Neighbourhood Old Age Homes (NOAH) is a non-profit organisation that offers communal and assisted living to the older persons. It’s head office is located in Woodstock, one of the oldest suburbs in Cape Town known for its mix of diversity and culture. Although the suburb has a vibrant and lively culture, there is also a culture of crime where the residents attest to a spike in criminal activities in the area such as break-ins, muggings and shop robberies that disturb the peace and harmony of the community.
The organisation was established in the year 1981 by Catholic Welfare & Development and is focused on making sure that social pensioners meet their basic needs, have a sense of purpose and remain active and independent for as long as possible. The organisation has 2 community centres and 2 primary health care clinics situated in Woodstock and Khayelitsha respectively. There are 11 independent, communal homes housing 105 residents and one assisted living home with 16 residents.
NOAH is concerned about the health and well-being of its residents and the broader population of older persons in the community as they understand that older persons often battle with a variety of ailments. With the current state of our country’s health system, older persons are expected to wait in long lines in the hospitals or clinics and often do not receive the help they need. To counter this, the NOAH primary health care clinics in Woodstock and Khayelitsha offer accessible, affordable and first-rate primary health care for social pensioners. Their model is in keeping with the intentions of the South Africa’s Older Persons’ Act namely, to keep older persons active in their community and which links to NOAH’s vision that every social pensioner should remain active and independent for as long as possible through participating in purposeful activities. In their great efforts to ensure health and well-being, NOAH also believes in togetherness and that it encourages happiness and wellbeing. Their centres provide social support to social pensioners in a form of a variety of occupations such as praise and worship, peer group support, arts and crafts, cultural exchange, choirs, library services, awareness talks, games and events. This social support emphasises their mission which is to ensure that the social pensioners have their basic needs met, have a sense of purpose and contribute to their own families, NOAH and the community at large.
So where does the Story of Change begin?
A partnership was established between UCT OT Division and NOAH and a meeting with the goal of developing a shared understanding around the challenges that the organisation was experiencing in the Happiness Programme. Management was deeply concerned about the lack of participation of the residents in the Centre despite the organisation having a daily programme for the month and putting various incentivised initiatives in place to encourage more participation in Centre activities. The Centre offers arts and craft activities, candle-making, health and awareness talks, sewing room, knitting and a bric-n-brac shop and small takeaway food initiative for income generation. Despite these opportunities, it was concerning to management that the lack of participation could potentially have negative consequences on both physical, mental and social health of the Centre members. It was agreed, that 2 final year OT students will be placed at NOAH over a period of 7 weeks. The role of the students were still undefined and we preferred it this way as it gave us the freedom to be responsive rather than prescriptive in addressing the challenges.
Where to start?
A context related assessment (CRA) was initiated where students used participatory methods of assessment with an intentional focus on building authentic relationships with residents and staff. We knew that this was going to be a challenge as relationships takes time and cannot be rushed but at the same time we had to be mindful of the tension of a limited 7 weeks and needing to gain trust so that information gained was meaningful and trustworthy. The target group in the CRA was residents who frequented the centre as well as those who never came and remained at home. Students walked to the different homes to have house discussions, used telephone to communicate and had group discussions with those who were at the Centre. Individual conversations were also needed at times. The assessment process had to be transparent, consistent and inclusive. We wanted to make sure we heard as many voices as possible. While engaging with the members, we also had to be mindful of our positionality and at times intersecting identities as remaining respectful was non-negotiable while working with members. Students had to consider their age, their culture and backgrounds mindfully as they engaged in conversations and realised that moving between their identity as OT students and grandchildren was critical if authentic relationships were to be exactly that. It was healing for both students and residents and made for trusting and authentic relationships. Students would participate in the morning exercise group and prayers, being quick to offer help and assistance. These informal engagements served as both an opportunity to develop relationships but also to gain critical information regarding the current occupational engagement patterns of members and the barriers and opportunities thereof.
As this was the first time that the organisation was hosting OT students in the scope of community development practice, the students also conducted a developmental reading of the organisation. This was critical in gaining understanding about how the organisation is run and its capacity to achieve its vision. This was important to understand so that students could work within the current capacity of the organisation but also identify strengths within the organisation that could support participation.
What did we discover?
In trying to understand the occupational profile and patterns of engagement, it was found that some of the residents included karaoke and bingo +/- once a month, reading , house chores (cleaning, gardening, cooking, laundry, shopping- Shoprite), community service/volunteering at NOAH centre, watching TV, listening to the radio, crossword puzzles or Sudoku (Blockbusters), socialising, exercise group, frequent talks on a variety of topics, prayer group, volunteer/community work (outside of NOAH eg: Prayers for Peace, Woodstock Community forum, gardening, poetry writing, composing music, various outings, home-based individual exercise including walking around the community, playing a musical instrument/singing, being actively part of neighbourhood watch and community police forum and lay counselling for FAMSA. The levels of engagement was different for every resident. It seemed like their occupational engagement was adequate but on further inquiry, we discovered some barriers that prevent meaningful participation for some.
NOAH has many aspects that help support residents’ occupational engagement. Resources such as stable finances, equipment and the centre property which all enable participation through their provision of space and resources to do activities. Additionally, it is evident that the NOAH staff care about the residents and are open to change within NOAH, which could be a facilitator for the resident's future occupational engagement. The affordable and safe accommodation NOAH provides, and the residents report great satisfaction with, provides a safe platform through which participation can occur. Furthermore, NOAH’s many ventures provide both funding for NOAH which feeds into resources available and some opportunities for participation.
The barriers to residents’ occupational engagement became clearer as the assessment process deepened and were grouped under common themes.
“Forced Participation vs incentivised initiatives to encourage participation”
The management was deeply concerned about those residents who did not come to the centre to engage in the opportunities provided. The residents however shared how the implicit and explicit compulsory nature of participation within NOAH centre was actually not motivating them to engage. The ‘incentive’ of the rent rebate was to reward those who did come to the Centre. Some residents reported that that they did not receive a choice in which community service activity they engage in initially. The idea of choice came up a lot. Furthermore, any similar community service activities which a resident may engage in outside of the NOAH context is not identified as active participation as this did not occur on the premises or as part of NOAH’s services. Certain events or activities are explicitly marked as compulsory and this reinforced the residents’ lack of choice and was then considered by them to be forced participation. The residents are also expected to sign a register at the centre because, as an additional complication, NOAH receives a subsidy from the Department of Social Development (DSD) who requires that the organisation has to account for the number of members which actively engage at the centre (as the subsidy is for centre activities). Thus, considering residents were not actively engaging in centre activities, an incentive of the rebate as well as making certain activities or events compulsory emerged in order to ensure the participation percentage requirement of the DSD is met. The question that emerged was: How do we support NOAH in providing opportunities for meaningful occupational engagement for their members?
“Us vs Them”
This theme emerged frequently and due to the trusting and authentic relationships, residents were forthcoming around this barrier. “Us” being the residents and “Them” being members of management. The “upstairs, office people” who need to work but there is no defined space in the Centre programme for management and the residents to engage with each other. This lack of engagement has thus led to disconnection and residents report that management upstairs is very busy with “important things” and thus although management “wouldn’t mind” a resident coming upstairs to talk to them, the discussion should be around something serious.
Some residents reported feeling that their voices are not heard by NOAH management as “they don’t listen to us”, “they never tell us anything” and “nothing ever changes”. Feelings of frustration are clearly evident as there have been several attempts at change through introducing specific activities or gaining outside input and each of these attempts have dissipated for various understandable reasons. Thus, there appears to be a lack of hope for change amongst the residents. There appears to be an idea that active participation can only occur at the centre (rooted in the Department of Social Development requirements for participation) and that one needs to be in their office to be working. These perspectives shape the way in which residents and staff are expected to engage. Some residents feel undermined by some members of management and feel as though they can be treated as children or talked down to. The residents are “told to behave” if they go on an outing etc. which is very frustrating for many residents as “we are adults, what do you mean behave!?”. While other members of management are viewed in a more positive light and are seen as “doing their job well” and very caring and supportive. These findings were challenging to discover as it required of students to hold these tensions while still remaining unbiased and committed to seek mutual understanding, rather than make assumptions and judgements. The question that emerged: How do we partner authentically with both resident and staff to improve participation while holding these tensions?
“Staying in touch”
Some residents reported that they lack knowledge around the correct line of communication with regards to raising complaints, suggesting ideas or discussing problems with NOAH staff/management. Residents have shared and students had observed that residents are not always informed when community service activities (especially talks etc) are cancelled and thus have repeatedly arrived at the centre to attend an activity and have to wait and later discover that it was cancelled as the presenter was unable to make it.
These were small challenges but still posed as a barrier to motivation to participate in the future.
“Ownership of the space”
A strong theme that emerged from the resident’s narrative was that of the lack of ownership of the NOAH and centre space. The residents do not have a say in their possibilities and choice in participation. They are provided with a very structured monthly calendar which repeat the same type of activities. Activities occur “when (management) make up their mind” to run an activity, thus the residents are not given autonomy in when, how or what these activities look like.
Although management holds monthly committee (one representative per house chosen by management) meetings to present the monthly calendar, on observation this space was to inform residents and not plan together where residents’ input and choices were included. The purpose of the meetings were to inform residents about the talks taking place that month, the days the centre is closed for management meetings etc, compulsory events and agreeing upon suggested days to hold big activities such as bingo and karaoke.
The residents were not observed to be given autonomy in the activities which or when they occurred despite a meeting being provided for collaboration. Those that felt comfortable to disagree with the dates proposed’ suggestions were sometimes turned down if they did not align with managements schedule and without a facilitator to lead the activity space, this space either ceases to exist or the recent attempt to re-create a space that was created for them, ignoring their autonomy in their own participation. There is limited facilitation of activities within the structure provided for the community service activities which could lead to a lack of buy-in to participation. The question that emerged was: How do we support NOAH in adopting a collaborative and inclusive approach to practice to address and improve the facilitation of participation?
Inter-personal dynamics
As in all organisations and families, there will always be person and inter-/intra-house dynamics and this came out clearly in resident’s narratives. Due to this conflict certain individuals or groups of individuals avoid certain spaces if they know other residents are going to be there, which acts as a barrier to their participation. The reasons for the conflicts and tensions are varied but residents often mentioned the fact some of the groups of residents try to lead activity spaces and tend to control the space and/or push their own views, which limits the willingness for other residents to engage. There are some reports of good dynamics within some houses as “no-one is trying to be in charge”. We realised that power in relationships and human politics can act as a barrier to participation for some.
Ideas around active ageing
Many residents shared how they thought that retirement should be burden free. This includes feeling as though you “have less burdens” and can ‘Relax and take each hour by hour… as you don’t know when your last day will be’. On the other hand residents explained that it is important to ‘keep busy’ and engage in activities in order to keep their ‘mind sharp’ and be healthy. Residents’ different understandings of active ageing to those of the organisation also influenced participation.
Other barriers to coming to the Centre included:
- Access to safe and reliable transportation from the houses to the centre for those who struggled with walking
- Health reasons where many reported feelings of fatigue
- Desire for solitude away from others and busyness
- Insufficient work opportunities available at NOAH for everyone
- Centre space is busy, small and loud
- Feeling unsafe (to walk in neighbourhood etc) due to crime in the area
- Challenge of accepting new level of inter-dependence (including denial of aging process)
- Nobody present to actively facilitate activities
- Lack of variety of opportunities for engagement
What was the design of the campaign going to look like?
At this point we sat with all this information and needed help to make sense of it but also give us direction in terms of what the design of the campaign needed to be to respond to the needs of both the residents and the organisation. Occupational science helped us in making sense and naming the issues that were happening but it also supported us in our rationale behind the design.
We knew that we had to work collaboratively in the design and so adopted the strategy of using group discussion spaces with residents both in the centre and in the houses. We used problem posing techniques and action learning to pose and reflect on the problem of ‘lack of participation in meaningful occupations’ and facilitated spaces where residents could spend time critically reflecting on issues around their participation. Students presented findings of the CRA to residents who were able to critically reflect and come up with solutions together. We had to be intentional about being transparent because of the interpersonal dynamics as well as inclusive and consistent. This was a challenge, as residents often expected a more clinical traditional service from students and thus it became clear that the role of OT students now needed to be defined. Much time was spent on ‘marketing’ the role of OT and helping the organisation and residents make the link between meaningful occupational engagement and health. We suddenly realised that the lines between the “Health and Happiness” programmes as defined in NOAH were blurring. It was clear that interpersonal dynamics and inability to deal with conflict was influencing mental health, relationships and participation. How do we promote both physical and mental health and wellbeing through meaningful occupational engagement?
As the discussion groups unfolded, residents and students started to ask and reflect on questions like: “So what do we want to do?”
What did we get up to in OT spaces?
We started facilitating spaces, using techniques which focussed on building collective solutions, self-reliant actions and action-learning. Residents co-constructed a list of activities they wished to engage in and engaged in a process of collective thinking and planning around implementation. Ideas from the residents of activities they wish to engage in included choir, Zumba/Dancing, more inclusive exercises, gardening projects (centre or home based), outings (engage in activities outside of the centre), for some of the existing monthly meetings for social gathering or team building (with all residents), which is “fun and festive” and occurs “away from home” such as in a church hall, talent shows – comedy, playing musical instrument, concerts (performances by the residents), bazaar, group walks in the evening, activities brought from outside facilitators/ organisations (such as arts and crafts) and storytelling (stories from their past and ‘good times’). It was clear that the residents were experiencing a sense of excitement around re-imagining their possibilities for engagement in the organisation.
While we know that these activities need to be further explored and extensive planning and costs needed to be considered, as a principle of practice, we value that the residents were contributing to the process and thereby exercising their agency in a small way. We also recognised that the residents were still placing a lot of their agency on the organisation to do for them but it was a step in the right direction. We knew we had to follow through with at least one of the new activities that they expressed. Using a process of elimination with criteria such as time available, costs, inclusion and space, we decided to start implementation with storytelling.
Through the use of posters and word-of-mouth, students asked residents who would like to volunteer in sharing their story. Three residents volunteered and were quite excited at the prospect of sharing their life story with everyone. Students video recorded the residents who shared freely their life stories, the highlights and challenges they faced. It was inspiring and very meaningful to them. The students then arranged for a slot in the daily programme when the stories were going to be shown and residents were welcome to come view and engage with the story. The 3 residents were nervous but excited to hear what others thought about their story. The space was facilitated by students who aimed to help residents get to know each other and too share their stories with each other. Word had spread and residents were asking when it was their turn next!
The occupation of storytelling was used as both means (for residents to engage in a different purposeful and meaningful occupation) and ends (to address occupational deprivation, promote relationship building and model to the organisation the value of facilitating occupational engagement) in this campaign. It also represented the prospect of change and sent a clear message to the residents that students were not only talk.
The next block started 3 months later and the focus was to continue with implementation of the ideas from residents but also to support the organisation in the implementation independent of students. In this block, students focussed on getting critical reflections of the daily programme with residents and gain deeper understanding of how the programme was being facilitated. Several new findings emerged and were centred around communication, relationships between staff and residents and lack of facilitation built into the programme. Zumba, self-defence lessons and new and improved Talk Topics were used as means and ends in the campaign. Means to address occupational deprivation, exclusion and lack of choice; and the ends was to improve the capacity of the organisation (and not only students) to facilitate health promoting occupations and to reflect and learn from their practice.
The daily programme was also communicated in better ways (hand written daily, in large print and only activities for the day, not the week), staff were given opportunities to learn and test new ways of facilitation (staff and resident received input in basic facilitation and supported in implementation), residents were included more in decision making and designing of the programme thereby improving the capacity of the organisation to better facilitate meaningful occupational engagement. The residents enjoyed Zumba and the new way in which Talk Topics were being facilitated and were inspired to initiate a new resident-facilitated exercise group. The possibilities for engagement and participation was visibly shifting.
So did it work?
Block ended in October 2019 and at the beginning of February 2020, a meeting between UCT and the management of NOAH took place to critically evaluate the work of students the year before and the way forward. Management reported that the there had been increased participation at the centre in general and more residents were participating in meetings and offering their contributions. It was also noted that some individual residents who were normally quite reserved and never engaged with others, were expressing themselves and participating more in social interactions. The centre manager recognised the value of being closer to residents and moved her office downstairs and ‘All-In’ meetings were now being run together with residents representatives from all the houses. A challenge that still remained was the poor attendance in the afternoons and how participation was experienced for those who did come to the centre.
After the most recent block, it was clear that residents were more forthcoming in group discussions and was willing to try new things. In the beginning, residents would be resistant to participating but once they witnessed the benefits and enjoyment of participation in others, were expressing interest in joining in next time! We suspect that as occupational engagement opportunities increase, their normal patterns of engagement will be influenced positively. The residents reported that the centre seems more alive and that they are wanting to connect more with each other.
What’s the next chapter?
This is still unfolding but there are some occupations, like storytelling, that we want to explore further. We recognise the power of telling your story and leaving your legacy behind as deeply meaningful for older persons. This is especially important for those who have strained relationships with loved ones and family and don’t have the privilege of leaving their wisdoms and life lessons with the next generation. We are exploring collaborations with film and media students.
While relationships and communication will always be an ongoing aspect in any organisation; we are committed to supporting the organisation in building their capacity to meet the physical and mental wellbeing of the residents in meaningful ways.