Revisiting the Do-Live-Well Health Promotion Framework: A Citation Content Analysis

Abstract

Background. The Do-Live-Well (DLW) framework was first published in 2015 and aimed to fill a theoretical gap in the health promotion literature related to the links between occupational patterns and health. However, the extent of uptake and use of the framework since publication is unknown. Purpose. To explore and reflect on the adoption and application of DLW in the literature. Method. Citation content analysis of two seminal DLW publications was conducted from 2015 to November 2022 across six databases. Findings. Seventeen citations directly applied DLW to inform research (n = 10), practice (n = 5) and knowledge translation (n = 2). Implications. The findings highlight uptake of the framework in a range of settings, and how it can inform an occupation-based understanding of health and well-being. Ongoing knowledge dissemination, development of practice tools, and research to update evidence and examine relevance are needed to further advance the utility and application of the framework.

Introduction

First published in 2015, the Do-Live-Well (DLW) or Vivez-Bien-Votre Vie framework is a Canadian health promotion framework based on public health and occupational therapy principles (Moll et al., 2015). The framework intended to fill a gap in the health promotion literature that focuses primarily on discrete behaviors such as diet and exercise and less on patterns of occupational participation that can have an important impact on health and well-being. The framework articulates key concepts that are often overlooked, and insights regarding the evidence-based links between occupation, health, and well-being of individuals and communities can inform health promotion policy and practice (Reitz & Scaffa, 2020). The main idea of DLW is that “what you do every day matters,” and the four framework sections represent this message. First, eight dimensions of experience capture a range of experiences that contribute to health and well-being (activating your body, mind, and senses, connecting with others, contributing to community and society, taking care of yourself, building security/prosperity, developing and expressing identity, developing capabilities and potential, and experiencing pleasure and joy). Next, five activity patterns represent how participation influences health and well-being (engagement, meaning, balance, control/choice, and routine). Optimal activity patterns promote positive health and well-being outcomes. Health and well-being outcomes in DLW are based on a broad vision of health and include physical, mental, social, emotional and spiritual well-being. Finally, DLW recognizes the personal and social forces that may affect activity engagement patterns.

DLW was designed as a health promotion framework to generate reflection and discussion on the impact of everyday activities on health and well-being at individual, community, and national levels (Moll et al., 2015). Since initial publication of the framework in the Canadian Journal of Occupational Therapy in 2015, the authors have conducted several workshops and presentations within the occupational therapy community. The framework has been translated into French and German, and various bilingual tools published on the website (www.dolivewell.ca) have been developed to support the framework application. In addition, information about DLW was published in the Canadian Journal of Public Health in 2016 to translate the central ideas to a broader public health audience. It is unknown, however, the extent to which the framework has been adopted since its initial publication. The purpose of this citation analysis was first step to explore how the DLW framework has been applied as reflected by published peer-reviewed and gray literature, and then to critically reflect on adoption patterns, including identification of opportunities and challenges to uptake and impact.

Method

A citation content analysis was chosen as it is a widely used and accepted way to assess the impact of scholarly work (Zhang et al., 2013). We followed the framework for syntactic and semantic analysis of citation content proposed by Zhang et al. (2013). Database searches were used to track citations of two seminal publications that presented DLW, including the original 2015 framework paper published in the Canadian occupational therapy literature (Moll et al., 2015) and the 2016 opinion paper published in the Canadian Journal of Public Health (Gewurtz et al., 2016). Content analysis of the citations was conducted to identify key trends in terms of the type of studies, where they were published, and the context for application (Zhang et al., 2013).

Citation searches were completed between March and November 2022 to identify published articles and gray literature sources citing the two seminal publications in six databases: CINAHL, Google Scholar, PsycINFO, PubMed, Scopus, and Web of Science. All citations were imported to the Covidence software to check for duplicates and for screening to apply the exclusion criteria. Citations were excluded if they were a conference abstract, an incomplete citation with no abstract or full text available, a source that did not cite a seminal publication, or a source that cited one of the articles, but did not apply DLW. Papers published in both French and English were eligible for inclusion. Included citations were exported to Mendeley Reference Manager for analysis and citations in languages other than English were translated using DeepL Translator (DeepL Translator, n.d.). Next, citations were labeled by the type of source (article or thesis/dissertation), the professional field, and the country where the study took place or where the authors were located. Lastly, citations were categorized by the type of use: research, clinical practice, or knowledge translation.

Findings

After duplicates were removed and inapplicable studies were excluded, the citation search yielded 17 citations (ten peer-reviewed articles and seven theses). The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram is shown in Figure 1. Tables documenting the 85 citations that cited but did not apply DLW are available as supplemental materials. Within the 17 citations applying DLW, the framework was used to inform research (10), to inform clinical practice (5), and to advance knowledge translation (2). The two citations that focused on knowledge translation included authors who are members of the DLW research team. Within these 17 citations, nine were from Canada, three from the United States, and one each from France, Sweden, Switzerland, Ireland, and Germany. Four of the citations were published in French and two were in German. The citations were published between 2017 and 2022, with 12 of the 17 published in the last three years. Populations of the study included adults with physical and/or mental health conditions (5), older adults in the community (3), college students (3), occupational therapists (3), families experiencing homelessness (1), veterans (1), and pre-retirees (1). Professional fields included occupational therapy, kinesiology, gerontology, and psychology. Of the ten citations published in journals, five were from occupational therapy-specific journals. All seven theses/dissertations were written by authors from occupational therapy or rehabilitation science programs.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram.

DLW Informing Research

Most of the citations noted DLW as a theoretical framework and data analysis tool for research. Five citations explicitly explained how DLW was used to inform the development of an interview guide and analysis of findings. Greenbaum's dissertation (2017), for example, adopted an occupational framework to explore the well-being of American college students who commute. She created survey and interview questions based on DLW and coded results according to dimensions of experience and activity patterns (Greenbaum, 2017). Another thesis explored the reasons pre-retirees in Quebec were retiring and what they planned to do in retirement (Roy, 2020). Dimensions of experience from DLW were used as part of the conceptual framework for the study, informed interview guide development, and were used to code results and classify the meaning of activities that pre-retirees intended to engage in upon retirement (Roy, 2020). Berthelier's thesis (2021) explored the role of occupational therapists in addressing social isolation to prevent depression among older adults in France. DLW was part of their theoretical matrix for developing interview questions, and results were linked to dimensions of experience and activity patterns (Berthelier, 2021). Kreider-Letterman and Schmelzer (2021) used DLW in their peer-reviewed article to conduct a needs assessment and proposal for the addition of occupational therapists as service providers for families experiencing homelessness in the United States. They developed the interview guide for the needs assessment phase using DLW and analyzed the results in relation to how dimensions of experience, activity patterns, and personal and social forces impacted health outcomes for the families (Kreider-Letterman & Schmelzer, 2021). DLW principles were then used to guide the proposal to add occupational therapy services. Turcotte et al. (2021) studied the experience of older adults acting as volunteer peer educators for health promotion programs in Quebec. Dimensions of experience, activity patterns, and personal and social forces were used to develop the interview guide and a coding tree to analyze the results (Turcotte et al., 2021). The authors also highlighted that their results provide empirical support for the DLW framework (Turcotte et al., 2021).

Five additional citations used DLW in a more general way, including the theoretical justification for the study and discussion of results in relation to DLW, but DLW did not explicitly inform data collection methods or analysis. Three theses/dissertations were written in 2021. First, Bäggli and Saxer (2021) conducted a systematic review of factors that impact occupational engagement during the recovery process of people with severe mental illness. The themes identified from the studies in the review were linked to dimensions of experience and activity patterns (Bäggli & Saxer, 2021). Phan (2021) explored performance anxiety in CEGEP students in Quebec through a focus group qualitative study using DLW as a conceptual basis. Strategies identified by the students for managing performance anxiety were related to dimensions of experience, activity patterns, and personal and social forces from DLW (Phan, 2021). To-Miles (2021) used a combination of quantitative and qualitative surveys across four studies for their dissertation that explored associations between occupation and health for Canadian adults with arthritis. DLW was used as the theoretical basis for the four studies and the results were linked to dimensions of experience (To-Miles, 2021). The author noted that the dissertation provided evidence supporting DLW because occupational characteristics found to be associated with physical health were equivalent to dimensions of experience and these relationships were influenced by personal factors (To-Miles, 2021). Shirazipour and Smith (2017) conducted a qualitative study to explore the quality of physical activity experiences of military veterans with physical impairments from Canada, the United States, and the United Kingdom. DLW was used as a conceptualization of participation and key themes from the results were connected to the framework (Shirazipour & Smith, 2017). DeBroux Leduc et al. (2020) used dimensions of experience to classify themes that emerged from their scoping review on the health benefits of participating in intergenerational activities for older adults.

DLW Informing Clinical Practice

Five citations used DLW to develop interventions or intervention tools. Liu (2021), for example, used DLW in their master's thesis as part of the theoretical foundation for a chatbot designed to help motivate people with serious mental illness to make activity changes. Features of the chatbot such as suggesting a wide range of activities, highlighting the benefits of activities, and providing links to resources were informed by dimensions of experience, activity patterns, and personal and social forces (Liu, 2021). The chatbot was designed to be used alongside the Action over Inertia intervention (Krupa et al., 2010; Liu, 2021). The remaining four citations were peer-reviewed articles. Hutchinson et al. (2017) described the development, evaluation, and subsequent changes made to an intervention program called “Steps to Connect.” This intervention was originally developed as a two-session group leisure education program for Canadian adults with chronic conditions and focused on helping participants explore how to engage in community recreation and connect with others (Hutchinson et al., 2017). Based on feedback from participants, the authors did a conceptual reframing of the program and used DLW to focus on helping participants identify personally meaningful leisure activities (Hutchinson et al., 2017). Woick (2018) developed a German-language reflection tool based on DLW called “Lebe dein Leben gut” or “Live your life well.” This tool is comprised of reflection cards that correspond to the four components of DLW and prompt individuals or groups to reflect on how the activities they do every day affect their health and well-being (Woick, 2018). Bergström et al. (2019) described the development and evaluation of a reablement intervention called “ASSIST 1.0.” The authors stated that DLW was used as part of the theoretical foundation for the program (Bergström et al., 2019). “ASSIST 1.0” is a ten-week program delivered in Sweden by occupational therapists and homecare staff with the help of a mobile application that aims to enable older adults in the community to perform activities that they need and want to do (Bergström et al., 2019). Hunt and Coombes (2021) also cited DLW in the description of their intervention called “Everyday Matters: Healthy Habits for University Life.” This intervention involved eight in-person group sessions and a companion online resource to encourage first-year undergraduate students in Ireland to reflect on their time-use habits from a 24-h perspective (Hunt & Coombes, 2021).

DLW Knowledge Translation

Two peer-reviewed articles, both including authors that are part of the DLW team, focused on DLW knowledge translation workshops. Kim et al. (2021) described the development of in-person and online workshops designed to increase awareness of DLW among occupational therapists in Canada. Kim et al. (2022) compared the effectiveness of the in-person and online workshops using a mixed-methods approach. The workshop was structured using the DLW framework, with four modules; dimensions of experience, activity patterns, personal and social forces, and overall application using case studies to link the framework to clinical practice (Kim et al., 2022).

Discussion

This citation content analysis was conducted to identify how DLW has been adopted and applied since its initial publication in 2015. A combination of peer-reviewed articles, theses, and dissertations revealed that DLW has been most frequently applied as a theoretical framework in the context of qualitative research, although it has also been used to inform clinical practice. These sources primarily cited DLW as an evidence-based framework to support the idea that daily activities have an impact on health and well-being. As a framework, DLW was designed to illustrate and help generate reflection on the connections between patterns of everyday activities, personal and social forces, and health and well-being outcomes (Moll et al., 2015). Results of this citation analysis revealed that DLW has been used in research studies focusing on health promotion across a range of populations, from college students and families to older adults. From a research perspective, it provided the structure to explore and explain connections between activity, health, and well-being. In particular, the eight dimensions of experience and five activity patterns were the most noted parts of the framework, providing the language to explain study findings. Some studies used DLW to generate individual and group reflection and discussion on the impact of daily activities (for example, Hutchinson et al., 2017; Liu, 2021; Woick, 2018). The influence of personal and social forces on various dimensions of health and well-being was less commonly cited. This may be because these were more conceptual ideas and less of a structured “list.” Several of the studies provided empirical support for the conceptual framework itself in terms of its value in capturing the links between activity, health and well-being. Turcotte et al. (2021), for example, assert that their study findings “provide empirical support to the Do-Live-Well model, and the feasibility and richness of its use to document older adults’ occupational engagement” (p. 11).

From a clinical practice perspective, the framework has been used to inform a range of clinical interventions, from an individual reflective tool on activity patterns (Woick, 2018), to a structured chatbot for an app (Liu, 2021) and various group-based self-management interventions (Hunt & Coombes, 2021; Hutchinson et al., 2017). In some cases, the framework provided general theoretical justification for the intervention, and in other cases, the framework provided the explicit structure for the treatment approach. Although DLW is more of a conceptual framework than a model of practice, it is interesting to note how the framework has been extrapolated for application in practice. This speaks to the pragmatic adequacy of the framework and the need for further development to explore and support clinical application (Fawcett, 2005). The DLW education studies support the need for explicit training to help occupational therapists (and other clinicians) translate the conceptual ideas of DLW to clinical practice (Kim et al., 2021). Application of the framework to advocate for policy and practice change was not as commonly noted in the literature, but it has been noted as a potential function of the DLW framework (Moll et al., 2015). Only one of the studies (Kreider-Letterman & Schmelzer, 2021) applied the framework at this level in the United States by using DLW as the foundation for their proposal advocating for the inclusion of occupational therapists as service providers for families experiencing homelessness. Since the citation analysis was limited to articles and theses available in empirical databases, it should be noted that there are likely clinicians and communities using DLW in other ways that are not as easily identifiable.

Language and culture may play a key role in the international spread and uptake of DLW. For example, the DLW framework has been translated into French and German. The French version of the framework may explain uptake of DLW in Quebec and France, as indicated by four French-language citations that applied DLW. The German translation also led to the development of an intervention tool (Lebe dein Leben gut; Woick, 2018). The translated framework does appear to resonate within these different cultures. However, to date, most of the publications applying DLW have been in Canada or the United States, with the remaining publications from Western European countries (France, Germany, Ireland, Sweden, and Switzerland). It should be noted that the authors of the framework were Canadian, white settlers and as such, the framework likely reflects Western Cultural norms and values surrounding activity patterns and time use. A critical exploration of the fundamental principles of the framework is needed to interrogate their relevance across cultures and ensure that the application of the model does not inadvertently exclude or marginalize individuals or communities.

Furthermore, the framework was developed by occupational therapists. To date, much of the literature has been authored by occupational therapists and/or published in occupational therapy journals. The framework is not, however, exclusive to occupational therapy. Publications outside of occupational therapy are evident (e.g., BMJ Open, Leisure & Society), which speaks to relevance for a broader audience, although occupational therapy authors appear to be the driving force in creating and disseminating the evidence. The DLW framework was developed to meet a gap in the literature regarding occupation as a determinant of health across a range of populations. Although occupational therapy is currently the main field using DLW, the citation analysis confirms the diversity and broad application of the framework with both clinical and general populations in a variety of settings.

Given the timeframe for the translation of theoretical ideas into practice, it is encouraging to see early adoption of DLW around the world, and across practice settings. However, citation analysis is only a first step in understanding the uptake of DLW as it can only trace the usage of the framework that is documented in published sources. To fully understand how DLW has been applied, the next steps may include qualitative or survey-based research to explore how occupational therapists and other professionals are using DLW in practice.

Conclusion

This citation analysis revealed how DLW has been adopted and applied since its initial publication in 2015. It is time, however, to revisit and reflect on the principles and application of the framework to ensure that it has continued relevance in the field of health promotion. This will include ongoing research to update evidence, research to ensure relevance across cultures, development of practice tools, and ongoing dissemination within and outside the profession through sharing resources on the website and educational workshops.

Key Messages

• DLW is an occupation-based health promotion framework designed to promote reflection on the evidence-based links between participation in everyday activities and health and well-being.

• Since its initial publication in 2015, the framework has been applied in a range of research and practice settings, from postsecondary education to supporting older adults in the community.

• Future directions include continued research and knowledge dissemination both within and outside the profession.

Author Biographies

Kennedy A. Hamilton is a year two student in the MSc (OT) program at McMaster University.

Lori J. Letts, PhD, OT Reg. (Ont.) is a Professor, School of Rehabilitation Science at McMaster University. She has been a member of the Do-Live-Well research group since 2013, and has studied outcomes from workshops (in person and on-line) about the Do-Live-Well framework.

Nadine Larivière, OT, PhD, is Full Professor at l’Université de Sherbrooke (School of Rehabilitation). She has been part of the Do-Live-Well research team since 2012 and offers workshops on the framework and application tools with francophone occupational therapists.

Sandra E. Moll is an occupational therapist and Associate Professor in the School of Rehabilitation Science at McMaster University. She is one of the developers of the Do-Live-Well framework.