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Abstract

Introduction:

The concept of participation has been extensively used in health and social care literature since the World Health Organization introduced its description in the International Classification of Functioning, Disability and Health (ICF) in 2001. More recently, the concept of social participation is frequently used in research articles and policy reports. However, in the ICF, no specific definition exists for social participation, and an explanation of differences between the concepts is not available.

Aim:

The central question in this discussion article is whether participation, as defined by the ICF, and social participation are distinct concepts. This article illustrates the concepts of participation and social participation, presents a critical discussion of their definitions, followed by implications for rehabilitation and possible future directions.

Discussion:

A clear definition for participation or social participation does not yet exist. Definitions for social participation differ from each other and are not sufficiently distinct from the ICF definition of participation. Although the ICF is regarded an important conceptual framework, it is criticised for not being comprehensive. The relevance of societal involvement of clients is evident for rehabilitation, but the current ICF definition of participation does not sufficiently capture societal involvement.

Conclusion:

Changing the ICF’s definition of participation towards social roles would overcome a number of its shortcomings. Societal involvement would then be understood in the light of social roles. Consequently, there would be no need to make a distinction between social participation and participation.

Keywords

Participation (WHO ICF)social and leisure activities activities of daily living rehabilitation role performance

Introduction

The concept of participation has been extensively used in the health and social care literature.^1–5 Participation, believed to contribute to health and well-being,^3,6,7 became a central concept of several policy articles.^8–11 In rehabilitation, participation is considered as the most relevant outcome.^3,12,13 More recently, the concept of social participation is frequently used in research articles^14,15 and is a core principle in European policy reports.^16,17 Several authors^18–21 consider social participation as an indicator of health, well-being and positive social behaviours. Social participation is seen as an important condition for children’s development, as children gather knowledge and develop social skills while interacting with other people.^3,22. For the elderly, social participation is regarded as a key determinant of successful and healthy aging.²³ The introduction of the International Classification of Functioning, Disability and Health (ICF)²⁴ had a major impact on the use and understanding of the concept of participation in healthcare. However, a specific definition for social participation does not exist within the ICF, nor is there a description of how both concepts differ. The central question in this discussion article is whether participation, as defined by the ICF, and social participation are distinct concepts. To answer this question, this article will illustrate the concepts of participation and social participation, present a critical discussion of their definitions, followed by implications for rehabilitation and possible future directions. Examples from paediatrics will be used to highlight issues.

Concepts of participation and social participation

The World Health Organization initially had the concept handicap within its International Classification of Impairment, Disabilities and Handicaps (ICIDH). Handicap was replaced with participation when discussions about participation, originated by the normalisation movement in the 1960s, emerged. These were initiated by Scandinavian countries as a response to human rights infringements that promoted the deinstitutionalisation and implementation of organised services facilitating community reintegration and the performance of activities of people with disabilities.²⁵ Since the 1990s, the concept of participation has been frequently used in the literature. The need for participation has appeared from an ideological shift in how society looks upon people with disabilities,²⁵ which considers a disability as a socially created problem and not as an attribute of an individual.²⁶

The concept of participation gained more attention when the World Health Organization²⁷ introduced its description in the ICF in 2001. The ICF became an important conceptual framework in rehabilitation to describe health-related states;²⁴ its core components body functions and structures, activities and participation, environmental factors and personal factors provided a global and collective language for health and disability.^28–30 Participation became a source for a better understanding of the possible impact of impairments and disabilities on the life of an individual person.³¹ The ICF defines participation as ‘involvement in a life situation’ or as ‘“the lived experience” of people in the actual context in which they live’,²⁴ while the activity is defined as ‘the execution of a task or action by an individual’.

The components of activity and participation have some overlap. Both components together are divided in a single list of nine domains; each domain consists of several subdomains that cover the full range of life areas from basic learning or watching to composite areas, such as interpersonal interactions and relationships or work and employment. In addition to the general ICF classification, a child- and youth-specific classification called the ICF for Children and Youth was developed; core domains were added to cover child- and youth-specific areas of life, like play.³² In addition to the description of the subdomains, the ICF uses two qualifiers for activities and participation.^24,28 A ‘capacity’ qualifier that specifies what a person can do independently of context, i.e. the best ability to execute a task or an action in a standardised environment. This qualifier aims to indicate the highest probable level of functioning that a person may reach in a given domain at a given moment (with or without assistive devices). The second qualifier ‘performance’ specifies what a person does do in the current environment, which includes a societal context.^24,28 This ‘real life’ environment has an impact on performance. For example, a child with cerebral palsy may have sufficient primary school capacities (in a standardised environment), but may not go to a regular school owing to the physical environment, the denial of access to services, discrimination or stigma.

Social participation has been discussed since the 1960s. However, a commonly accepted definition of social participation is still lacking.³³ Authors have frequently been using the concept of social participation interchangeably with participation.^34–36 Further, authors use social participation in relation to concepts of social integration, social inclusion or social activity.¹⁵ While the first authors consider participation and social participation as synonyms, the latter seem to differentiate between the two concepts. We identified three ways that authors may refer to social participation as a separate entity: as consumer participation, social activity and levels of involvement in society.

To begin with, social participation as consumer participation, derives from authors connected to social inclusion and the rights-based movement. The Institute for Social Participation describes social participation as (the right for) ‘meaningful involvement in decision-making about health, policy and planning, care and treatment, and the well being of self and the community’.³⁷ According to the Institute for Social Participation,³⁷ three components are central in their description of social participation that enable people to experience self-determined modes of social engagement: the references to the concepts of social capital and social inclusion, the individual’s human right to experience self-determined modes of engagement in all aspects of society and the societal responsibility to provide conditions necessary for the above. The emphasis on active involvement in contributing to society is central to this perspective on social participation. Although the World Health Organization did not mention social participation in the ICF manual,²⁴ the website of the World Health Organization³⁸ describes social participation from a similar angle: ‘… a way to contribute to a broader society by working with, consulting and empowering communities.’ This kind of social participation, also referred to as consumer participation or community engagement,^39–41, can take place at a micro-level (e.g. partner in the delivery of care), meso-level (e.g. engagement in service and information planning) or macro-level (e.g. part of health system consumer councils) of society.

The use of the concept of social participation as a synonym for social activity is witnessed by authors in several research areas, like Koster et al.⁴² and Shattuck et al.⁴³ These authors restrict social participation to interactions between people. Koster et al.,⁴² (p.135), conducted a literature review in the area of primary education and described social participation as ‘the presence of positive social contact/interaction between pupils and their classmates, acceptance of pupils by their classmates, social relationships/friendships between pupils and their classmates and the pupils’ perception that they are accepted by their classmates’.

Other authors operationalised social participation in a similar way, for example, as social activities that take place with friends or groups,⁴³ as involvement in voluntary activities or events^44,45 or as involvement in activities with a social element.^46,47

Finally, we found levels of involvement in society as a way authors refer to social participation. Levasseur et al.²³ conducted a systematic review in the literature on aging to capture the meaning and definition of social participation. Based on 43 original definitions, they found that, overall, definitions mostly focussed on the person’s (who) involvement (how) in activities that provided interactions (what) with others (with whom) in society or the community (where). Levasseur et al.²³ suggested a definition of social participation and a taxonomy of social activities based on the level of involvement. The proposed definition portrays what was found in most of the definitions that were included in the review: ‘Social participation can be defined as a person’s involvement in activities that provide interaction with others in society or the community.’ Levasseur et al.²³ stress that involvement can be seen on a continuum from relatively passive to very active, and that social participation can be both an objective and a subjective outcome. The proposed taxonomy of social activities has, along a continuum, six proximal to distal levels of involvement of the individual with others in social activities having different goals (Table 1). The levels distinguish the individual proximity of involvement with others (level 1: alone; level 2: in parallel; levels 3 to 6: in interaction), and the goals of the activity (levels 1 and 2: basic needs oriented; level 3: socially oriented; level 4: task oriented; level 5: oriented toward helping others; and level 6: society oriented). The taxonomy is regarded as an operationalisation of the concepts of participation, social participation and social engagement. In the words of Levasseur et al.,²³ the concept of participation encompasses all six levels, while social participation concerns levels 3 through 6 and social engagement includes levels 5 and 6.

Table 1.

A taxonomy for social activities based on the levels of involvement adopted from Levasseur et al.²³ with examples.

Levels	Description of the levels of involvement	Examples using parental roles in relation to involvement in society
First level	Doing an activity in preparation for connecting with other people	Reading a policy report to prepare for a meeting with a rehabilitation team and/or child’s teacher
Second level	Being surrounded with others	Sitting in a metro or train to get to a rehabilitation centre
Third level	Interacting with others without physical contact	Discussing inclusive education with others through Facebook, Twitter or LinkedIn
Fourth level	Doing an activity with others	Joining a creative workshop for parents and children
Fifth level	Helping others	Helping a child with physical education at primary school
Sixth level	Contributing to a community	Being an active member of a parent organisation or a political party

Discussion on the concept of the ICF definition of participation

Despite the extensive use of the ICF in education, research and rehabilitation, there is a lot of debate about the definition of participation. A crucial aspect of any conceptual framework is its internal coherence and its ability to differentiate among concepts and categories within the framework.⁴⁸ The definition of participation in the ICF as ‘involvement in a life situation’ or ‘the lived experience of people in the actual context’ does not succeed in limiting its scope. The question ‘what is not being involved in a life situation?’ is not easy to answer. Dijkers⁴⁹ (p.S6) stated: ‘being born and dying, and everything we do in between, involve being in a life situation’. Some authors, like Adolfsson et al.⁵⁰ who connect participation to role performance, wonder why the definition is restricted to ‘a life situation’, as performance of a role includes many life situations. Also, the qualifiers capacity (can do) and performance (does do) raise questions about the scope of participation. Capacity emphasises the ability to execute a task in a standardised environment. As current environments are not standardised, this qualifier seems to be more appropriate for activity. Both capacity and performance focus strongly on acting. Involvement in a life situation may be broader than acting or doing. One can be involved in a life situation also when one is not actually doing things himself or herself;⁵¹ a child who is physically completely dependent on others, but who is still in control of how and when things are done according to his or her wishes, is participating by fulfilling his societal role and personal goals.

The emphasis in the definition of the ICF on acting further evokes questions about whether participation is merely an objective condition rather than a subjective experience. Several authors^{12,31,52–55} criticised the definition of the ICF for not including the subjective experience or satisfaction.^12,51,56 Is it possible to talk about a child’s participation at school without including the child’s subjective meaning about the ‘lived experience’?

Furthermore, the lack of distinction between the definition of participation and the definition of activity is often criticised. In the ICF, the activity and participation components are presented in a single list that covers the full range of life areas. Several authors^5,57 claim that the differentiation is essential if the ICF is to achieve acceptance by individuals, organisations and associations as an international classification of human functioning and disability.

Discussion on the concept of social participation

Two concepts are distinct when a person is able to clearly and distinctly differentiate one concept from another.⁵⁸ How clear are the suggested descriptions of social participation and how do they relate to the concept of participation as described by the ICF?

A clear definition of social participation as consumer participation or community engagement is lacking.^59,60 A complication in defining the scope of social (consumer) participation is its reference to different overlapping groups of people: patients and service users, carers, taxpayers and representatives.⁶⁰ Further, the challenge is to make a definition so clear that it distinguishes social (consumer) participation from concepts like empowerment, social inclusion and participation.^61,62

Social participation as consumer participation emphasises both engagement of people in society as well as the societal responsibility to provide the conditions necessary for social engagement. Here lies a major difference with the concept of participation as defined by the ICF. According to Fougeyrollas,²⁵ it is this focus on the responsibility of the environment that distinguishes concepts as social integration and inclusion from participation. Environment is a separate component within the ICF. Although the ICF manual does emphasize the interaction between the environment and functioning, quality indicators of environmental factors determining the quality of participation are not included in the ICF manual. Moreover, social participation as consumer participation seems to be goal oriented. The aim is involvement in decision making to increase the well-being of self and the community. Participation, as defined in the ICF, does not specify any specific goal of involvement in a life situation.

Social participation as social activity is also not yet a well defined concept. The concept of social participation in this perspective is often used without a specific definition.¹⁵ Some authors^43,45 refer to the concept as an objective state; the amount of social contacts or the number of activities one is engaged in. Others, like Boutot and Bryant,⁶³ include a subjective experience in the concept (e.g. social preference). Likewise for participation in the ICF, it is important to question whether social participation without the subjective experience is of any relevance in relation to health status and well-being. Social participation as a measurable state of social activities seems to be very close to the concept of activity in the ICF. What is the difference between the activity ‘playing’ described by Koster et al.⁴² and the same activity in the ICF for Children and Youth? For the acknowledgement of social participation as a single concept, it is important to question whether it makes sense to distinguish between social activities and non-social activities.

Social participation is described as levels of involvement in society by Levasseur et al.,²³ who do not claim their definition of social participation to be distinct from the ICF definition of participation. Moreover, in their taxonomy they show that both social participation and social engagement fall under the umbrella of participation. Levasseur et al.²³ stated their definition and taxonomy to be a starting point for further discussions on the conceptualisation of social participation. By saying that: ‘social engagement necessarily involves a desire for social change or to be heard to affect community choices (…) to contribute to making the community a better place to live’, their description of the concept of social engagement is close to the concept of consumer participation. At the same time, it differs from the way the ICF portrays their subdomains (e.g. community, social and civic life) as possible actions and tasks (e.g. recreation and leisure, religion and spirituality, political life and citizenship) that are required for people to engage in organised social life. Furthermore, the ICF subdomains are presented as single bodies without explanation as to how they link to each other and contribute to engagement in a social life. In contrast, representation of concepts by Levasseur et al.²³ in their taxonomy has the advantage of highlighting links between the concepts and suggests how they relate to each other.

Implications for rehabilitation

Previously we showed that a clear definition of social participation is still lacking and proposed definitions have an overlap with participation and activity as defined by the ICF (see Figure 1). Concepts, theories and models guide research and practice. In daily rehabilitation practice, core concepts, like participation, serve as a basis for a deeper understanding of aspects of clients’ lives, support analyses and assist in problem solving. These concepts form the base of measurement instruments. Nevertheless, defining concepts is never an easy process. Although quality of life has been an important key concept in research and clinical services, there is still no agreement on what quality of life is and how it should be measured.^64–66 Discussion in the literature about (social) participation might mirror the whole conceptual development of the perceived quality of life concept.

Figure 1.

Presentation of the overlap between concepts related to Social participation (social activity, consumer participation, levels of involvement in society) and Participation, activity, environment as defined by the ICF.

The ongoing critique of participation as defined by the ICF justifies a further debate in rehabilitation on the concept especially concerning issues as the meaning of involvement, the subjective experience of participation and measurement of participation. Recent literature reviews^67,68 into measurement instruments for participation found that most instruments measure capacity related to activity, primarily built on normative standards (frequency and/or duration) and are based on the assumption that ‘more is better’. However, a domain for satisfaction or engagement is not included in most of these instruments.

The number of studies and reports using the concept of social participation does urge further debate. Participation as defined by the ICF might inadequately capture the relevance of social activities or societal involvement. The ICF activity and participation domain and its subdomains currently illustrate types of actions or tasks required for people to engage in organised social life. For example, for paediatric rehabilitation purposes, this might be too broad and too narrow to capture parents’ and childrens objective state and subjective experience of their involvement with others in society.

Recent developments put even more emphasis on the relevance of societal involvement. Health literacy and self-management, Web 2.0 social media, empowering communities and ‘Nothing About Us Without Us’⁶⁹ are developments that will (continue to) have a major impact on healthcare.³³ Increasingly, people themselves will be held responsible for their health and social participation in society. These developments will change how individuals with chronic diseases and disabilities relate to and engage with society. As a consequence, rehabilitation practitioners should be able to support clients’ involvement on all levels of society. For example, in paediatric rehabilitation, family-centred service will be challenged to create opportunities for parents/children to interact, to provide parents/children with tools for self-management, to enable parents/children to help each other and to contribute to society.

Possible future directions

Are participation and social participation distinct concepts? This article shows that, besides a warrant for further deliberation on defining social participation, there is a need for further debate on the definition of participation. In our opinion, the distinction between the two concepts depends on the direction that further discussion on participation, as defined by the ICF, will take. We agree with several authors that a more clear distinction between activity and participation, and an emphasis on subjective experience of participation, can be achieved by putting participation in the perspective of societal involvement defined by an engagement in social roles. Earlier work on disability models showed the importance of social role performance. For Nagi,⁷⁰ role performance was the defining concept at the societal level to understand disability. Whiteneck¹³ suggests that Nagi’s conceptual focus on roles may offer an effective way to differentiate activities and participation in ICF-2. In addition, Badley⁷¹ recommends an emphasis on engagement in roles as one possible alteration of the ICF definition of participation. Participation then does not refer to performing single activities, but to performance of a socially and culturally defined role. Social roles for children are for example daughter, pupil, friend or teammate. The wider environmental, social and cultural contexts are crucial for setting the scene for societal involvement, as are the personal characteristics of the individual.⁷¹ As these set the opportunities and the nature of role performance, its assessment is largely subjective. Whether or how a social role is carried out depends on personal preferences and on the demands of the role and external factors.⁷¹

Engagement in social roles frequently includes social interaction with others.¹³ According to Badley,⁷¹ interaction with other people is usually integral to societal involvement. Consequently, one could argue that social interaction with others would have to be understood in the light of social roles. Being a teacher in a primary school involves a high frequency and variation in social interaction with pupils, co-workers and parents. Barriers in social interaction in this role differ from barriers in social interaction in the role of a fisherman (used to fish alone).The taxonomy of Levasseur et al.²³ can be used to specify the type of social interaction or involvement taking place in a specific social role as highlighted in Table 1. There would be no ground to separate social participation from participation, once participation is defined as engagement in social roles.

Conclusions

This article critically discusses the concepts of participation and social participation as described in the literature. To summarise, a clear definition for participation or social participation does not yet exist. Definitions for social participation differ from each other and are not sufficiently distinct from the ICF definition of participation. The ICF definition of participation itself does not adequately capture the objective state and subjective experience of involvement with others in society. Therefore, a redesign of the ICF’s definition of participation toward social roles is warranted.

Clinical messages

Participation and social participation are not sufficiently defined as distinct concepts.

Every person’s societal involvement is an important outcome for rehabilitation.

Rehabilitation professionals should note that the definition of participation, and measurement instruments based on this definition, do not capture the subjective meaning and societal involvement.

Societal involvement can be well understood in the light of social roles.

Footnotes

The authors wish to thank Professor Dr DT Wade,Professor of Neurological Rehabilitation,Oxford Centre for Enablement,UK for his valuable contributions to this article.

Conflict of interest

The authors report no conflict of interest. The authors alone are responsible for writing this article and for its contents.

Funding

This research project was financially supported by Zuyd University of Applied Sciences.

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Participation and social participation: are they distinct concepts?

Abstract

Introduction:

Aim:

Discussion:

Conclusion:

Keywords

Introduction

Concepts of participation and social participation

Discussion on the concept of the ICF definition of participation

Discussion on the concept of social participation

Implications for rehabilitation

Possible future directions

Conclusions

Clinical messages

Footnotes

Conflict of interest

Funding

References