It is easy to think about toileting issues as just another problematic activity that can be solved by providing a piece of equipment or an adaptation. However, when we consider toileting in this one-dimensional way, we are in danger of failing to see how toileting as an occupation brings meaning and purpose to the lives of older and disabled people we work alongside.
In this article, we focus on the cultural dimensions of toileting and how this can help us better understand what makes meaningful occupations within toileting activities. We also discuss the challenge occupational therapists have in England in keeping toileting activities meaningful for older and disabled people from different cultures due to the legislation behind the main funding routes for adaptations – the Disabled Facility Grant (DFG).
Culture and cultural heritage are essential in the meaningfulness of everyday activities – including toileting. This is because culture is how society communicates ideas, customs and behavioural norms of everyday activities people perform. So, through theoretical models of practice, occupational therapists learn how culture shapes the roles, rituals and habits that shape the routine and rhythm of everyday life. And when changes in occupational performance disrupt those rituals and habits, it also disrupts the meaningfulness of those activities and negatively impacts a person’s health and well-being.
In social care, occupational therapists use their assessment skills to determine how to restore people’s everyday roles, rituals, and habits by adapting[1] the home environment. By adapting the home, occupational therapists work with older or disabled people to prevent, reduce, or delay health and social care needs from developing. Activity analysis is an integral part of this assessment process. When an occupational therapist does an activity analysis of toileting, they will have a ‘template’ in their mind of the task that should be performed. They will compare that template with what they observe the person doing, which helps them to think about what solution may or may not help the older or disabled person with the difficulties they are experiencing.
Unfortunately, one of the dangers of activity analysis is that it is based on the cultural norms the therapist is familiar with. As a result, they can often forget that how another individual carries out the activity may differ depending on whether that older or disabled person is from a different culture or cultural heritage. So as part of any activity analysis, an occupational therapist needs to understand how the older and disabled person’s culture and cultural heritage influences how they find meaning in the activity.
For most people, talking about their toileting needs, let alone how their cultural heritage influences the meaningfulness of toileting, is embarrassing and distressing for some people. However, the issue for occupational therapists is that we only have a limited amount of time during a home visit to build that ‘trusting’ relationship that puts a person at ease to discuss those needs. This is why occupational therapists must consider how they use their continuing professional development time to build their cultural competence around different cultures’ meanings, rituals and habits of toileting.
The Care Quality Commission describes cultural competence as having the skills and knowledge to be sensitive to people’s cultural identity or heritage and being alert and responsive to those beliefs or conventions. While occupational therapists want to be responsive and find equipment and adaptation solutions that accommodate the cultural needs of older and disabled people, it can be challenging to do this within criteria that are embedded in legislation that does not easily accommodate those cultural norms.
For example, when an occupational therapist in England supports an older or disabled person in applying for a Disabled Facilities Grant (DFG), they guide the housing authority on the necessary and appropriate solution. The therapist may want to recommend a toileting solution that uses running water to enable the disabled person to cleanse themselves as part of the cultural ritual of toileting. Unfortunately, the DFG sits in housing legislation that was written nearly 30 years ago. At that time, there was less understanding of the cultural needs described above, so it can be challenging for occupational therapists to make the case that a disabled person’s requirement for a solution that incorporates running water is a need and not a want.
Fortunately for occupational therapists in England, the new DFG guidance, published in 2022, has helped to address this weakness in the legislation. It does this by advising local authorities to move away from designing adaptations that focus purely on the person’s safety and function and to consider broader factors that help provide more sustainable solutions. For occupational therapists, the guide is invaluable because it provides a framework of nine guiding principles[2] that should be considered by those involved in assessing the necessary and appropriate elements of the DFG process.
Although culture is not explicitly mentioned in the framework, one of the principles is ‘having values recognised’. This could and should include how culture shapes an older or disabled person’s values system and, thus, the necessary and appropriate adaptations to meet their needs. By enabling occupational therapists to consider culture as part of the assessment process, there is an opportunity to ensure that the meaningfulness of activities such as toileting is captured in the design of adaptations. However, the solution has to be cost-effective, which can be another barrier to providing a culturally sensitive solution.
In this article, we have reflected on culture and its role in the meaningfulness of activities such as toileting. Being culturally competent enables occupational therapists to practice and provide person-centred solutions, but as this article has shown, we must also recognise the impact that policy and legislation have on the funding of equipment and adaptations, which doesn’t always fully accommodate the cultural needs of older and disabled people.
[1] As an intervention ‘adapting’ the home includes providing advice, recommending equipment, and supporting the design of structural changes to the home environment.
[2] The guiding principles can be found on pages 36 and 37 of the DFG Guidance Disabled Facilities Grant (DFG) delivery: Guidance for Local Authorities in England (publishing.service.gov.uk)
