Occupational Therapy Philosophy Research Articles

Occupation-based practice in hand therapy – perspectives from a South African occupational therapy survey

Introduction Hand injuries affect occupational engagement and participation, yet anecdotal evidence reports a focus on body structures and functions within hand therapy. Failing to address occupational challenges may result in sub-optimal patient outcomes. In line with the growing body of evidence of positive outcomes relating to occupation-based practice (OBP), this article aimed to describe the knowledge, attitudes and practices towards OBP of occupational therapists treating hand-related conditions in South Africa. Methods In this quantitative, cross-sectional study, South African occupational therapists treating hand conditions were recruited. Data were collected via an emailed survey developed for the study. Data were analysed descriptively. Results Sixty-seven responses met the inclusion criteria, a response rate of 62%. Most respondents worked in the private sector (73%) with many holding postgraduate qualifications (54%). Lack of access to evidence and a preference for biomedical literature impacted on acquiring knowledge on OBP. Attitudes towards OBP were mostly positive. Barriers were contextual, patient-related and therapist-related. Practice focussed predominantly on performance components and aimed to reduce impairment rather than promoting occupational engagement. Conclusion Current hand therapy services in South Africa reflect a biomechanically-focused practice that is mis-aligned with occupational therapy philosophy. In line with existing research, OBP should be adopted more routinely in hand therapy in South Africa.

Validity and Reliability of the Occupational Balance Questionnaire (OBQ11) in a U.S. Sample of Adults With Type 1 Diabetes.

Although occupational balance (OB) is a construct of importance to occupational therapy, existing OB assessments have not been validated in clinical populations. To examine the validity and reliability of the 11-item version of the Occupational Balance Questionnaire (OBQ11) in U.S. adults with Type 1 diabetes. Data were analyzed from adults with Type 1 diabetes enrolled in a larger longitudinal study examining the relationships among blood glucose, emotion, and functioning. Dimensionality of the OBQ11 was assessed with item response theory (IRT); convergent validity was tested by examining whether associations between the OBQ11 and other constructs were consistent with a priori hypotheses. Three outpatient clinical sites in the United States. Data from 208 U.S. adults with Type 1 diabetes were included in the analyses (42% Latino, 29% White, 14% African American, 7% multiethnic, and 8% other). Assessments administered include the OBQ11, Patient Health Questionnaire (depression), and Diabetes Self-Management Questionnaire. Overall, results from IRT models and correlational tests supported the reliability and validity of the OBQ11. For instance, higher scores on the OBQ11 were significantly associated with better self-ratings of diabetes management behaviors (r = .28, p < .001), lower depression symptoms (r = -.53, p < .001), and greater positive affect (r = .32, p < .001). A single-factor generalized partial credit model fit the OBQ11 acceptably well, supporting its unidimensionality. The OBQ11 may be a reliable and valid measure of OB appropriate for use in clinical populations such as adults with diabetes. What This Article Adds: OB is not often formally assessed by occupational therapists in the United States, even though the contributions of OB to health and well-being are core components of the philosophy of occupational therapy. The current evidence supports the validity of the OBQ11 in a clinical population of adults with Type 1 diabetes and demonstrates significant associations between OB and health management behaviors. Study results may encourage greater consideration and assessment of OB in occupational therapy clinical practice in the United States.

Dr Eamon O'Sullivan: psychiatrist and forgotten pioneer of occupational therapy.

This paper provides a brief overview of the history of occupational therapy in psychiatry in Ireland and explores why the contribution of an early Irish psychiatrist and proponent of occupational therapy, Dr Eamon O'Sullivan (1897-1966), was not fully recognised in the decades after his retirement in 1962. A review of selected key reports, papers and publications related to the history of occupational therapy was undertaken. Eamon O'Sullivan was appointed Resident Medical Superintendent at Killarney Mental Hospital Co. Kerry in 1933 and developed an occupational therapy department at the hospital from the 1930s until his retirement in 1962. He wrote one of the first textbooks of occupational therapy published in 1955. His occupational therapy philosophy reflects the early decades after the formalisation of the profession in 1917 when beliefs about the curative properties of occupation flourished and professional education programmes were scarce. By the time O'Sullivan's textbook was published it received a lukewarm reception within occupational therapy as it did not reflect 1950s practice and professional philosophy. The professionalisation of occupational therapy in Ireland in the 1960s was also a factor in the lack of acknowledgement of O'Sullivan's contribution to the profession. Practice and professional philosophy change and the paper concludes by considering O'Sullivan's work in light of contemporary occupational therapy which once again places occupation at its centre and emphasises the importance of balance, health and wellbeing.

Occupational therapy practice with terminally ill Chinese older adults in Singapore: A qualitative exploratory study.

As the majority of occupational therapy philosophy has Western origins, occupational therapists working with palliative care clients in Singapore can provide invaluable insight into the practice of occupational therapy within a non-Western, family-centric population. This study aimed to describe occupational therapists' perceptions of the occupations of terminally ill Chinese older adults and their caregivers and explore occupational therapy practice with terminally ill Chinese older adults in Singapore. Eleven occupational therapists were recruited via convenience and snowball sampling. Inclusion criteria were being fully registered with the Allied Health Professionals Council (Singapore) with at least 2 years of working experience and currently working with/had experience working with terminally ill patients within the past 2 years. Interviews were transcribed verbatim, and data were analysed using reflexive thematic analysis. Five themes were constructed from the data: (1) Independence may not be for everyone, (2) it is a family unit, (3) contributing to others' lives is important, (4) what respecting clients means, and (5) a different way of engaging. These themes describe how occupational therapists adapted their practice to better meet the needs of clients and families in Singapore. In family-centric societies, it may be more relevant for occupational therapists to facilitate interdependence instead of independence in activities of daily living. In addition, activities that contribute to others' lives tangibly/intangibly may be more meaningful and relevant. Finally, occupational therapists could engage clients through the 'being' instead of 'doing' dimension of occupation. While occupational therapists in Singapore faced some challenges working with terminally ill clients and families due to differences between occupational therapy philosophy and practice context, by reframing their thinking, they were able to adapt their practices to meet the needs of a family-centric population.

Handwriting and typing: Occupational therapy practice when supporting adolescents with handwriting difficulties

Introduction While most children have developed effective handwriting by secondary school age, some have handwriting difficulties that hamper academic progress. Occupational therapists play a role in assessment and planning support, which may include introducing typing as an alternative. However, there is limited understanding regarding how decisions are made about recommending typing. This study explored the support provided to adolescents with handwriting difficulties by occupational therapists, and the contextual factors that influence their decision-making. Method Semi-structured interviews were conducted with 13 occupational therapists and analysed using thematic analysis. Findings Although there was shared practice underpinned by occupational therapy philosophy, there was also divergent practice due to different approaches. Roles and responsibilities, resources, and evidence and experience influenced occupational therapists’ practice. Understanding the adolescent’s motivation, the effect of handwriting difficulties on well-being and the need for a functional method to record schoolwork, was central to occupational therapists’ decision-making to recommend typing. Conclusion Strategies are needed to address the knowledge-practice gap, including evidence-based guidelines. Closer collaboration between occupational therapists and school staff could increase understanding of roles and highlight the unique occupational therapy contribution. Further research examining whether, when and how to introduce typing as an alternative to handwriting would support best practice.

Psychological Factors Predicting Functional Ability and Participation After Hip Fracture.

Positive psychological factors have been related to better outcomes among adults with various health conditions. To predict functional ability and participation in older adults who had experienced a hip fracture on the basis of data at admission to acute (inpatient) rehabilitation. We measured physical factors, as well as positive and negative psychological factors, at three time points. Prospective and cross-sectional cohort study. Data collection occurred during admission, at discharge, and 6 mo after rehabilitation. Inpatient geriatric rehabilitation center and follow-up at home. Seventy-one older adults (M age = 78.58 yr, SD = 6.09) who had sustained a hip fracture because of a fall and who attended acute rehabilitation; 55 completed follow-up assessments 6 mo after discharge from rehabilitation. Participants completed the Adult Hope Scale, Life Orientation Test, Positive Affect Questionnaire, Geriatric Depression Scale (at admission only), hand-grip strength measures, Numeric Pain Rating Scale, and FIM® Motor domain (mFIM) before and after acute rehabilitation and after 6 mo. The Activity Card Sort (ACS) was administered only at follow-up. Outcome measures were the mFIM and ACS. At 6-mo follow-up, functional ability was correlated more with optimism than with age, gender, or hand-grip strength measured at admission. Participation was predicted by age, the hope-agency component, and pain in walking at admission; however, the hope-agency component was only marginally significant. At discharge, functional ability was strongly predicted by age, hand-grip strength, and mFIM scores at admission. Optimism and hope played a role in explaining rehabilitation outcomes at 6-mo follow-up. Occupational therapy evaluation should address positive psychological factors, and intervention should aim to strengthen these factors as powerful aids in older adults' recovery from hip fractures. What This Article Adds: This study reflects the philosophy of occupational therapy, which places great emphasis on the connection between clients' mind-body-spirit and their participation in daily life occupations.

Selecting from their toolbox of interventions – A realist study of the role of occupational therapists in reablement services

Introduction Reablement services support people to regain skills and increase their independence. This aim resonates with occupational therapy philosophy. This article presents results of a study of the role of occupational therapists in reablement services that involve two organisations. Method Theories on the role of occupational therapists in reablement were identified using a realist synthesis approach and were tested and expanded using a qualitative case study design. Each of the three case studies consisted of one reablement service in England. Methods of the study included observations and interviews with occupational therapists, interviews with managers in both organisations and focus groups and interviews with reablement support workers. Findings Findings conclude that occupational therapists’ education and experience underpin their ability to undertake assessments and person-centred goal setting. They utilise a range of intervention techniques selecting from their toolbox of interventions to support people. Occupational therapists have a role in training reablement support workers to work in an enabling way. Regular communication and co-location support levels of trust and shared purpose between members of the reablement team. Conclusion The conceptual framework developed from the study can be used by organisations when commissioning and developing reablement services to consider the different contextual layers of reablement.

Being a feral occupational therapist

ABSTRACT This case study explores the background and practice of a feral occupational therapist working in community mental health. The concept of feral occupational therapist is explained and the socio-economic and political climate of feral practice is described and considered. The practice began when unmet occupational and mental health needs in the community were identified and the opportunity for slow rehabilitation was found possible. The feral occupational therapist role, which is outside the restrictions of targets and time limits set by others, allows creativity in thinking drawn from the deep philosophy of occupational therapy, perhaps in some ways now lost in contemporary, mainstream practice.

An integrative review of case study methodologies in occupational therapy publications

Abstract Introduction The philosophy and practice of occupational therapy is subjective and this provides a challenge in reflecting the essence of practice within research methodologies for this profession. The individualistic practice of client centredness and the importance of context are core elements of occupational therapy. Objective The aim is to conduct a descriptive analysis of contemporary use of case study research in occupational therapy based on selected articles using this methodology. Method An integrative literature review was carried out to explore contemporary occupational therapy application of case study as an approach. The search comprised the publications between 2006-2016, containing the keywords: “case study method”, “case study approach” and “case study methodology” were combined with “occupational therapy” in the following databases: CINAHL, MEDLINE and PSYCHINFO, and Royal College of Occupational Therapistsonline dissertation database. Results Thirty-two papers were synthesised; the studies predominantly featured mixed method data gathering as would be expected within a case study approach. There was a global uptake of the case study approach; UK, Canada, USA, Australia, Qatar, Brazil and Hong Kong in order of incidence. There was a relatively equal division between explanatory case studies and exploratory case studies. Conclusion The case study approach is a strongly viable and acceptable research tool to reflect the elements of occupational therapy practice and enhance the evidence-based practice of this profession. Occupational therapy research would benefit from a higher number of case study designs to reflect the complexity, subjectivity and person centredness of the profession.

Occupational therapy medicolegal assessment of domestic assistance requirements: Focus group perspectives.

Estimating domestic assistance requirements within the medicolegal field is a role for occupational therapists. It is a complex multidimensional process of clinical reasoning with no published research outlining how an occupational therapist translates assessment data into the number of hours of domestic assistance required. This study describes the current occupational therapy practice of estimating domestic assistance hours within the medicolegal context. Three focus groups, totalling 14 occupational therapists providing medicolegal reports in New South Wales, were conducted. Sydney University provided ethics approval. Focus group data were thematically analysed. Four themes were identified: Tasks included as housework. Assessment process - interview of pre-injury and recovery status; functional performance on specific tasks and a tour of the home. Influential factors - include legal system restrictions, medical management, cultural and society values, family expectations, location and impact of diagnosis. Strategies to determine care - triangulation of observed data with medical reports and clinical experience. Knowledge of community and own performance times within the framework of occupational therapy philosophy DISCUSSION: No single method of translating assessment data to hours of care was identified. Therapists use of their own housework performance raises ethical issues. Use of claimant only statements raises issues of inaccurate data on which to base decisions. Therapists should refer to occupational therapy process of clinical reasoning to explain their recommendations even though the reasoning does not give a definite number of care hours. Therapists need to understand the factors influencing their clinical reasoning when integrating all available information into an estimating of domestic assistance hours. Further study analysing the content of medicolegal report may provide information as to how therapists document their clinical reasoning for court.

The post-retirement work support from an occupational perspective: A literature review of issues within the silver human resources center in Japan

The number of working elderly in Japan has been increasing, and one-fifth of workers in 2016 were older than 60 years. Silver Human Resources Center (SHRC) is a Japanese organization provides post-retirement work. SHRC has a purpose resembles the philosophy of occupational therapy: to support retirees improve their well-being. The aim of this research is getting suggestions from an occupational perspective for post-retirement work support through a literature review of issues within the SHRC. The research was conducted in Cinii Articles with a keyword: “Silver Human Resources Center”. 31 Japanese studies were extracted from 211 results based on “aims” and “methods” description and 55 labels refer to issues of SHRC were extracted from them. The labels were analyzed based on a categorizing method to reveal the relation each other. 5 categories occurred. <A better matching of jobs with human resources> was a systematic issue of SHRC, and taking on this issue was important for <increasing active working>. In addition, a difficulty of proactive management by members and gathering new members were also identified as issues, and it was needed <to be matured as an organization>. This maturing was related to the propulsion of community-based efforts and being a place enables local residents to spend time with others. It means <to be a part of every day>, and efforts <to be a part of every day> and for <increasing active working> were expected to expand to support <not only member's working but also their lives>. Analyzed issues of SHRC seem to include an occupational perspective: to support one's occupation from personal history and environments. Therefore, occupational therapy may be able to contribute preventing from occupational crisis due to change ways of spending life after retirement. One of the important tasks is revealing the subjective experience process of life changing with retirement.

A case study of the development of occupational therapy at St. Patrick’s Hospital Dublin, 1935-1969

PurposeThis paper aims to examine the relationship between psychiatry and occupational therapy in Ireland through a case study of the development of the occupational therapy department in St. Patrick’s Hospital, Dublin, from 1935 to 1969. Patronage by psychiatrists was an important factor in the professionalisation of occupational therapy internationally.Design/methodology/approachDocumentary sources and oral history interviews were analysed to conduct an instrumental case study of occupational therapy at St. Patrick’s Hospital from 1935 to 1969.FindingsThe research identified key individuals associated with the development of occupational therapy at St. Patrick’s Hospital, including psychiatrist Norman Moore, occupational therapy worker Olga Gale, occupational therapist Margaret Sinclair, and social therapist Irene Violet Grey. Occupational therapy was considered by the hospital authorities to be “an important part in the treatment of all types of psychiatric illness” (Board Meeting Minutes, 1956). It aimed to develop patient’s self-esteem and facilitate social participation. To achieve these objectives, patients engaged in activities such as dances, arts and crafts, and social activities.Originality/valueThis study has highlighted the contributions of key individuals, identified the links between occupational therapy and psychiatry, and provided an insight into the development of the profession in Ireland prior to the establishment of occupational therapy education in 1963. Occupational therapy practice at St. Patrick’s Hospital from 1935 to 1969 was congruent with the prevailing philosophy of occupational therapy internationally, which involved treatment through activities to enhance participation in society.

A Concept Analysis of Spirituality in Occupational Therapy Practice

Health policy and high profile investigations about poor care delivery in England emphasise the need for health professionals to ensure care is patient-centred, addressing each individual's physical, emotional, social and spiritual needs. Person-centred practice, valuing the uniqueness of the individual, is central to the philosophy of occupational therapy. Spirituality is a key dimension of person-centredness but how to address it in everyday practice remains a challenge. This article reports on a concept analysis which was undertaken to explore the empirical referents of addressing the spiritual as a means of guiding practice, and the antecedents and attributes underpinning spirituality as a dimension of occupational therapy practice. A range of health-related databases were searched from 2000 to 2013. Eight studies that focused on spirituality and occupational therapy practice were included in the concept analysis. Spirituality in occupational therapy practice was found to be associated with a holistic, person-centred approach to care. It aimed to restore a sense of wellbeing and to recognise individual coping strategies. A framework was developed to operationalise spiritually competent care for occupational therapy practice. The study concluded that occupational therapists respond to a disruption in wellbeing and quality of life by mobilising patients’ spiritual coping strategies in order to support and restore the patient's sense of meaning and purpose.

A qualitative meta-synthesis about challenges experienced in occupational therapy practice

Introduction Information about challenges for occupational therapists is typically provided in small-scale studies from different perspectives. The purpose of this meta-synthesis was to synthesise and report about challenges in occupational therapy practice that appear to penetrate across the profession. Method Databases searched were Ovid Medline, EMBASE, AMED and CINAHL. Search terms were selected after gaining understanding of the topic: occupational therap* AND Exp burnout / OR Exp morals / OR retention OR clinical reasoning OR new graduate OR novice OR transition-to-practice. Studies were critically appraised using the criteria of credibility, transferability, confirmability and dependability. Findings, along with direct quotes, were extracted and data compared and contrasted through first, second and third order analysis. Findings Twenty-four studies were included in the meta-synthesis and three constructs were identified: ‘challenges in context’; ‘personal challenges’ and ‘social and cultural challenges’. These findings inform knowledge about constraining factors on clinical reasoning and the alignment of practice with the occupational therapy philosophy, and give insight into satisfaction with practice, ethical and professional behaviours. Conclusion These findings could inform provision of professional support, education for students and enhance agency to reform practice. More research is needed about professional socialisation, clinical reasoning and ethical issues.

Occupational therapists as change agents in multidisciplinary teams

IntroductionThis qualitative study explored the experiences of occupational therapists attempting to implement change within multidisciplinary teams via a 5-week training intervention. This encouraged ward staff in inpatient mental health rehabilitation units to facilitate service user engagement in activities. This study is supplementary to a randomised control trial (RCT).MethodDaily diaries and training reflections completed by two therapists (P1 and P2) during the training were subjected to Framework analysis. The indexing stage of this process was completed in collaboration with the participants.FindingsWhen implementing change, the occupational therapists encountered a number of barriers such as emotional responses and attitudes towards service users. Facilitators of change included openness, sharing knowledge and skills, and reported change. The analysis revealed a change process moving from ‘assessing the context’, to ‘building relationships’ and ‘addressing issues’ that was aided by the therapists’ high-level skills and capacity for social and self-awareness.ConclusionThe process of change aligned well with the chosen three-stage model of change as well as occupational therapy philosophy. When acting as change agents, the therapists adapted and applied their clinical skills to the organisational context in accord with their core values and capacity for social and self-awareness.

A call for sustainable practice in occupational therapy.

The ability of the earth to sustain health among humans and in the natural world is under threat from overpopulation, environmental degradation, and climate change. These global threats are anticipated to harm health and human occupation in many direct and indirect ways. Strategies are needed to mitigate the effects of these threats and to build individual and community capacities to foster resilience. This paper links issues of sustainability with occupational therapy philosophy and discusses how employing a sustainability lens with professional reasoning can help practitioners integrate sustainability into their practice. Human occupation is inseparable from the environments in which people live. Human occupation has caused the current environmental crisis, and targeted human action is required to safeguard future health and well-being. Occupational therapists have an ethical obligation to use professional reasoning strategies that, taken collectively, can help to build a sustainable and resilient future.

Living with Parkinson's and the Emerging Role of Occupational Therapy.

Parkinson's disease is a chronic and increasingly complex condition, demanding multidisciplinary management. Over the last twenty years or so, alongside the growth of specialist services and healthcare teams specifically developed for people with Parkinson's, occupational therapy has grown in recognition as a treatment option, especially since evidence of its efficacy is now slowly emerging. The purpose of this work is to outline the role of occupational therapy clinical practice in the management of people living with Parkinson's disease and its emergent evidence base, combined with details of current occupational therapy philosophy and process, as applicable to occupational therapy practice for people with Parkinson's. The Canadian Practice Process Framework is used to structure this overview and was selected because it is a well-recognized, evidence-based tool used by occupational therapists and encompasses the core concepts of human occupation and person-centred practice. The framework employed allows the flexibility to reflect the pragmatic occupational therapy intervention process and so enables the illustration of the individually tailored approach required to accommodate to the complex pathology and personal, domestic, and social impacts, affecting the functioning of Parkinson's disease patients on a daily basis.

Contemporary occupational therapy practice: The challenges of being evidence based and philosophically congruent

Several authors have written of the need to embrace occupation and use it to energise our practice, research and education for the benefit of the profession, individual occupational therapists and ultimately, and most significantly, our clients. However, Wilcock (1999) best summarises the issues and the work that must be done, calling for the profession to adopt a consistent professional philosophy. This approach is entirely congruent with the paradigm approach proposed by Kielhofner (2009). Reinforcing the ideas of Doris Sym, Wilcock (p. 192) states that ‘the first essential for each individual in any profession is the acceptance of a philosophy that is the profession’s keystone.’ Wilcock is clear that such a philosophy should not be adopted and enacted in a rigid way, but it should be dynamic so as to enable the profession to respond to research and theories, and changes in the world. In essence, a professional philosophy should guide research, education and practice and be a touchstone when considering potential changes to practice. It is our suggestion that occupational therapists, individually and collectively, need to use our occupational philosophy, currently best operationalised by the Contemporary Paradigm, to inform EBP. In conclusion, we again find ourselves at a cross road for the profession with the occupational philosophy of the Contemporary Paradigm at times challenged by the adoption of research evidence into practice. We would encourage all occupational therapists to engage in EBP but do so ever mindful of its complexity. We would suggest that evidence-based decision making is viewed through the lens of the occupational therapy philosophy, with occupational therapists critically questioning whether or not the ‘procedure’ for which there is evidence is consistent with the Contemporary Paradigm. This is a complex matter, with many remaining issues to be explored. We would encourage all occupational therapists to interrogate the ways in which they implement EBP and consider the extent to which the profession’s philosophy guides practice decisions.

Muriel Driver Memorial Lecture 2013

Given the nature of occupational therapy philosophy and practice, it is not surprising that "change agent" has been identified as one of the seven professional roles that occupational therapists fulfill. This Muriel Driver lecture examines the change agent role, what it means, and what knowledge, skills, and personal qualities are necessary to be effective. Overall, relatively little has been written about the change agent role in the occupational therapy literature. Much of what does exist is implicit and often embedded in related topics, such as advocacy. An examination of literature from outside of occupational therapy uncovered four major themes about this role: (a) Change agents are insightful, reflective, and disciplined; (b) Charnge agents are visionary leaders and mobilizers; (c) Change agents are knowledge integrators and translators; and (d) Change agents are diplomatic interventionists who produce meaningful outcomes. These themes point to several areas of silence in the occupational therapy literature. Overcoming these areas of silence and moving forward will require open, challenging, and scholarly debates; reconsideration of change agent role competencies; and clear messaging that we all have the capacity to be competent and effective change agents regardless of our title or setting.

Special Issue of Obesity and the Role of Occupational Therapy

occupational therapy within the obesity epidemic. The obesity epidemic is a public health concern. Bazyk, continuing with her commitment to a public health approach to improving the lives of children, especially in mental health, has developed “A Multitiered Approach to Addressing the Mental Health Issues Surrounding Obesity.” Through this paper, readers are introduced to a three-tiered public health approach that focuses on multiple ways occupational therapy professionals can address the mental health issues surrounding obesity, obesity prevention, and the promotion of healthy weight. The author nicely details how public health can easily interface with occupational therapy values, philosophy and practice, and reasons that this approach may be crucial to meet society’s needs. I suggest that all readers examine her references to further the work this author has developed to help meet society’s needs, in this case, the need to address obesity and mental health. Children who are obese or overweight are a family health issue and must be viewed from an open systems lens. Pizzi and Vroman, in their article on “Childhood obesity: Effects on children’s participation, mental health, and psychosocial development,” make the case for occupational therapists to consistently be aware of the psychosocial and mental health dimensions of health in order to promote full participation. They address the concepts of occupational marginalization, deprivation, and alienation through being client and family centered and occupation focused using a systems approach to care. The authors emphasize the need to always address the multiple mental health challenges faced by children who are obese or overweight and to develop strategies and programs that are