poverty, in comparison with 14 percent in American-born families [10]. Data from the National Survey of American Families [10] reports that excruciating conditions are greater for children of immigrants than for children of US born in three areas: food, housing and health care. Some research even shows that immigrants are often keeping away from public programs and assistance even when they are eligible, due to concern about consequences for their legal status [10]. Housing segregation by race/ethnicity (regardless of income) is associated with a variety of health risk factors [10]. Neighborhood characteristics (e.g., crime, lack of recreation space) intertwined with socioeconomic status also have an impact on such health conditions as obesity, violence and substance use [10].

Lack of insurance and monetary support: Most immigrants are in working families with adults often holding more than one job; however, the nature of their jobs (low income, no health insurance) as well as restricted access to insurance for other reasons leads to the situation that approximately 42–51 percent of non-citizens have no access to health coverage, compared to 15 percent for native citizens [10]. Lack of insurance associated with reduced access to care, and consequently to disadvantageous health status [10].

Difficulties in access to health care and treatment bias: If we turn blind eyes on age, legal status or insurance coverage, immigrants receive about half the health care services which are provided to Americans-born populations. Financial, cultural and language barriers all make it hard for immigrants to afford care, understand medical advice or recommendations from English language doctors and nurses [10].

Differences in health knowledge and practice : people who have migrated to the US from all over the world may come with different knowledge and perception about health, health care systems and the community resources. Or, some immigrant populations may have no proper information regarding preventive and treatment procedures available in the US for specific health conditions [10].

Migration and immigration experiences including acculturative stress: Three crucial sets of factors must be considered as unique ones to immigrants/refugees’ population [10]: home country trauma, migration trauma, and the influence of social, cultural, and economic change after arriving in the US. Immigrant and refugee families might experience social role shifting, generational family disruption, economic hardship, language and other related challenges. There is a high risk that these factors have a negative influence on health status. Related to this set of factors is the role-shifting that happens among immigrant families. This might result in undeniable impacts on health outcomes and health care [10].

Lack of community efficacy: Because of the language barriers, unfamiliarity with resources, fear and mistrust to the system, large groups of immigrant populations are reluctant to take action or make complaints regarding such conditions (community conditions that impact health status. e.g. housing and limited services) and may feel they are not able or eligible to do anything to change the community. This sort of association between perceived self-efficacy and health outcomes is supported by other research as well [10].

Lack of data and systems to address health needs of immigrant and refugee populations: Before such disparities can be addressed, they must be figured out. That is, data need to be gathered and maintained on health status and disparities among racial-ethnic minority populations of immigrant origin [10].

1.2.2. A cross-national framework for understanding immigrant health

The health status of people who have not migrated is totally influenced by the environments they are living in, while the health of immigrants’ population, their families and communities of origin is dependent on the environments in both sending and receiving countries. As shown in Fig. 2 and discussed below, sending-country (home country) factors may influence immigrant health before and after immigration, along the life course, alone or in combination with receiving-country (host country) factors. The impact of cross-national factors might demonstrate differently depending on the etiology of specific outcomes (infectious versus chronic disease), critical exposure periods, and age at migration [2].

Fig. 2 Cross-national frame work for research on immigrant health (citation?)

Social determinants in sending countries: Social determinants of health in home countries influence immigrant health before and after migration as well as over the life course. The level of effect of social determinants on health may be different by country’s level of economic development. Gender is another social determinant that influences either migration or health. Similarly, migration affects gender relations and modifies them in both the sending and receiving countries in ways that may have health implications [2].

Health distributions in sending countries : Studies showed that in the U.S., since the 1970s, the majority of immigrants have arrived from developing countries in Latin America and Asia, where the prevalence of infectious diseases is higher than in the U.S [2].

Push and pull factors: Push and pull factors (e.g., wage differentials or other, non-labor market failures) keep the migration continuing, but can also be considered as determinants of health. For instance, political violence, unemployment, and the social and economic policies that produce them may be considered as push factors as well as social determinants of health in sending countries. Push and pull factors often interact with gender. But this interaction can be varied in different circumstances [2].

Life course: There is a large body of evidence suggesting that social economic status in childhood has a long-life impact on health along the life course [12]. Therefore, immigrants’ childhood socioeconomic conditions in sending countries and age at migration may influence the health of adult immigrants in receiving countries. In addition, infectious or environmental exposures in sending countries may develop into active disease in destination countries [2].

Health distributions in receiving country: Having arrived in the host country, immigrants are vulnerable to the health distributions and epidemics in the host country. For instance, HIV was first identified in the U.S. and Haiti. Also, migration may result in exposure to new health norms in the receiving country [2].

Social determinants in receiving countries: Sociologists interested in immigration studies have suggested that immigrant adaptation is influenced d by the context of reception, including economic opportunities for upward mobility and racial discrimination. Governmental, societal, and community dimensions of the context of reception all have the potential to affect immigrant well-being and health outcomes [2].

1.2.3. Conceptual frame work for life course modifiers for immigrants in the U.S.

Fig. 3 Life-course modifiers for immigrants in the U.S. (citation?)

Home Country Factors and Healthcare/Health outcomes for Immigrants

Biological factors: Genetic and biological factors play a fundamental role in determining health outcomes. Although people might have less control over these factors. Regardless of the country of birth, persons born with congenital disorders typically experience significant health care challenges and lower quality of life than their healthy counterparts. However, children with special needs born in countries whose health care systems are not as advanced as the U.S. suffer additional challenges that can further debilitate quality and quantity of life. Some of these challenges include stigmatization, neglect, isolation, and poor coordination of care, resignation to fate in cases where parents and caregivers view the situation of such children as hopeless. This is particularly true of developing countries [13].

Environmental influences: Multiple studies have proved that the environment in which surrounds individuals is a major contributor of health. Environmental influences include language, lifestyle behaviors, and dietary preferences. There is a growing body of research on the impacts of lifestyle behaviors on individuals and public health. Some argue that new immigrants to developed countries including the U.S. show improved health outcomes compared to native-born populations. Others have also stated that persons who immigrate to the U.S. are more likely healthier and wealthier than the people who have not migrated so that a self-selection process increases the chance of incoming healthier immigrants [13].

United States Factors and Healthcare/Health Outcomes for Immigrants

Social network influences: The concept of social network focuses on the necessity of ones’ characteristics as well as the relationships and ties with other individuals within the network [13]. For instance, Christakis and colleagues found that although obesity is due to product of voluntary choices or behaviors, the fact that people were integrated in social networks and influenced by the evident appearance and behaviors of those around them proved that weight gain in one person might influence weight gain in others [14].

Environmental influences: Living in the host country, immigrants are exposed to both positive and negative cultural values, lifestyle and behaviors that may or may not impact their health. Actually, higher level of acculturation does not necessarily guarantee positive health outcomes [13].

Sociodemographic influences: The role of an individual’s social economic status (SES) on healthcare outcomes cannot be overemphasized. Several studies have been done to show significant positive impacts of education, on health care outcomes, [15,16]. Physical activity among immigrants tends to be lower among immigrants than for most American-born persons. Recently immigrants are typically low-to-middle income persons dealing with multiple jobs and trying to settle and integrate into their new environment, so they do not have much time to engage in physical activities as American-born do [13].

Access to healthcare: By arriving in the U.S., immigrants are often confronted with a healthcare system significantly different from what they get used to [13]. Study shows that this huge difference might turns into the excruciating obstacle to immigrants with low income, limited language proficiency and education who are at higher risk of encountering both economic and systematic barriers to care [17].

2.1. Occupational Engagement: Developing sense of Doing, Being, Becoming and Belonging

(smith,2015) Engagement in purposeful and valued daily occupations has the potential to promote health, well-being and coping skills, even in excruciating conditions and the ability to engage in daily occupations is positively linked with well-being. Migration might be considered a complex and multi dimential process, leading to an enormous and unpredictable transition, with the huge loss of a familiar life and the removal of many dignified occupations. Migrants are increasingly acknowledged as experiencing occupational issues, from temporary disruption to long lasting deprivation from necessary engagement. They deal with restricted access to opportunities and options, poor social capital, poor mental and physical health, dwindling performance skills and wasted human potential. There are significant predicaments to occupations, including work, education, volunteering and networking, excluding individuals from mainstream society, exacerbating social exclusion and creating high levels of underemployment. These occupational limitations have a negative impact on individuals and communities, eroding skills, increasing vulnerabilities, worsening the impact of poverty and ill-health, emphasizing isolation and fostering community disharmony. The World Federation of Occupational Therapists has identified occupation as a human right that enables people to flourish, fulfil their potential and experience satisfaction. World Federation of Occupational Therapists’ (2012) position statement on Human Displacement highlights the impact of forced migration on occupation and the potential for occupation to enable individuals to move beyond displacement. Occupation promotes the adjustment, integration and reconstruction necessary to manage migration, without which mastery and competency are undermined. Occupational access and opportunity are important feature of success in transition, allowing individuals to renegotiate ways of doing, being, becoming and belonging in their new context.

· Doing: the importance of being busy and having some degree of daily structure, expressing the pleasure of getting up with a purpose, and ending the day feeling tired. The key message from immigrants lay in their desire not only to ‘keep busy’ but also to ‘keep busy with a purpose’ – whilst any occupation was better than no occupation.

· Being: the impact of migration on their sense of self, their spiritual self and their well-being.

· Belonging: The discussions on belonging fell into two categories, belonging associated with place and belonging associated with people.

· Becoming: Uncertainty made their day-to-day lives very challenging, with difficulty planning and preparing for a future that cannot be anticipated.

Implications: For individuals facing forced migration, managing their transition and making meaning in an unfamiliar host country may be particularly difficult, and whilst we are beginning to explore the potential of occupation to help people during the process, we need to consider not only access to occupation but the nature of that occupation. Occupation has enormous potential for enhancing post migratory experiences, but the choice of occupation is also important. People strive to move beyond simply ‘keeping busy’ to find occupations of real meaning that foster connections and purpose, and in particular feed their need to feel valued. Occupations undertaken for the benefit of others tap into culturally appropriate collectivist ideals, using the desire to be altruistic to promote ‘doing, being, belonging’ and even the elusive ‘becoming’. Occupational therapists may be able to consider the application of desired activities as effective routes to inclusion and meaningful engagement.

2.2. Social Participation: Establishing identity

During the migration process, people may experience changes in physical, economic, political, social and cultural aspects of context. In turn, their occupational engagement, senses of place and ultimately their identities may be affected. One’s occupations and the places one engages with are shaped by identity. It has been repeatedly proposed within the occupation-based literature that it is not solely the doing of occupation that contributes to identity, but also the meaning individuals attach to, and derive from occupations that influences identity. Term social participation refers to more than participation in goal directed pursuits. In Wilcock’s terms, it connotes people’s involvement in meaningful occupations “for being, becoming, and belonging, as well as for performing or doing occupations”. In his Eleanor Clarke Slagle lecture, Christiansen (1999) explicitly highlighted the connection between occupation and identity, stating, “occupations are key not just to being a person, but to being a particular person, and thus creating and maintaining an identity”. He based his argument, that occupation is the primary means through which individuals both develop and express their personal identities, on four propositions: identity is an overarching concept that shapes and is shaped by relationships with others; identities are closely tied to what people do and their interpretations of those actions in the context of their relationships with others; identities are important to self-narratives and life stories that provide coherence and meaning for life and everyday events; and life meaning is an essential element for promoting wellbeing and life-satisfaction. Social participation serves to enhance opportunities for identity reconstruction and growth. ‘Maintaining an acceptable self-identity’ addresses people’s use of occupation to maintain an acceptable form of personal identity - understood as “the arrangement of self-perceptions and self-evaluations that are meaningful to a person”. The occupations people engage in influence their social and personal identities. Likewise how they see themselves and are, or wish to be, seen by others also influences what occupations they choose to engage in.

Habits and routine are formed in part through occupation – doing similar things at similar times, day after day; or as Brockelman (2002) stated, “The ways in which humans shape their everyday behavior towards life into predictable patterns” which ultimately contributes to the “emergence of one’s personal identity”. Yerxa (2002) similarly described habits as “significant learned behaviors embedded in an ecocultural context (of time, place, and society)” and argued that ‘positive’ habits can contribute to “personal meaning, identity, competence, satisfaction, and self-expression”. Individuals within a given society do not all have the same knowledge of, and access to, the social rules and resources within which habits are shaped and reinforced. Thus, when transitioning into a social context that differs from that in which individuals have been socialized and developed habits, as may occur with international migration, they may experience a destabilization of routine and may need to re-negotiate their habits (comfort zone). The discussion of performance and habitus highlights the importance of routine or noticeable lack thereof, for identity; as it is within everyday doing, in interaction with others, located in particular places that structure and agency interact, and that identity is experienced and negotiated. Understanding how identity is situated by habitus, and performed in social interaction on a daily basis through occupation, can advance explorations of how and why identity and its performance are affected by international migration, as people move from one place to another and experience changes to their engagement in meaningful occupation and senses of place. Drawing on the work reviewed, it is argued that routines contribute to people’s identities, and that occupations contribute to routines by enabling people to structure time and space. People engage in similar occupations, at similar times of day, in similar places, with similar people, day after day, on an ongoing basis, so that the routine nature of everyday life becomes tacitly understood. These routines both enact and reproduce habitus. The range of occupations people engage in directly contributes to, confirms, and re-affirms people’s identities over time as they form daily routines and interact with others on an ongoing basis, performing their identity in place. When people migrate internationally, everyday interactions and routines done in previous places may no longer enable impression management in desired ways, thus challenging personal and social identity and taken for-granted elements of habitus. Occupations and places change, altering routines, affecting the meaning accorded to and derived from familiar occupations and places, and ultimately influencing migrants’ identities. They no longer interact with the same people, and the ‘rules’ in which such interactions are to occur may not be available in a non-problematic, taken-for-granted way. They are located within different contexts, where the people they now interact with were socialized within a different social structure with different social norms. Migrants may lose the ‘comfort place’ provided by their habitus, and need to consciously search for cues regarding how to ‘do’ in order to negotiate their personal and social identity. They may be challenged to learn the habitus of the dominant group or groups in their new places, leading to alterations in occupation and, ultimately, in identity. Attending to changes experienced by migrants at the structural macro-scale and the agential micro-scale, and their influences on occupational engagement and senses of place, entails consideration of identity. Drawing together notions of performance and habitus into an occupational perspective can both enrich understandings of migration, as well as intersections of occupation, place and identity, when addressing questions such as: What is the role of, and impact upon, occupation during the process of migration, settlement and integration? What are the influences of place upon occupation throughout this process? What are the implications of changes to migrants’ occupations and place for their identities? How do people ultimately reaffirm or recreate identity following migration? argue that addressing these questions require an exploration of the issues including but not limited to migrants’ renegotiation of routine and meaningful occupations, formation of new senses of place, and development of performances that reflect the aspects of identity that they seek to emphasize within changed ‘interaction fields’ shaped within a novel habitus, all of which occur over time as migrants negotiate new routines according to their changed contexts. An occupational perspective is valuable for unpacking such multi-faceted human experiences, as an individual’s occupational engagement and development of senses of place are considered within the context in which they are undertaken. Exploring migrants’ identities (their sense of being within their new context); their anticipated futures (who they seek to become); and their integration within the host society (whether they feel they belong) can all be explored by applying an occupational perspective that considers how people do their identities in place.

3. Measurement

3.1. Activity Card Sort

The ACS is an occupational therapy assessment tool that employs a q-sort methodology, requiring the subject to sort cards depicting people engaged in real-life activities into categories. The sorting procedure allows the subject to describe how he or she is involved with various activities. Pictures of people actually performing the activity prompt the subject to recall the level of that activity in his or her life. The activities in the pictures represent occupations from three categories of activity: instrumental, leisure (both low-demand and high-demand), and social. One recently developed tool is the Activity Card Sort (ACS) (Baum, 1995), which is a standardized assessment tool aimed at evaluating the amount and level of involvement in various activities. Different from the few other available tools, such as the Matsutsuyu interest checklist, the ACS employs pictures of people involved in real-life activities and thus can elicit vivid responses from participants. The ACS provides us with the opportunity to identify the underlying dimensions of occupational performance, as experienced by various groups, and to better comprehend the theoretical and practical implications of activity classification (Sachs & Josman, 2001). ACS is the only assessment available that measures the full range of activities that adults do and includes 20 instrumental activities, 35 low-physical-demand leisure activities, 17 high-physical-demand leisure activities, and 17 social activities

The Activity Card Sort, 2nd Edition has three versions:

· Community Living version for community-dwelling older adults

· Institutional version for older adults in a hospital, skilled nursing or rehabilitation hospital

· Recovery version for older adults recovering from an injury or disease.

The individual sorts the picture cards according to their engagement in each activity. Sort categories vary according to the version used

Healthy older adult version: which will be used for this study

· Never done

· Not done as an older adult

· Do now

· Do less

· Given up

Institutional version:

· Done prior to illness

· Not done

Recovering version:

· Not done before illness or injury

· Continued to due after illness or injury

· Do less after illness or injury

· Gave up due to illness or injury

· Beginning to do again (Baum & Edwards, 2008; Law et al., 2005).

Why do I use?

· The Activity Card Sort (ACS) measures participation in (social activities) (descriptive assessment)

· Comparing premorbid engagement in activities with current activity participation (Baum, Perlmutter & Edwards, 2000; HartmanMaeir, Soroker, Ring, Avni & Katz, 2007)

· Useful for initial assessment, goal setting and intervention planning (descriptive assessment)

· To monitor changes in activity participation following onset of illness (Albert, Bear-Lehman & Burkhardt, 2009; Chan, Chung &

· Packer, 2006; Packer, Boshoff & DeJonge, 2008) (evaluative assessment)

· To evaluate the effects of an intervention designed to impact on a person’s activity participation (evaluative assessment)

· Creating an occupational history (descriptive assessment) (Canadian Stroke Network – Stroke Engine Assess, n.d.)

4. How to implement ACS in terms of accessibility and culturally informed

Following some characteristic of middle easterners cultures are illustrated to provide readers with a snapshot of the main components of cultural considerations.

Context. Given the intensity and frequency of their relationships, Middle Easterners' culture is highly contextual-that is, persons seek understanding of events by examining the entire web of circumstances in which they occur. A Middle Easterner needs to know more about another person than an American does for a relationship to develop. American culture is low in context; the emphasis is on the verbal message and less so on the context in which the message is given.

Time. Punctuality is less important in the Middle East than in the United States. A patient might be late for an appointment, or not come at all, because another matter immediately at hand was seen as more important than the previously scheduled appointment. Americans are annoyed by such a nonchalant approach to time, and the Middle Easterners may be offended by the American proclivity to immediately talk about the business at hand instead of taking the time to establish a relationship.

Space. The appropriate conversational distance between Middle Easterners is about .6 m (2ft), in contrast to about 1.5 m (5ft) for Americans. This proximity allows a Middle Easterner to finely read the other person's reactions in a conversation. Middle Easterners touch more frequently. The American-born author (J.G.L.) needed months to become comfortable sitting shoulder to shoulder in a room full of Iranians and being embraced on greeting and taking leave.

Passivity in the presence of a physician (an authority figure) also interferes with eliciting information. Because the authority of a physician is never questioned, a Middle Easterner is not likely to ask questions or give information that would contradict or "show disrespect." This very respect for a health professional's expertise prevents a Middle Easterner from understanding why a physician cannot diagnose and pre- scribe without resorting to tests and "irrelevant" questions. A third obstacle to communication is the Middle Easterners' resistance to disclosing detailed personal information to strangers. Arabs value privacy and guard it vehemently, even though privacy within a family is virtually nonexistent. They view the comprehensive health assessment on admission with suspicion and as an intrusion until the relationship between medical problem and personal questions is made clear to them. A formal interview in a non-Arabic language tends to yield answers designed to please the interviewer, to save face and to absolve the family from responsibility for the illness.23 Once trust with a caregiver is established, personal information is given more freely. We remind readers that political refugees, such as Iranians, Palestinians and other Middle Easterners who are here illegally, are likely to be highly suspicious of the questions of any "official." They may assume that a health professional has direct and regular contact with the immigration office or other government officials. According to what explained above, the following considerations will be taken into account:

1. Make sure that instructions are sufficiently clear to their language: why? What? How?

2. Time and dates needed to be set according to prayer time and Ramadan Karim

3. Participant need to be aware of the number of persons coming to their home and their gender

4. They need to be conscious of the time required for implementing the assessment

5. Ensuring participants that no voice will be recorded and no video will be taped from them, their home and their belonging

6. Making sure that take of shoes before entering the house

7. Make sure that the gender of the examiner is similar with participants if it is the priority or let them know the gender of the examiner in advance

8. Avoid touching any parts of the body’s of participants

9. Avoid asking them to take out their clothes

10. Avoid talking about drinking alcoholic drinks or pork meat

11. Avoid shaking hand unless the participant invites it

12. Avoid showing pictures related to sexual activates

13. Avoid asking questions related to family background, women and immigration status

14. Avoid searching the home

15. Try to welcome any treats served by participants

16. Try to avoid using the bathroom

17. Avoid bringing any pets to their home

18. Ensuring them that there are no any pictures related to undermining Muslims and middle easterners

19. Assuring that no photographs will be shown to inquire about their private activities

20. Make sure that they are provided with contact information for further questions

21. Let them give any comments or make any suggestions by the end of the evaluation

Accessibility considerations:

1. Discuss what is a need and discuss at least two different theories that explain needs assessment.

1. Critically appraise two different approaches to needs assessment. Within the approaches chosen, discuss the phases/steps involved in conducting a needs assessment.  

1. Drawing from the literature on needs assessments, identify a needs assessment approach and methods you will recommend to identify the health care needs of an immigrant group of your interest, with disabilities and chronic conditions. Explain why the approach and methods you are proposing aligned best with the purpose of your needs assessment and the population of interest.

1. Based on the review of the literature, make recommendations to occupational therapists on the best practices in the application of needs assessment.

0. Theories of Need Assessment

(Ndirango, 2007) Planning models used to engage community members in designing interventions in health have been developed. One example is comprehensive participatory planning and evaluation (CPPE).

Participatory planning models such as the CPPE model allow community members to actively participate in designing nutrition and other health interventions in their community. These models recognize that community members know their communities best. They allow researchers and intervention planners to take into account communities’ perspectives, strengths, and needs. The CPPE process enabled the community members engaged in this exercise to share knowledge of their community. Directly involving community members in identifying their problems and solutions to these problems allows program planners to develop interventions that may have greater acceptability with the community and likely more effectiveness and sustainability in the long term. Working in partnership with the universities benefit the community by bringing research resources into the community and potentially enhancing the capacity of its members. In turn, the university partners gained an insider’s perspective of the community, thereby increasing the likelihood of developing targeted programs that are more likely to be sustained.

(Hernandez, 2004) Most of the models that have been proposed as a guide for needs assessment are composed of two basic components: (1) description and prioritization of needs; and (2) analysis of possible resources and solutions for identified needs. In this way, needs assessment models have assumed that institutions and formal organizations are the primary source of support for individuals in need. Taking this perspective, we have developed a needs assessment model consisting of two main components: (1) description and prioritization of needs; and (2) analysis of both

Phase 1: Needs assessment planning: The main objectives in this phase are planning the study and contacting the community whose needs will be evaluated. Planning includes the following activities: (1) to define needs assessment’s objectives, as clearly and precisely as possible; (2) to establish the limits of the context, specifying the geographical area and the population whose needs will be evaluated; (3) to identify available information about need areas in order to make a first approach to the problems under study; and (4) to determine the information that is required to meet needs assessment’s objectives, the sources that may provide such information, the most appropriate research techniques, and the potential uses that will be made of needs assessment’s results. Together with planning, contacting the population whose needs will be evaluated is a central activity at this initial stage, particularly if community participation is to be promoted during the whole process of needs assessment. The identification of key members of the community is very important in this phase, not only as a relevant source of information about community needs, but also as possible mediators who may facilitate the researcher’s entry into the community. This initial contact is particularly important when assessing the needs of minority groups such as immigrants, homeless people, drug addicts, disabled people, victims of gender violence, etc., given the general difficulty in accessing these groups.

Phase 2: Needs analysis: The second phase is focused on the identification, description and prioritization of needs. Data gathering is organized in two stages: (1) exploration of need areas; and (2) description and prioritization of needs. In the first stage, key informants may be a relevant source of information, as individuals with personal and/or professional knowledge and experience regarding the population whose needs will be evaluated. Key informants could be part of this population (e.g. community or religious leaders, members of grass-roots organizations, etc.), but not necessarily, as is the case with professionals who provide diverse types of services to the people in need, and who are not members of this population. The use of qualitative research methodology (e.g. In-depth interviews, focused groups) is suggested, given its ability to provide in-depth descriptions about need areas. The second stage is focused on the description and prioritization of specific needs in each area, emphasizing the perspective of the community whose needs will be evaluated. The use of qualitative research techniques is again suggested (e.g. in-depth interviews, participant observation, focused groups), being a very appropriate means to analyses individuals’ perceptions, opinions and subjective valuations .This can be used together with quantitative methodology (e.g. structured interviews, surveys), due to the advantages of this latter approach for accessing big samples of individuals and generalizing results to all the population under study. The perspective of the community can also be complemented with information from other sources using diverse techniques (e.g. structured observation, archival records), in order to have a more reliable and complete description of existing needs. However, once such needs are described, the community is given a central role in setting priorities.

Phase 3: Social resources analysis: The last phase of the model is focused on the analysis of available social resources for needs satisfaction, distinguishing two complementary sources of assistance: the formal and the informal social support system. The former one is composed of those organizations implementing programs and services in certain areas, and the latter one by the whole interpersonal relationships that induvial maintain, as an important source of diverse kinds of social resources (material, informative, affective, etc.). The analysis of both systems is suggested, paying special attention to the following questions. As far as the formal support system is concerned: (1) identification of the organizations and institutions providing resources in the areas under study; (2) description of the programs and services implemented by those organizations; (3) analysis of the level of knowledge and use of these programs. Regarding the informal support system, two dimensions are explored: (1) social network structure; and (2) support functions performed by social relationships, paying special attention to the mobilization of resources. Social support has been analyzed from two main perspectives: the structural and the functional approach. Although the key aim in needs assessment is to identify and value the support functions performed by interpersonal relationships through the provision of diverse kinds of resources, social integration into a network of interpersonal ties is a necessary condition for support processes to be activated .The dimensions of interest will depend on the specific objectives in each research, however, some variables that are suggested to be examined are: (1) from a functional perspective: emotional, informative and material support that individuals obtain in their interpersonal relationships; (2)from a structural perspective: social network size, composition, density, homogeneity, dispersion, frequency of contact, reciprocity and multiplicity.

Once data gathering about needs and resources is concluded, the following step is the assessment of formal and informal support systems’ capacity to meet identified needs, emphasizing the valuation of their potential to solve existing problems, and the identification of needs that are not being met by available support. The analysis of the level of adjustment between needs and resources is essential to design interventions in order to fulfil deficient areas unmet by community formal and informal resources, and to mobilize those kinds of support that are insufficient but could be promoted through programs and services. Some of the questions that may be examined to evaluate if needs are being met by avail-able social resources are: (1) regarding the formal support system: Are there programs and services for each identified need? Are they known and used by the target population? What is the coverage of these programs? Are they effective to meet existing needs? (2)concerning the informal social support system: Do individuals have social ties who may act as a source of support? Do they have the resources needed to meet their needs? Are available resources sufficient? Are they utilized? To what extent are needs being met by informal social support?

2. Approaches in Needs Assessment

2.1. Practice-defined approach

The primary health care team is ideally placed to assess the health needs of its registered population. Members of the team typically have contact with 70% of registered patients annually and 90% of all health problems are dealt with in the primary care setting (Fry, 1993). An advantage of needs assessment at practice level is that solutions to problems can often be found more easily when supported by detailed local knowledge and research (NHS Training Division, 1994). However, just as general practitioners frequently fail to recognize individual needs in the community (Reid, 1992; Hopton and Dlugolecka, 1995), an undisciplined eye may neglect the needs of particular sections of a practice population. In Bradshaw's terms, this approach reflects expressed needs-or demands. 2.2. Patient-defined approach

A patient-defined approach to needs assessment is based on the demands, wishes and different perspectives of people on the practice list. The NHS reforms were supposed to promote greater responsiveness to users. The growth in consumerism as reflected in Patient's Charter initiatives, attempts to render fundholders accountable, and the development of audit are further encouraging the direct involvement of patients (Neve and Taylor, 1995). There are many ways of engaging patients in priority setting. Patient feedback can be obtained from suggestion boxes, participation groups, public meetings, interviews and postal surveys.

Qualitative strategies

Qualitative methods involve listening to people and becoming involved in their world-an exciting process that is already a motivating force for some general practitioners (Britten and Fisher, 1993). Qualitative research encompasses a variety of methods such as semi structured interviewing, observational studies, group discussions, and the analysis of written documents. Qualitative research can close the gap between the sciences of discovery and implementation (Jones, 1995). A range of qualitative techniques is needed to complement quantitative research (Pope and Mays, 1995). They are especially relevant in general practice (Murphy and Mattson, 1992). The qualitative approach requires researchers to listen to people and communities in an open way. The respondents themselves can select the important questions on an issue. The validity of such research does not stem from statistical generalization but on logic other than probability theory. Qualitative studies allow a better understanding of why people think and act in the way they do and allow them to express their needs freely. This approach allows people to feel actively involved rather than being passive providers of information. It can provide information on sensitive topics (Currer, 1991). It is flexible and allows the research design, the sample, the topics to be covered, and the means of exploring these topics to be amended during the research process in the light of earlier findings. Qualitative research will not establish how many people in a locality need a particular kind of service, but it will provide a sense of the range of perceived health needs within the area, the relative importance individuals attach to them, and ideas about how they can be met (Ong et al., 1992). One strategy or 'toolbox' which brings together a number of qualitative methods is rapid participatory appraisal.

3. Methods

Focus group and interview:

Part 1. Summarize what the literature says about the occupational transitions experienced by this population during and after migration. Consider the importance of roles and routines and how these are affected by the migratory process.

Part 2. Identify and describe barriers and supports that influence the occupational participation of refugees and immigrants, and subsequently their integration into their adopted community(ies).

Part 3. Discuss/present two case studies from the literature you have reviewed to illustrate your responses in Parts 1 and 2 through the lived experiences of these individuals.

1. Occupational transition

(Bennett, K. M., Scornaiencki, J.M.2012) Engaging in meaningful occupations is essential to one’s health and well-being. occupation is everything people do to occupy themselves” including self-care, productivity, and leisure. Individuals often immigrate in search of an improved quality of life; however, with any move, life disruptions are inevitable, impacting an individual’s ability to engage in familiar roles, routines and habits. The process of immigration can often lead to occupational interruption, deprivation or alienation, which can all impact a person’s quality of life. According to Yerxa (1991), finding meaning, having an active role in society and having a sense of cultural connectedness are all possible through engagement in occupations, and McKay and Molineux (2000) stress that occupations play a significant role in formulating a person’s identity.

1.1. role change

Role change is described as a change in “a culturally defined pattern of occupation that reflects particular routines and habits. Whiteford (2005) discovered that the experience of trauma in a refugee camp and the process of immigration have a profound impact on the refugee’s ability to engage in basic occupations. Two other important factors in the literature on role change are social isolation and exclusion. Burholt (2004) found that older Bangladeshis were more segregated, disadvantaged and socially excluded than other South Asian immigrants. The author attributed the Bangladeshis’ pattern of settlement and relocation within the UK to several factors including “living arrangements, education and language abilities, occupational status, and settlement and moves within the United Kingdom”

1.2. Work

The relationship between work and immigration location, pre-immigration education and postimmigration employment, as well as the overall impact of work on immigrant’s lives, were all factors that influenced employment. In their study on location choice for immigration, Scott et al. (2005) found that high wages and educated populations were the most significant influences for employment-seeking immigrants when choosing a host country.

1.3. Identity

Nayar and Hocking’s article (2006) highlighted the importance “of retaining activities that are culturally familiar and involve traditional practices, both when new immigrants initially arrive in the country and as they go about establishing their daily lives in New Zealand”. Nayar et al. (2007) also found that continuing cultural practices and the individual’s personal motivation to perform occupations of interest, as well as the individual’s increasing familiarity with the new environment, played an important role in their adaptation.

1.4. Health and Well being

Articles that presented both physical and mental health issues had an emphasis on stress and trauma experienced in the immigrant’s home country, which impacted their ability to engage in occupations within their new culture. the decreased availability and increased costs of ethnic foods, as well as changes in preparation routines, resulted in poor dietary intake following immigration to the United States . Im and Choe (2001) found that Korean women who immigrated to the United States reported a lack of social supports, limited financial resources, language barriers and marginalized status as the main barriers to participating in physical activity. These authors also found that immigrant women faced barriers to physical activity because of their busy daily lives, financial problems, lack of social supports, lack of skills in the English language or marginalized social status. Furthermore, a study by Colby et al. (2009) found that environmental and social barriers, social norms and a busier lifestyle led to decreased physical activity. Many authors also considered the relationship between immigration and stress and trauma. Life satisfaction was positively influenced by standard of living, degree of religious observance and perceived identity by others . Delle Fave and Bassi (2009) found that an immigrant’s experience in a new country is improved by having hobbies, productive activities and social relations and that access to optimized life experiences can be related to higher educational level, engagement in professionally qualified jobs, length of stay in the host country and immigration status.

The findings from this review have demonstrated that the effect of immigration on occupation is complex and multidimensional, often affecting key areas of an immigrant’s life, including self-care, productivity and leisure. As identified in this review, immigrants’ occupations change as a result of immigration and thus who they were and how they once saw themselves also change. In an attempt to adapt to one’s new culture, immigrants often feel forced to abandon previously known occupations for new and unfamiliar occupations; therefore, Gupta and Sullivan (2008) stress that integrating into the country of immigration, while still maintaining one’s cultural heritage, is the best method for acculturation.

Implication for practice:

(Kim, H., Hocking,2016) Research reveals that in order to fit in and interact, immigrants need to learn and adapt to differences in the host society, changing the way they dress, eat, drive, shop and even their greeting procedures . This suggests that immigration can be defined as a process of adaptation and to understand how immigrants re-build their lives it is necessary to question what these adaptational tasks are. A critical component of building that understanding is the occupations in which immigrants engage. The rationale for this claim is that people must engage in occupation to continue their lives. occupation provides a mechanism for social interaction; People enact occupation within their culture, and every occupation has physical, social, psychological, emotional, and spiritual dimensions . Occupation is thus understood to provide the basis for people’s feelings about themselves and their relationships with others .They attach meaning to their occupations and, through engaging in occupation, make sense of their existence and give life coherence. immigrants often assigned meaning to occupations based on this belief, regardless of the quality of those occupations, as they believed it was a way of fulfilling their cultural values. Engagement in personally meaningful occupations thought to influence health, identity and well-being; thus, understanding the meaning of occupation is a necessity when supporting participation in society.

language and cultural differences constrain Korean immigrants’ social activities , create difficulties establishing relationships with neighbors and limit their involvement in the host community . Their potential is underestimated by members of the host community, further limiting their capacity to participate in civic society. they experience a degree of acculturative stress, ranging from language difficulties to disruption of their family and social support networks. in particular, constraints in the labor market and difficulties in employment are associated with an increased risk of low self-esteem and isolation. Many immigrnats do not have a specific goal or plan for their new life. This resulted in them being in a vulnerable position when it came to adapting to New society. It is undeniable that the majority of the participants in this study experienced occupational disruption for a period of time. Social isolation, coupled with discrimination, meant that many of them were initially unable to participate fully in occupations of meaning and necessity in the context of their new country. Limiting opportunities for participation in many aspects of life, such as work, and resulting in some of the immigrants being overqualified for their cur-rent job. Many participants started their new life from the bottom; for example, learning English, enrolling in a course to get a qualification, or taking menial jobs. his experience was associated with diminished life satisfaction, leading to devaluation of themselves.

Existing Networks (family and friends who already resided in new area) are vital to immigrants gaining familiarity with their new environment, as they could seek advice or support from them. immigrating to a new culture presented an immediate challenge in preserving cultural traditions. This experience resulted in losing control of occupations which had previously enhanced their social identity. immigrants continuously make an effort to interact with the out side world, such as by visiting local shops, travelling around, or being a volunteer. Whilst gaining familiarity with their new surroundings, some immigrants come to appreciate what this country offered them, such as family time and the natural environment. These positive experiences contributed to some immigrants accepting this land as their new home. For Korean immigrants, successful settlement was not all about mastering physical surroundings nor adjusting to a new culture. Instead, it was about finding a location whereby they hoped to value themselves. Many of the immigrants defined the community as an ideal place to create new networks and worked on getting to know their neighbors and being involved in the community. To achieve enough balance to continue their lives, immigrants initially behaved in Korean ways. This strategy was deliberately chosen by those who wished to retain control by using their existing knowledge and networks. To retain internal continuity, participants used familiar skills such as eating Korean foods, reading Korean books, listening to Korean music, and preserving the Korean language. Some Korean immigrants gradually learnt about their new community and established their own networks with local people. In response, they made their best efforts to manage disrupted occupations and many eventually demonstrated the capacity to be adaptive.

(mayne,2016) Occupational expectations particular to individuals were also identified in this review, suggesting a potential mismatch between refugees’ expectations and the opportunities afforded to them by the Australian community on arrival. These men, who had previously been employed within their home countries, described their expectations of being self-sufficient and productive members of the Australian community. Instead, they found themselves unable to obtain work and reliant on government support for housing and financial assistance.

Establishing Occupational Routines on Entry: A number of studies suggested that the establishment of occupational routines becomes particularly important during the resettlement of refugees and asylum seekers in their host country. During this phase of transition, instability in occupational routines has been reported to negatively affect the health and well-being of refugees and asylum seekers. As such, the establishment of a home and occupational routines have been suggested as imperative to refugee and asylum seekers’ sense of adjustment and readiness to engage within society. A number of studies also noted that the initial period of transition requires adaptation to a wide range of new information, sights, sounds, people, and places , and further, that the demands of the new environment typically require restructuring of routines and habits, and learning new cultural practices. Certain occupations were also reported as needing to be prioritized more than others. For example, low wage employment might be prioritized more than language classes , or homemaking more than physical and mental health–related appointments . A number of papers suggested the importance of considering the impact of trauma experiences on the occupational engagement of refugee and asylum seekers . Others suggested that restorative and restful occupations such as leisure and sport , as well as places of peace and safety , could serve to remediate the negative impact of trauma. Some studies suggested that rehabilitation of basic occupational skills may be necessary for those who have experienced a loss of valued occupations for extended periods .It should be noted, however, that in some instances, access to support services, health care, and working rights can be restricted .Where these restrictions apply, the ability for asylum seekers and refugees to establish meaningful routines and contribute productively to society may be significantly impaired . The impact of discourse on roles and relationships was also noted as significantly affecting the ability of asylum seekers and refugees to develop stability within their new community. For example, several studies noted that in some communities, particularly those faced with economic challenges, refugees and asylum seekers may be discursively represented as destitute, dependent, and demanding people, arriving to strip the community of resources and welfare. A number of studies also found that those unaware of the circumstances of refugees and asylum seekers, questioned at times the increasing presence of these individuals in their community and what impact this may have on their own job opportunities and social cohesion .

Pursuing a personally meaningful life: Another theme identified in the review was related to pursuing a meaningful life. Several papers suggested that once a sense of initial stability has been attained, refugees and asylum seekers were able to more confidently pursue occupations of greater personal meaning within their country of resettlement . In their recent scoping review, Huot et al. (2016) highlighted the process of identifying and negotiating identity, values, and goals within the new context as being key to this derivation of meaning. Werge-Olsen and Vik (2012) suggested that the extent to which refugees and asylum seekers can realize their occupational potential is heavily influenced by the cultural norms and social attitudes to which they are exposed. Volunteer roles and involvement in local school boards have also been reported as providing structure to days, a sense of contribution to the community and important social connections. suggested that these meaningful occupations not only foster well-being but also nurture a sense of belonging and restoration. Furthermore, they argue that positive occupations, safe places to undertake them, and local communities with whom they can be shared, all contribute to the capacity to pursue a personally meaningful life. (nayar, 2006) occupational therapists have identified that immigration can be a stressful proposition that requires adaptation and adjustment of valued occupations, such as shopping and socializing with friends and family . For those individuals struggling to adjust to their new environment, occupations may be uncomfortable, unfamiliar or energy-intensive experiences, which give rise to feelings of incompetence, frustration, foreignness and ‘dis-ease’. When also confronted by commonplace practices and assumptions of the local people that contravene their values and beliefs , the potential for disruption to immigrants’ occupational performance and wellbeing may be immense. The act of immigrating has a significant impact upon immigrants’ wellbeing. Arriving in a new environment, migrants are confronted by major changes in lifestyle in terms of work situations, language difficulties and loss of social supports, to name but a few. Making these lifestyle changes in a culture complete with its own implicit rules and expectations poses threats to migrants’ perception of themselves as competent beings. In addition, the overall challenge of integrating with society has the potential to undermine psychological wellbeing. occupation is an important determinant of immigrant health. This assumption is consistent with the known relationship between what people do and their health, as seen in Fidler and Fidler’s (1983) proposition that having good health (physical, mental and spiritual)relies on the individual being ‘active’ or ‘doing’ in the context of occupation. Increasingly, this assumption is recognized not only in the disciplines of occupational therapy and occupational science but more globally, particularly in the field of health promotion (HealthPromotion Forum 2004).

Immigration as disruption of occupational routines: When people live in one place for long enough, the spaces in which they perform everyday occupations become familiar. Indeed, Kielhofner (2002) proposed that overtime, habits are generated by consistently performing the same occupation in the same context and that much of what an individual does during the course of a day or weeks guided by these habits. However, given that occupational patterns take time to develop, a key factor in the immigration process is the ensuing disruption to established ways of doing things. It is not surprising, therefore, that immigration has been described as a ‘discontinuity’ in a person’s life space (Adams et al 1976) and, according to Blair (2000),‘discontinuity requires alteration to routine, habit and the taken-for-granted configuration of occupations’ (p232).Leaving one’s home environment carries the risk of leaving behind established and comfortable routines, which were supported by familiarity with the place and ease of locating the objects within it.

Occupation as socially sanctioned: as well as performing to our own satisfaction, wellbeing is derived from the performance of occupations in ways that conform to societal expectations. Indeed, it has been argued that a major part of wellbeing stems from the interaction between the individual engaged in occupation and others in the environment. Hence, occupation that both satisfies the individual and meets societal values can be assumed to support wellbeing. In this context, values are defined as sets of convictions, beliefs and commitments that bind individuals to action over the course of their lifetime. Naturally, different societies hold values that have evolved from, and align with, their particular culture and there is growing recognition of the importance of cultural differences in occupation. Recognizing that immigrants bring their cultural heritage with them, occupational therapists might predict that the extent to which immigrants experience occupational disruption will relate to the extent and nature of the differences between their values and beliefs and those typically held by people in their new context. In particular, individuals entering a new environment where they are unfamiliar or uncomfortable with local values and beliefs may find themselves engaging in occupations that are not socially sanctioned; for instance, drinking in public and wearing shorts are common activities in New Zealand but are not traditionally encouraged for Indian women. This may place stress on the immigrant’s personal value systems, which will potentially have an impact on his or her satisfaction and wellbeing.

Occupation as underpinning identity and sense of competence Christiansen (1999, 2000) and Kielhofner (2002) have both made significant contributions to identifying the relationship between occupation and identity. Christiansen (1999) asserted that identities are shaped through the choices that people make about which goals to pursue and the everyday activities that will achieve them. Kielhofner(2002) spoke about ‘occupational identity’, a term that serves both as a means of self-definition and as a blueprint for what will happen in the future. As Kielhofner (2002)portrayed them, some of the key ideas that form the essence of occupational identity are one’s sense of capacity and effectiveness for doing, the things one finds interesting and satisfying to do, and a sense of the familiar routines of life. Thus, occupational identity is a complex term that takes into account not just the individual but the world in which that individual exists. This notion of the ‘world in which one exists’ or the environmental impact on identity is further highlighted in Taylor’s (2003) assertion that occupations have both personal and social meanings, all of which are interwoven with the complexities of the sociocultural context. This is a particularly important concept when thinking of culture-specific identities and how these are formed. Within cultures, specific occupations and rituals have been passed down through generations and, when combined with one’s chosen occupations, merge to define and shape one’s identity (Desai 1999). From this notion of culture-specific identity, engagement in occupations can be seen to enhance opportunities for growth and construction of identity, whereas having restricted access to occupations could potentially limit one’s perception of oneself and one’s social identity.

Supporting immigrants to incorporate cultural activities in their daily routines may engender a sense of comfort, safety and familiarity in an otherwise turbulent time. findings suggest that building routines, such as repeated use of key community resources like the supermarket, helps to establish a sense of familiarity and ease in new surroundings. From this stable base, immigrants can begin to explore other aspects of their community and to try new activities. In so doing they gain skills and expertise and learn how the local people do things, thus supporting Hamilton’s (2004) assertion that the things people do are influenced by the places in which they find themselves. Achieving this, cautiously and overtime, provides a sense of competence and lays the foundation for a sense of belonging, which supports health and wellbeing. Moving towards finding their place in society requires perseverance, particularly in relation to seeking and creating opportunities to get involved indifferent activities. This is a necessary part of choosing which activities or aspects of activities to pursue, and allows immigrants to make decisions for themselves about what they need to do in their daily lives to support their health and wellbeing. Assisting immigrants to engage in everyday occupations in a new and unfamiliar place is likely to increase their ability to master new ways of doing things and thus support the development or nurturing of a positive sense of self and wellbeing. This in turn will ease the stress implicit in integrating into a new culture. Connecting new immigrants with support groups within the local community might also provide avenues for the immigrants to share their experiences of trying to do things in a new environment as well as assisting with the development of an extended network of support, a significant marker of wellbeing.

2. Barriers

(Koczan, 2016) In the popular mind, migration is often associated with an increase in well-being, as embodied in narratives of the ‘promised land’ and a move ‘in hope of a better future’. Recent studies have also increasingly looked at the impact of migration and integration on life satisfaction and have raised concerns that migrants may be less satisfied than the native population and that this could be driven by cultural factors, such as feelings of not belonging. Two explanations were often brought forward for this: discrimination and feelings of not belonging or loyalties towards immigrants’ countries of origin.

(Hon, 2011) Human occupation involves abilities, skills, time place and is dependent on personal, cultural,,social, institutional, historical, and geographic contexts. Immigration can result in occupation disruption. Finding ways to maintain culturally meaningful occupations, such as sewing, has been found to be a meaningful for some immigrant women in South Australia. engagement in meaningful occupation not only meets biological needs but is essential for healthy adaptation, and that health should be ‘‘perceived as possession of a repertoire of skills enabling people to achieve their goals in their own environments’’

(Krishnagiri, 2013) Understanding what individuals‘‘ need and want to do’’ is critical to explaining the relationship between occupation and health. In immigrant populations, the ability to adapt and establish routines in a new environment is important in determining health. That is, learning to maneuver in the new environment, finding out where one can meet peers from one’s own culture, and learning ways to access social programs and community resources are key to a sense of control and choice.

immigrants undergo dramatic changes when moving to the US: many feel a loss of resources and an absence of accumulated personal accomplishments. Within immigrant population, lack of cultural continuity, instability in the family home, or dysfunction in interdependence can lead to diminished role identity, and feelings of loss and isolation. These are risk factors for depression and migratory grief.

Immigration presents a major challenge to developing and establishing new occupational routines, especially for immigrants who not only experience disruption of their former routines (People who immigrate later in life experience disruption of their former routines that may prevent their participation in meaningful and health-promoting occupations) but also encounter limited English proficiency, lack of mobility, lack of awareness of community services, and lack of culturally relevant or responsive services. However, having spousal companionship, upper middle class living status, and education mitigates these issues; Higher levels of education mediate mental health. Discerning how they develop meaningful acculturative responses is crucial to understanding the barriers and facilitators of health.

many immigrants faced barriers to engagement in health promoting occupations (Regarding perceptions of health and health-related occupations, immigrants have markedly different underlying metaphors and philosophies of health and healing from mainstream Americans, and they view health holistically in terms of overall well-being, functionality, and happiness). The barriers include limited English proficiency, transportation issues, lack of opportunities for socializing with peers, and lack of knowledge and access to community programs, time constraints, lack of knowledge pertaining to medical diagnoses, poor communication with health professionals, and lack of motivation which result to loneliness, isolation, boredom, compromised mental health, and dis-satisfaction with their lives in their new environment. Barriers to engaging in occupations that lead to being healthy appear when interdependence with the family/community and individual control are out of balance.

These barriers prevent immigrants from knowing, understanding, and choosing to engage in healthy occupations such as some form of exercise, healthy cooking, hobbies, and socializing. Several studies examined leisure and non-leisure physical activities and compared the elder immigrant group to native born elders, concluding that immigrants were much less likely to engage in physical activity due to lack of motivation, understanding, and access.

The particular relationships with family members, peers, and spouses and the attendant role expectations reinforce new identities and influence engagement in occupations. immigrants echoed needing to be with others of the same culture and similar age, aware of themselves as interdependent social beings, and that social participation was natural and desirable for their mental wellbeing.

The lack of access to cultural peers for socialization and lack of independence in mobility were the main areas of dissatisfaction. The desire to preserve their culture and being aware that they not only belong to their country of origin but also their adopted countries motivated occupations. The ability to engage in daily activities is dependent on one’s physical health and general well-being (Health is perceived by these study participants, in terms of functional ability for daily occupations, including roles in the home, access to leisure and social participation, and as far as possible being free from physical and emotional pain and disability). Routine engagement in physically demanding occupations was often perceived as necessary to health, and part of a personal regime, like yoga or aerobics, but also as more enjoyable when done with others. Control surfaced when participants were asked about the meaning of health. Many defined health by the ability to participate in occupations with-out physical or psychological restrictions. in summary, the participants consistently explained their daily routines and rationales for occupations in terms that involved their inter-dependence with other people and the amount of choice or restrictions they faced, whether this involved diet, physical exercise, time of activity, transportation, health, or socialization.

(smith, 2018) n arrival in another country, they may find their occupations inhibited by policies such as the denial of opportunities to work and study, or made more difficult by everyday practicalities such as language barriers. These barriers can create lasting negative outcomes for individuals, families and the host community.

Contexts that disrupt or deprive people of the opportunity to engage in satisfying and meaningful occupations are thus regarded as contributing to occupational injustice. Racist social attitudes, government policies that perpetuate inequality, and media campaigns that portray groups of people as threatening, can all contribute to occupational injustices through the discourses they promote.

2.1. Supports

status, and better access to community/social resources were found to have a more positive effect on their occupational engagement experiences.

(hout, 2018) They expressed that meeting with people who have a lot in common, including but not limited to a shared language, was helpful in several ways. they explained that ethnic communities could provide a base for helping to raise one’s children and especially for immigrants, a faith-based community could provide an extended/surrogate family where one’s own family may have been left behind in the country of origin. Such connections could help cope with stress.

(Martines, 2007) Immigrants have to adapt to a new physical, social, cultural, political, and economic environment in the new host country. The process of adjustment is greatly influenced by these components . From an occupational standpoint, the adjustment process involves taking on a variety of new occupations as well as retaining and modifying many roles and routines.

As occupational therapists we seek to understand occupations. Occupation, however, is a highly cultural concept and different occupations hold different meanings in different cultures. Fitting into society and coping with a new life is seen to be a process influenced by personal and emotional factors, the ability to maintain old cultural values whilst adopting new cultural values, and the ability to cope with new weather condition. Being young and healthy is described as a key factor in adjusting to a new life in, especially in light of the winter climate for some of the participants. The main challenges that the majority of participants mentioned related to a lack of leisure time and adjusting to the climate. Goals and concerns related to employment, growing children, and housing were expressed by the majority of participants. Other concerns related to the acculturation process affecting their children and housing issues. adopting new cultural values such as learning to live independently without support from extended family and friends was the biggest change reported. This can affect occupational balance negatively and can lead to burn-out and other health issues. Overall, although the participants experienced several challenges related to adjusting to a new life, they were able to clearly identify a number of coping strategies. From an occupational standpoint, these strategies can be thought of as new occupations. Learning new skills, such as attending language classes, upgrading educational and job-related skills, accessing and utilizing community resources, building new friendships, and actively seeking out information about their new environments, are all examples of such occupations. Engaging in these new occupations had a positive effect on the experience of adjusting to a new life. The majority of the participants also expressed that a key benefit of living in place was the fact that there was a variety of community resources available that they could access easily. When they accessed these community centers, they described feeling that they encountered friendly service providers who were helpful and pointed them towards the information they were looking for, such as parenting classes, language classes, social groups, and other educational programs. Exploring affordable and meaningful leisure pursuits that have the potential to simultaneously provide pleasure and opportunities to learn more about the new society or include children in activities can facilitate an occupational balance when leisure is lacking.

3. Case study

(tavares, 2017), Disability and migration interact to affect participation in daily life . Both can create social, economic and cultural distress, affecting emotional health, well-being and occupational adaptation . Different opportunities and differing ability to participate in these opportunities has been found to result in a broad variation of experiences and a struggle to achieve occupational participation and normality. A variety of factors may explain the health vulnerability of people living with a disability. The World Report on Disability (World Health Organization, 2011) highlights that people living with disabilities around the world have to focus on everyday survival, with less focus and resources directed to productive employment and personal fulfilment. to improve the health of people living with a disability, there should be a focus on increasing social participation and physical activity, improving financial conditions, and decreasing disrespectful treatment and discrimination. Studies of immigrants’ health in Europe point in different directions, and health differences between immigrants and non-immigrants seem to be related to socioeconomic status. In general, immigrants have been shown to have poorer health and an inferior position in the labour market. Additionally, immigration has been shown to impact on daily occupations in a complex and multifaceted way. Participation in daily occupations is vital for all humans, and participation in meaningful occupations is considered essential to health and well-being.

Participation process:

 Mastery of daily occupations : endeavoring to manage daily life by being able to perform occupations, understanding occupations and their context, and by communicating with others

 Meaning in daily life: endeavour of achieving fulfilment, satisfaction and pleasure in daily life, as well as the need to produce and contribute to society

 Connection to places and people: The subprocess where the participants strove to

achieve connection meant that they were in places and had contact with others; through meetings and occupations interactions took place. To achieve a connection, access to places and social contact with others was required.

 Belonging to groups: self-perceived role within a group and the group’s view of their role. The subprocess of belonging could lead to inclusion in, or exclusion/ alienation from a group.

 Trust of others: striving to achieve respect from and credibility with others. Participation among people living with a disability has been described as complex a multidimensional, and has been shown to be important on both a personal and a social level.

Participation has also been described as a dynamic transactional process , ,supported by occupations that are also understood as transactional processes. Professions can take a critical approach by focusing in changing the regulation, policies, laws, economic practices, media images, professional practices and other forces creating inequalities that constrain equality of occupational opportunity. Previous research about refugees with disabilities resettled in the United States has shown a disconnection between refugee and disability service system which resulted in both unmet disability-related needs and limited access to resettlement resources. Participation in occupations has been highlighted as a contributor to identity, and when the identity is accepted and consistent with other people’s views, it contributes to coherence and well-being. According to Hammell (2015), participation should be addressed as being related to an equality of opportunities, to occupational rights and to human rights. Equitable access to participation in daily life should be ensured, regardless of any differences that exist. In fact, the occupation of individuals and groups in society is seen as the key to achieving participation and inclusion in society. Occupational opportunities in society and the person’s abilities to perform occupations influenced the participation process. The intersection of disability and migration could lead to disadvantages and social exclusion.

(whiteford, 2005) Upon arriving in the new country, refugees will be looking for the creation of a new home and achievement of equal status in country of resettlement. Interestingly, occupational participation is seen as central to this process. That occupational participation is also an important means through which the effects of trauma, torture and refugeeism can be ameliorated. A case study of Kosovo Ian Refugee suggests three issues that attached in the area of occupational deprivation. The first challenge is that discrimination of different cultures and ethnical diversity result to occupational deprivation by preventing refugees from taking advantage of available opportunities that lead to fulfilling occupation with the passage of time. The second one is that the resettlement process and all issues therein sometimes create a situation for refugees to push them to struggle with overcoming those issues thus preventing them from engaging in the activity of their choice occupation. The third challenge is the context of new community, which presents as a barrier to the development of meaningful occupation for refugees