Critique of Austin’s Health Protection/Health Promotion Model
KEY WORDS: Therapeutic Recreation, Model, Health and Wellness
On quick glance, the Health Protection/ Health Promotion Model (Austin, 1998) appears to be an extension of the Leisure Ability Model (Peterson & Gunn, 1984). The Leisure Ability Model’s ultimate goal is leisure. The Health Protection/Health Promotion Model utilizes leisure as the final means towards its ultimate goal of optimal health. The Leisure Ability Model’s population is persons with “disabling conditions” (Peterson & Gunn, p. 4). The Health Protection/ Health Promotion Model’s population is expanded to include persons desiring or needing to improve their health. Today, with the focus/goal of managed care purported to be health protection and health promotion, Austin’s model is more congruent with contemporary health care. Thus, Austin’s model opens the door for therapeutic recreation to become an important reimbursable service, benefit service, or provided service for a broad segment of the population in a variety of traditional and non-traditional settings. Interestingly, the recreation and leisure profession, as embodied by the National Recreation and Park Association and its benefits and healthy lifestyles campaigns, is also directing its focus on health and wellness. Therefore, this model remains congruent with the recreation and leisure profession.
The Health Protection/Health Promotion Model’s outcome is health (health protection) and wellness (health promotion) with prescriptive activities, recreation, and leisure as means towards these ends. By utilizing a broad, holistic definition of health, the model focuses on the whole person. Health care is gradually moving to a broader definition of health. It is undergoing a paradigm switch from allopathic medicine (i.e., focus on illness and disease) to holistic medicine (i.e., focus on whole person) and incorporating alternative methods with traditional methods within a continuum of care framework. Given this changing health care environment, Austin’s model becomes particularly meaningful, especially if supported by research. Unfortunately, the operationalization of the model has weaknesses. (See Components and Implications for Practice Process below.)
Austin(1998, p. llO) identifies “four major concepts that underlie the model . . . humanistic perspective, high-level wellness, the stabilization and actualization tendencies, and health.” Although he uses recreation and leisure as avenues to health and wellness, and the model is consistent with current leisure theory, he neglects to answer the question “Why recreation and leisure as means to health and wellness?”. Further, he fails to identify and discuss recreation or leisure as part of the foundation of the model. Without such a discussion, the utilization of recreation and leisure to reach health and wellness lacks substance. Additionally, Austin omits discussing intrinsic motivation and existentialism; both appear highly relevant to his model.
Austin’s model could be strengthened by considering the following:
1. Leisure is a complex phenomenon. The meaning, context, form, and function of leisure vary at any given time, among individuals, over the life span, and in relationship to health and wellness. Further, no activity is innately or consistently leisure (Kelly, 1996; Mannell & Kleiber, 1997; Shaw, 1985).
2. Leisure’s defining characteristics are (a) freedom and (b) intrinsic motivation. Freedom may be viewed as “freedom from” and “freedom to” (Kelly, 1996). “Freedom from” can be equated with health protection and “freedom to” can be equated with health promotion. It is in the former instance that the individual moves away from illness. It is in the latter instance that one is “becoming,” “developing,” which is consistent with the humanistic perspective and high level wellness.
3. Leisure is “activity chosen primarily for the experience itself ‘ (Kelly, 1996, p. 31). As such, not all activity that constitutes leisure contributes to health protection and health promotion. Leisure, therefore, cannot be viewed principally as a means to health. Finally, it would be useful if Austin identified the basic assumptions on which the model operates (e.g., recreation and leisure have the potential to act as therapeutic agents.)
The model consists of three components: prescriptive activities, recreation, and leisure. These components are depicted along a continuum with prescriptive activities at one end and leisure at the other end. Throughout the continuum, Austin (1998) recognizes the importance of motivation and enjoyment in living to health, wellness, and successful treatment. As the client moves along the continuum from prescriptive activities to leisure, the role and control of the therapeutic recreation professional diminishes and the role and freedom of the client increases. The components are correctly positioned on the continuum in relationship to freedom and control. That is, by definition, prescriptive activities encompass the least amount of freedom and leisure encompasses the most amount of freedom. The difficulty is that Austin does not delineate the content of each component nor provide specific direction for the implementation of the therapeutic recreation process within the components of the model. Further, the model is complicated by Austin’s choice of component names. It is unclear if Austin intended the component names to be simply titles or also tasks, content, or outcomes of the particular component. Leisure is conceptualized with perceived freedom as a primary characteristic. As such, how can it be subjected to treatment; that is, manipulation and intervention? Austin ( 1998) further confuses the situation by discussing recreation participation and outcomes without indicating how and why it is a therapeutic recreation intervention rather than just recreation participation. In the “case study,” he discusses the acquisition of new skills and leisure counseling within the context of the recreation component without previously explaining the relationship. It would be helpful if Austin returned to the components and provided more direction for the practitioner. This is necessary to enable the therapeutic recreation practitioner to articulate and implement the practice model as well as to position therapeutic recreation for a future in the changing health care arena.
Implications for Practice Setting
Today, health care services extend far into the community beyond hospitals and physicians’ offices and services. Health insurance is requiring that service providers do more with less. Many health insurance providers are promoting health prevention as a cost-saving means. As such, they are reimbursing, or providing discounts, for fitness, wellness, health education, and health promotion programs in a variety of settings (e.g., work place, health/fitness club). They are also sponsoring health-related programs including work and community special events.
The Health Protection/Health Promotion Model, as Austin indicates, enables therapeutic recreation to be practiced in all settings within the health care system while limiting its practice in other settings. In light of the above, this model has the potential for increasing the presence of therapeutic recreation in non-traditional settings such as health clubs, hospital/community health/ wellness education programs, and employee wellness programs. Also, this model could maintain therapeutic recreation’s presence in community recreation and school settings as their focus and roles are re-defined.
Appropriately, the Health Protection/ Health Promotion Model is based on client need rather than client characteristic. As such, it enables therapeutic recreation to serve the general population if persons are seeking or needing to learn/gain attitudes, skills, and knowledge to enable them to achieve optimal wellness. This model requires further delineation in relation to the specific needs of various populations (e.g., persons of any age with permanent physical disabilities, chronic non-mental health illnesses, terminal illnesses, developmental disabilities, and frail, older adults). To an extent, Austin (1997) has done this in his text.
Austin indicates that within the Health Protection/Health Promotion Model the focus of therapeutic recreation is to facilitate the client’s movement through the continuum to optimal health. How this is to occur remains unanswered. In his text, Austin (1997) presents a variety of techniques a therapeutic recreation specialist could use but does not attach any to specific parts of the model or specific outcomes within the model. There is no mention of an education process yet health care today is heavily incorporating it. Also missing is the development of functional skills, a major focus of rehabilitation. As previously discussed by this author in the component section above, the major difficulty in implementing the model is that the components are unclear and do not provide sufficient direction for practice. Consequently, it is very difficult to plan and implement the therapeutic recreation process (e.g., assessment, intervention including content, strategies, modalities, and techniques) and evaluate outcomes. Before the therapeutic processes can be further developed (e.g., protocols) and implemented in a systematic way to produce the outcomes of health protection and health promotion within the context of this model, the components need to be better delineated. Professional Issues Education The model still requires a strong academic basis in recreation and leisure with supportive knowledge in social and biological sciences and health care. As Austin’s (1998) model utilizes recreation and leisure as means to health protection and promotion, it remains appropriate for therapeutic recreation to be an option within recreation and leisure. What is critical is that recreation and leisure curricula continue to develop and emphasize leisure theory and behavior within a social sciences framework. Additionally, therapeutic recreation students and professionals will need more knowledge and higher level skills related to health and wellness. Definitions and Standards of Practice Austin’s (1998) model meshes with ATRA and NTRS’s definitions of therapeutic recreation with the exception of target population. ATRA and NTRS’s definitions identify the recipients of therapeutic recreation services as persons with disabilities and illnesses. Austin’s model identifies recipients based on health related needs. Providing therapeutic recreation services based on client need rather than client characteristic (i.e., disabling condition) better fits the therapeutic recreation process. NTRS’s Standards of Practice relate directly to the Leisure Ability Model and, therefore, are not compatible with the Health Protection and Health Promotion Model. The Health Protection and Health Promotion Model, as explained in Austin’s text (1997), would be congruent with ATRA’s standards if ATRA re-defined its target population. Relationship with Recreation and Park Professionals This model finally takes therapeutic recreation professionals out of the realm of providing “recreation for special populations” and allows therapeutic recreation to re-partner with leisure professionals. Therapeutic recreation professionals would work with recreation, park, and leisure professionals to bridge the gap between recreation, leisure, wellness, and health care for all people. The economic constraints and goals of managed care and Healthy People 2000, as well as the therapeutic recreation process, would further define their relationship. Public Policy Health care payers and policy makers want an outcome of lasting value. They want this achieved in the most efficient, effective, economically feasible way possible. They are not interested in leisure per se. If research can demonstrate that therapeutic recreation produces health protection and health promotion in an efficient, effective, lasting, and economically feasible manner, then therapeutic recreation may become more prominent in health care practice and policy. This may be particularly significant as therapeutic recreation lends itself to being practiced outside the traditional model of health care and tends to cost less than other traditional rehabilitation and health care services.
Healthy People 2000 (1990), a project of the U.S. Department of Health and Human Services, identified three goals to significantly improve the health of Americans: “increase the span of healthy life for Americans,” “reduce health disparities among Americans,” and “achieve access to preventive services for all Americans” (p. 6). The Pew Health Professions Commission (1995) called for changing the roles and education of health professionals, establishing new linkages, and revamping the delivery of health services. If Healthy People 2000 strategies extend into the school system, then therapeutic recreation may find a new niche in education including in relationship to IDEA legislation. Austin’s (1998) model nicely positions therapeutic recreation to be a part of this agenda. Implications for Research Under the Austin (1998) model, the cry for more efficacy research remains the same with the focus switching to health protection and health promotion. One major problem for research is that the model lacks an operational definition of health protection and health promotion that lends itself easily to efficacy research. Further, as the model does not specify techniques or content and the true meaning of the components is unclear, efficacy research is impossible. Although recreation is identified as restorative and leisure is identified as growth promoting within the Health Protection/Health Promotion Model, this is not enough of a description to direct meaningful research relevant to the efficacy of the model.
Questions that beg to be addressed by this model include: What specific techniques, settings, and modalities produce the desired outcome at different phases in the continuum? What is the relationship between activity, recreation, leisure, and wellness? What particular patterns and/or forms of recreation and leisure correlate with wellness? Promote wellness? Ameliorate disability or illness? Prevent secondary disability? Are there different patterns and forms across the life span that correlate with and promote health and wellness? Do causal relationships exist? Once therapeutic recreation treatment is completed, can the individual maintain the benefits independently through recreation and leisure participation?
To date, some research has found a positive relationship between activity and health outcomes (cf, Coyle, Kinney, Riley, & Shank, 1991). Most research cited as demonstrating benefits of therapeutic recreation, however, has not explored whether the participant is actually experiencing recreation or leisure nor if the outcome resulted from a specific therapeutic recreation intervention. Rather such research tends to equate certain activities with being recreation/leisure (e.g., jogging, exercise). Without knowing if the individual is experiencing recreation/leisure during their participation, it is not possible to claim any found benefit as an outcome of recreation or leisure. Further, without identifying the specific therapeutic recreation intervention utilized the benefit cannot be attributed to therapeutic recreation. Research, especially in relationship to this model, needs to demonstrate that activity found to produce social, emotional, intellectual, and/ or physical benefits (a) is relevant to optimal health and (b) would be even more beneficial when participants experience leisure/recreation during engagement. Further, research needs to explore the question: When a health promoting therapeutic recreation activity is experienced as leisure, does it more aptly become a part of the person’s lifestyle and produce more lasting health and wellness benefits? Finally, to declare the outcome as a result of or related to therapeutic recreation, the intervention must be specified. To accomplish this a variety of sophisticated research designs and techniques will be required.
Conclusions Austin’s model is current with health care and health policy today and has the potential to provide direction to the field of therapeutic recreation in the changing health care environment. It must, however, be further developed to be useful. Leisure theory and motivation theory need to be incorporated into the theoretical discussion of the model. The components need to be clarified and include specific direction for treatment modalities and intervention techniques. Also, health protection and health promotion need to be operationalized to enable evaluation of treatment as well as for research.
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Jo-Ellen Ross, Ph.D., CTRS is a Credentialing Specialist with NCTRC, with 20 years experience as a practitioner in a variety of settings; most recently Maine Medical Center and New England Rehabilitation Hospital of Portland. The views expressed herein are those of the author and do not represent current or past employers.
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