Occupational therapists’ perceptions of the need to enact health promotion in community development through occupational justice

Percepções dos terapeutas ocupacionais sobre a necessidade de implementar a promoção da saúde no desenvolvimento comunitário por meio da justiça ocupacional

Abstract

Introduction

Social determinants of health underlie and contribute to health inequalities. Stigma, poverty, and unequal access to health care are examples of social determinants that affect people’s well-being and participation in society. Although occupational therapists use occupation to promote health and well-being, they rarely consider how to address the reduction of health inequalities in their practice.

Objective

The study aimed to explore how occupational therapists perceive the need to enact health promotion in community development through occupational justice.

Method

Following critical participatory action research principles, group discussions were conducted by six professionals from across France. Occupational justice frameworks and public health reports were used to prompt a group dialogue over four months. A content analysis of the discussion was conducted, guided by the theory of practice architectures to understand how the therapists’ practices were shaped by discursive, economic, and socio-political circumstances.

Results

Four themes reflected the professional needs to undertake community development: ‘the professional skills needed to enact the community’s own know-how and self-expertise’, ‘the importance of seeing the ‘whole’ picture and reaching out to other sectors’, ‘the need for occupational justice to understand the complexity of community development’, and ‘the need to move beyond body functions in education’.

Conclusion

Community development offers unique opportunities to work in the complex context of everyday living. Reasoning informed by occupational justice concepts enables occupational therapists to consider health outcomes caused by social determinants. Occupational therapy education must train students for complex reasoning on how occupational injustices are rooted in everyday social contexts.

Keywords:
Occupational Therapy; Health Promotion; Community Development; Occupational Justice

Resumo

Introdução

Os determinantes sociais da saúde fundamentam e contribuem para as desigualdades em saúde no mundo. Estigma, racismo, pobreza e acesso desigual aos cuidados de saúde são exemplos de determinantes sociais que afetam o bem-estar e a participação das pessoas na sociedade. Embora os terapeutas ocupacionais usem a ocupação para promover a saúde e o bem-estar, raramente consideram seu potencial para lidar com a redução das desigualdades em saúde.

Objetivos

Explorar como os terapeutas ocupacionais percebem a necessidade de implementar promoção de saúde no desenvolvimento comunitário por meio da justiça ocupacional.

Método

Seguindo os princípios críticos da pesquisa-ação participativa, as reuniões do grupo foram conduzidas por seis profissionais de diferentes regiões da França. Enquadramentos de justiça ocupacional e relatórios nacionais de saúde pública foram usados para estimular um diálogo durante quatro meses. Uma análise de conteúdo foi conduzida, guiada pela teoria das arquiteturas da prática, para entender como as práticas dos terapeutas ocupacionais foram moldadas por circunstâncias discursivas, econômicas e sociopolíticas.

Resultados

Quatro temas refletiram as necessidades profissionais para praticar o desenvolvimento comunitário: as habilidades profissionais necessárias para decretar o próprio know-how da comunidade; e auto perícia, a importância de ver o quadro “por inteiro” e de alcançar outros setores; a necessidade da justiça ocupacional para compreender a complexidade do desenvolvimento comunitário; e a necessidade de ir além das funções do corpo na formação.

Conclusão

O desenvolvimento comunitário oferece oportunidades únicas para trabalhar no complexo contexto da vida cotidiana. O raciocínio informado pela justiça ocupacional permite aos terapeutas ocupacionais considerarem melhor os efeitos dos determinantes sociais sobre a saúde. A formação em terapia ocupacional deve abordar a realização de raciocínios complexos sobre como as injustiças ocupacionais estão enraizadas nos contextos sociais cotidianos.

Palavras-chave:
Terapia Ocupacional; Promoção da Saúde; Desenvolvimento Comunitário; Justiça Ocupacional

Introduction

The health of individuals and communities is seen as the result of multiple determinants including social factors, economic factors, government policies, availability and quality of health services, and physical environments (Lang & Ulrich, 2017). Social determinants of health, such as lack of access to education, proper living conditions, and poverty, are deemed as mostly responsible for health inequalities. They affect people’s sense of self and the ability to engage in meaningful occupations, thus infringing people’s occupational rights (Hammell, 2020; Wilcock & Hocking, 2015). Several international agencies have called health professionals, including occupational therapists, to address the social determinants that create and sustain health inequalities within marginalized communities (European Public Health Association, 2020; Paris, 2017; World Health Organization, 2012, 2003). The World Health Organization (WHO) (World Health Organization, 2003) views social determinants of health as particularly complex and challenging as they are concerned with populations’ living conditions and lifestyles.

Health promotion is conceptualized as an essential approach to reduce health inequalities among populations (World Health Organization, 2010), often defined as “[...] a process of enabling people to increase control over, and to improve, their health [...]” (World Health Organization, 1986, commencement sentence). According to Tucker et al. (2014), occupational therapy and health promotion share many similarities, such as the goal to enable individuals and communities to take ownership of their health and the conditions that affect their well-being. Population-based health promotion is an approach that focuses on identifying and reducing health inequalities as well as enhancing the overall health and well-being of a population (Comité Régional d’Education pour la Santé, 2018). Occupational therapy’s role in population-based health promotion has been identified as an important occupational therapy domain of practice (Braveman, 2016). Occupational therapy population-based health promotion services have the potential to contribute to public health national and international goals such as the Sustainable Development Goals [SDG] (e.g., SDG3: Ensure healthy lives and promote well-being for all at all ages), those outlined in Healthy People 2030 by the United States Government, and Health 2020 by the WHO/Europe. North American studies by Clark et al. (2001, 2012), Hay et al. (2002), and Levasseur et al. (2019) demonstrate a sustained effect from occupational therapy health promotion interventions for older adults living independently in urban communities. Research conducted by Suarez-Balcazar et al. (2016) with Latino youth with disabilities at risk for obesity and Schepens Niemiec et al. (2021) with rural-dwelling Latinos shows positive outcomes of lifestyle programs led by occupational therapists.

Although addressing health inequalities through health promotion is consistent with the tenets of the profession (American Occupational Therapy Association, 2020), occupational therapists still struggle to define their roles in this area of practice (Lauckner et al., 2019). Scholars propose that occupational therapy practice within communities affected by health inequalities should follow an occupational justice perspective (Whiteford et al., 2018; Wolf et al., 2010) which provides a broad framework for working within communities. Examples of context-specific approaches and frameworks that have been proposed to work within communities but not specifically focusing on health promotion are the Social Occupational Therapy from Brazil (Malfitano et al., 2014), the Community Development Framework (CDF) from Germany (Zinkstok et al., 2018), and Australia (Hyett et al., 2019), and more recently the Occupation-Based Community Development framework from South Africa (Peters & Galvaan, 2021). The study of occupational justice addresses the social determinants that shape the inequitable availability of health-promoting occupational opportunities for different groups in society (Hammell, 2020). As a result, issues of occupational injustices and justice have been identified as fundamental issues for the occupational therapy profession (Hocking, 2017; Kinsella & Durocher, 2016; World Federation of Occupational Therapists, 2019). Hammell (2020) raised the need for occupational therapists to effectively address the social determinants of health to further people’s engagement in meaningful occupations that contribute to their well-being and their communities.

It has been suggested that the application of the Participatory Occupational Justice Framework (POJF) (Whiteford et al., 2016) can be useful to occupational therapists in promoting engagement with social issues related to participation in everyday life occupations (Wolf et al., 2010). As such, it has been extensively used, including locations beyond the Global North, to engage with communities and reflect on issues such as territorial occupation (Simaan, 2021), drug abuse (Sy et al., 2021a), and immigration (Whiteford et al, 2018), among others. Yet, the unfolding of the continuum between the roles and processes required to operate as occupational therapists working with communities, remains underexplored (Lauckner et al., 2019). Occupational therapists need more contextual empirical evidence to develop occupational therapy in health promotion interventions. This lack of knowledge constraints the potential contributions of occupational therapy to the field of health promotion, as well as the application of the POJF to reduce health inequalities through occupations. As such, an examination of the perceived needs of occupational therapists currently working in this field can increase understanding of the complexities of occupational therapy in health promotion. It may also improve the potential application of conceptual frameworks, such as the POJF or the CDF, to support population-based interventions.

According to Harrison & Graham (2012), the first step to support the implementation of programs is through inquiry that focuses on local context in a problem-focused and context-driven approach. In line with this, this study aims to explore the contextually situated perceptions of the needs of four occupational therapists working in health promotion and community development in France. The research question is: What are occupational therapists’ perceptions of the need to enact health promotion in community development through occupational justice?

Method

Design

This study is guided by critical participatory research principles (Kemmis et al., 2014) and uses collective reflection to co-create knowledge that can be applied to emerging occupational therapy health promotion practice. This approach takes into consideration participants’ perceptions on how ‘things are done,’ allowing them to explore the needs for practice (re)construction while revealing assumptions and challenges in current practice (Whiteford et al., 2016). Through collective critical reflection, participants can understand their practice and its consequences while considering how it is socially set (Farias et al., 2019; Herr & Anderson, 2014). In alignment with the critical paradigm underlying this study, participants are valued as full members of the knowledge creation and action process (Cockburn & Trentham, 2002; Kramer-Roy, 2015). For example, reciprocity is amplified using open communication principles, and research is taken as a collective endeavor as “we” or “us”, while decisions are taken collectively until an intersubjective agreement on a perspective of practice is found. Such space offers new local insights and transfers new knowledge into the practice (Herr & Anderson, 2014). After the completion of the study, it is expected that participants will be able to act toward eliminating the constraints hampering their practice needs (Kemmis et al., 2014; Savin-Baden & Wimpenny, 2007).

To support contextually situated discussions, participants were provided with three documents: (a) a compilation of the last three national reports on the role of healthcare professionals in health promotion from the High Authority in Public Health (Comité Régional d’Education pour la Santé, 2018), (b) the Community Development Framework: A Reflective Framework for Practical Projects in Occupational Therapy (CDF) (Zinkstok et al., 2018), and (c) the Participatory Occupational Justice Framework (POJF) (Whiteford et al., 2016). For a description of these documents, see Table 1. These documents provided a foundational structure for identifying the needs and potential ways of overcoming barriers through collective and sustainable actions (Kemmis et al., 2014; Savin-Baden & Wimpenny, 2007).

Table 1
The three documents provided for discussions for enacting health promotion in community development.

Document	Description
(a) Documentation on the role of Prevention and Health Promotion in Healthcare Delivery	Compilation of three national reports on the role of healthcare in health promotion in France
(b) The Community Development Framework: A Reflective Framework for Practical Projects in Occupational Therapy (CDF)	Framework to support occupational therapists’ participation in community development projects for improving quality of life, social inclusion and participation
(c) The Participatory Occupational Justice Framework (POJF)	Framework designed to provide conceptual foundations to raise a critical dialogue on occupation, enabling and justice among practitioners

Ethical approval for this study was obtained from Aix-Marseille University (ref. 2018-13-12-001). All participants in the study provided written informed consent and agreed to sign an ethical code of collegiality promoting open communication, equal participation, respect, conflict resolution, and confidentiality. The possible benefits, challenges, and ethical issues within a critical participatory action research were outlined, including the right not to actively participate and to decide together how the data generated would be used (Herr & Anderson, 2014; Kemmis et al., 2014).

Participants

Eight potential participants were identified through purposive sampling (Kielhofner, 2006) via the French Association of Occupational Therapists network, from a heterogeneous group (i.e., gender, years of experience, regions, and diverse experience and roles within community development) to promote maximum variation sampling and to maximize the application of findings to diverse contexts. All invitees who met the criteria were invited to participate via email, three respondents consented to participate in the study. Few occupational therapists are engaged in health promotion and community development, which are emerging fields of practice (Albuquerque, 2019; Monin, 2019). To improve the knowledge base and reflect better the professional organization in practice (Herr & Anderson, 2014), two non-occupational therapist community professionals, acquainted with occupational therapy practice and the first author, were invited to collaborate, and responded affirmatively. One is a social worker, the second is a health promotion educator and community development advocate. They provided outsider perspectives for organizational learning regarding occupational therapy practice in community development and health promotion (Herr & Anderson, 2014). Out of the six participants (including the first author of this study), four were registered occupational therapists in France, identified as having at least six months experience in community practice. For details on the community settings of the participants, please see Table 2.

Table 2
The participants represented different situated practices to provide multiple perspectives.

Participants	Community work setting experiences related to practice and education
P1	Occupational therapy practice in a Community Health Center, Quebec; private community practice, France
P2	Occupational therapy practice in community development for socio-economically deprived populations
P3	Occupational therapy practice in community mental health services and adjunct lecturer in occupational therapy
P4	Occupational therapy practice in community development for socio-economically deprived populations, consultation in health promotion, and lecturer in occupational therapy
P5	Community-centred project social worker
P6	Health promotion manager and educator and community development advocate

Data collection

To enact reflection and open communication, the group followed the theory of practice architectures, developed by Kemmis, Wilkinson, Edwards-Groves, Grootenboer, Hardy, and Bristol (Kemmis et al., 2014). This theory highlights the need for an atmosphere of inclusion to promote horizontal and voluntarily active involvement of diverse views of practice in sayings, doings, and relatings that hold the practice in place. Data was gathered through online and face-to-face meetings. TalkSpirit® was used to establish a virtual public space for dialogue in-between face-to-face group meetings and provided a space for exchanging documentation, continue the dialogue, and translate some of the provided documents to French.

The group met face-to-face three times over four months. The first session’s goal was to launch the study’s aim, and to collaboratively define the role and purpose of each meeting (i.e., topics and questions to be discussed in the next sessions). The second session aimed to identify and discuss the participants perceived needs and barriers when trying to enact health promotion programs. Some questions that guided the second meeting were: how is a practice conducted in community development and health promotion fields? and what are the prerequisites, contexts and settings needed to work in community development and health promotion? After the second session, transcripts of the discussion were handed to the participants to support critical reflection before the next meeting (Farias et al., 2019). The third session mainly focused on participants reflections on the discussion that took place during the second meeting as well as on participants interpretations of the discussion. During the third meeting, participants also came up with questions for discussion such as: how could occupational therapists’ practice benefit from an occupational justice perspective? And how to support coordination between sectors and settings to empower populations? (See Table 3 for the description of the research study phases and purposes, research leading questions, documents, and tools). The sessions were conducted in French (native language of the first author and the participants) and each meeting lasted approximately 120 minutes.

Table 3
The research study phases and purposes over four months, research initial and consequent questions, documents, and tools.

Phases & purposes	Study questions leading the dialogue	Documents & tools
Meeting 1: Reconnaissance launch into the study	What are the needs that occupational therapists identify in community development practice related to health promotion within France’s new healthcare system?	Distribution of the POJF, the CDF, and Healthcare Recommendations on Prevention and Promotion of Health
After meeting 1 until closing of data collection: Dialoguing, reflecting & collecting data through virtual dialogue	Id.	The Talkspirit® virtual community platform
Meeting 2: Dialoguing, reflecting & collecting data around practices and documents	How is the practice conducted in community development and health promotion? What are the prerequisites and settings/contexts to practice community development in health promotion?	The CDF, Healthcare recommendations on prevention and promotion of health
After meeting 2 until closing of data collection: Dialogical reflexivity over data analysis	Id.	Data analysis
Meeting 3: Dialoguing, reflecting & collecting data around practices and documents.	How to relate to practice? What is the coordination between settings/sectors? Can occupational therapists practice without an occupational justice perspective? How to empower the population when the projects are professionally driven? Is empowerment at the intersection between the individual, the community and society? How to empower citizens to enact their place within society? What professional education? What change is needed and to what extent?	The POJF, Healthcare Recommendations on Prevention and Promotion of Health

Data analysis

Group sessions were audio-recorded and transcribed verbatim by the first author and two participants. Communication theory and content analysis (Lindgren et al., 2020; Vaismoradi et al., 2013) were used to analyze the data, focusing on assumptions within the practice architectures; that is, participants’ sayings (i.e., languages, discourses they used), doing (i.e., material, economic and practice arrangements they described within the social and healthcare system) and their relating (i.e., their social and political arrangements within the social and healthcare system) (Kemmis et al., 2014). The primary analysis was made by the first author in discussion with the second author. Through an iterative process, the authors and the participants established a consensus on common patterns of issues or themes, also paying attention to meaning making (i.e., agreements and disagreements between participants), and to when decisions were made regarding directions for actions and practice. To ensure a representational process of analysis, and to voice participants’ viewpoints, participants reviewed the preliminary themes and provided written comments that were integrated into the final analysis (Farias et al., 2019). Later, a thorough and holistic analysis of the data was performed to recapture the process as well as the practice (Herr & Anderson, 2014).

To ensure that meaning would not be lost during the translation of the quotes from French to English, the first author, who is a native French speaker with a good command of English language, translated the participant quotes after completion of analysis (van Nes et al., 2010). Then, the second author and a native English-speaking person external to the study checked the quotes and made grammatical corrections, which were thereafter revised by the first author to ensure authenticity of the quotes presented.

Findings

Participants’ working needs concerning the complexities of health promotion and community development, as well as the application of POJF and CDF to support occupational therapy health promotion interventions, are summarized in four overarching themes described as follows: ‘professional skills needed to enact the community’s own know-how and self-expertise, ‘the importance of seeing the ‘whole’ picture and reaching out to other sectors’, ‘the need for occupational justice to understand the complexity of community development’, and ‘the need to move beyond body functions in education’.

Professional skills needed to enact the community’s own know-how and self-expertise

According to participants, the focus of occupational therapy working with communities was to meet individuals and groups in their natural context of living. Unlike the practice in medical or institutional facilities, occupational therapists meet individuals and groups within the context in which they perform their occupations. Medical settings were described as hindering health promotion intervention since they do not provide the same ‘everyday’ spaces. As P3 described, “I felt restricted by the medical institution whenever I wanted to use the potential of an activity. In my everyday life, in the community, I witnessed encounters that are not happening in medical settings”, P4 stated that “we meet citizens, not patients” and P2 stated that in medical settings “there is too much inertia.” P3 added that, at the community level, there are more opportunities to work more collectively, creating “the real social nexus: where different individuals come together around a collective activity.”

Participants agreed on the need to acquire skills to enact community members’ know-how and competencies that allow the latter to become active collaborators in health promotion. Supporting such competencies and skills were considered as a determinant factor in enabling communities to recognize and claim their expertise in issues about their own health. P2 described that solutions to acquire these competencies and skills were still unclear in practice and felt “like if I lack the tools, the experience, or the know-how. I’m not sure whether I always succeed at enabling participation, or if I end up setting up participation.”

Another important skill that was highlighted by participants as important is to have a horizontal approach with communities. P6 described this professional approach as taking part “within the community, as an insider, not as an outsider […] we enact the community’s own know-how and self-expertise”. P4 illustrated this approach in practice by empowering communities to lead the changes and occupational therapists “to let go of solving problems.”

Participants highlighted the importance of enacting a genuine bottom-up approach to lead these changes, where initiatives are geared by the community and for the community. P4 described this approach as a shift in professional stance from expert in medical conditions to facilitator of participation: “As healthcare professionals, we shift from treating a medical condition to caring for health by enacting social and occupational determinants”. For example, P3 described this approach as “further ahead, beyond [one’s] own person” and P2 as coming from the people and not from a “poster”: “Neither a program for patient education nor a public health poster boy shouting ‘eat your veggies!’”.

The importance of seeing the ‘whole’ picture and reaching out to other sectors

Most participants described that work in community development provide them with a ‘whole’ picture of people’s everyday occupations. P4 pointed out how occupations can be both observed “explicitly and implicitly in the real context” and P3 described this setting as going “down below the iceberg, the immersed part, where prevention lies. The system, the living environment, the meaning and the purpose the person is immersed in”. Yet, occupational therapists need to collaborate with diverse actors and reach out to other sectors that can support social change, “otherwise” stated P2, “you just don’t work in social [field]. You need to be optimistic and see that you can change things”. P1 reflected on the process of reaching out to other sectors, “It’s not the occupational therapist alone, it’s the whole community stakeholders […] bridging over at every stage.” Most participants agreed on the idea that working in community development needs to be made with individuals and professionals from diverse sectors. P6 stressed on several occasions that professionals need to lean on the community’s “every day tacit knowledge and experiential knowledge”. Several participants, such as P4 and P5, experienced that occupational therapists had specific expertise in reaching communities and stakeholders, because of their occupation-based skills rooted in social and medical fields. Using human occupations as common ground for community projects was also considered to be an important asset in building relationships across communities and stakeholders.

The need for occupational justice to understand the complexity of community development

Most participants mentioned that they were unaware of theoretical concepts underpinning their community practice before getting to know the POJF or the CDF. P4, as an educator, had been aware of these concepts and described how she developed her community development practice thanks to the ability “to figure how occupations impacted health. Before, my vision would have been more restricted”. An occupational justice perspective offered participants a value-based perspective that strengthened their practice. P3 stated that the POJF had provided her with: “a real feel for political practice [in occupational therapy]!”. Such a perspective also unlocked discussions among the participants of how occupational rights are linked to citizenship and civil rights. P4 described that using an occupational justice-based perspective “raises awareness of occupational injustices, engage collaboratively with partners, mediate agreements, strategize resource finding, and support implementation and continuous evaluation”.

Occupational justice awareness and genuine collaboration were deemed essential to enact transparency and avoid making decisions for the communities involved and risking losing their trust as described in other projects. P3 illustrated how “they [authorities] tell the communities: ’that’ll be your project, you’ll make the decisions’, but in fact, everything is already decided upfront. This is the reason some communities get demotivated, there is a lack of transparency.” As such, some community projects appear to be managed from health policies agenda imposed from the top or by private funds and not benefit the communities within which they work.

Participants also expressed dilemmas regarding public funded accountability. Participants highlighted that such requirements regarding efficiency and outcome measurements hindered sometimes building trust with communities. P2 described this dilemma as “bipolar thinking”, depicting the contradiction of measuring efficiency processes while building trust and competences. P3 and P5 expressed their struggle “against the principle that two realities can be the same, that the project is going to unfold timely, according to a pre-planned budget of +1, +2, +3… or +5 years ahead.”

The need to move beyond body functions in education

Participants expressed the need to review the current occupational therapy curriculum to better support the provision of health promotion services, beyond biomedical perspectives. P4 highlighted how providing occupational concepts related to community practice and occupational justice can support students to think about community practice in other terms than biomedical: “I explored further [with students] the concept of occupational justice and how to apply it in different settings. Later a couple of occupational therapists came to talk about community practice with vulnerable populations (substance users, low socio-economic backgrounds, ex-convicts). […] A student came to me at the end and told me: ‘I wanted to thank you, for once the practice matches the theory!” P2 pictured the need to integrate these community-related concepts in the educational system as the need to turn “bilingual” in addressing impairment-based as community-based issues. P3 reflected on reducing the “disarticulation of the body and the mind” to strengthen the consistency between body, mind, and social. P4 complemented on the need to integrate community issues and occupational justice as the “cultural revolution in healthcare education” expected from public policies regarding the tackle of social inequalities in health and the development of health promotion services.

Discussion

This study aimed to explore knowledge assumptions and perceptions of needs for developing health promotion services among occupational therapists working within community settings in France. The findings raise some needed skills in this context of practice. Among them, occupational justice reasoning grants greater considerations on ill-health outcomes concerning social determinants. Wilcock & Hocking (2015, p. 431) view such reasoning “a gradual increase of understanding of the relationship between illness and the composite effects of individual and collective occupations” in the socio-political context. According to Kinsella & Durocher (2016), occupational justice enables occupational therapists to understand how policy designs are used to enact programs toward vulnerable communities and how they can contribute to occupational injustices. The application of occupational justice frameworks promotes occupational therapists’ engagement in the communities’ social environment. For instance, the POJF underpins three concepts: occupation, enablement, and justice (Whiteford et al., 2016). The use of these concepts supports a critical perspective on power relations (Whiteford et al., 2016, 2018) that can help occupational therapists to work for and with communities following a horizontal approach. An occupational justice perspective can facilitate the work with other sectors and promote work with a diversity of community actors and stakeholders to make sustainable change towards a social justice agenda in community development (Irvine‐Brown et al., 2021). Despite the observation that professional skills and reasoning are needed to work horizontally in community development, occupational therapists are perceived as particularly well suited to partner with other community workers and stakeholders, by their interest in human occupation (Scaffa et al., 2010). The use of human occupations as a central focus in community development seems to facilitate the process of reaching out to both healthcare and social workers. This provides a consensus for occupation-based societal issues of ill-health (Scaffa et al., 2010) and allows occupational therapists and social workers to address collective solutions for vulnerable populations (Hocking, 2017; Pereira, 2017; Whiteford et al., 2016, 2018).

When building these relationships, occupational therapists may encounter tensions related to power relations and trust-building, and face pressures to demonstrate efficiency or ‘counting’ outcomes of community projects, to satisfy policy or funding agencies pressures. These issues have been mentioned by Farias & Laliberte-Rudman (2019) who argue that ‘counting’ outcomes can co-opt and work against practice related to social issues given that the complexity of community work does not easily translate into standardized measures and predetermined outcomes. Another tension highlighted in the findings of this study is that, to build sustainable relationships with communities, occupational therapists need to learn to rely on communities’ know-how and expertise. In line with several authors (Gerlach et al., 2018; Lauckner et al., 2019; Turcotte et al., 2019; Whiteford et al., 2016), participatory processes are needed to build a more occupationally just society. As such, within community development, pressures related to ‘counting’ outcomes can work against the flexibility required to foster relationships of trust with communities and the incorporation of occupational therapists and communities’ experiential knowledge (Farias & Laliberte-Rudman, 2019; Guajardo et al., 2015). Occupational therapists are uniquely skilled at assessing communities’ occupational participation in doing and becoming (Law et al., 2016). Developing occupational therapy practice in this field could provide innovative ways to assess specifically how communities are affected by social inequalities. Lately, complex models of reasoning, such as the POJF based on a critical perspective to acknowledge the influence of power relations on the environment (i.e., policy, funding opportunities) where occupations take place, or the Occupational Justice Health Questionnaire (Sy et al., 2021b), a qualitative assessment that aims to enhance reflective practice and recognize the interweaving and evolving nature of injustices. They enable the occupational therapists’ professional reasoning to provide interventions beyond the socio-economic constraints linked to inequalities (Whiteford et al., 2016, 2018).

Lastly, the findings suggest that occupational therapy education must take into consideration certain aspects to work in community development. Education should train students’ reasoning on how occupational injustices are rooted in everyday doing and social contexts (Rensburg, 2018). To this end, Sakelliarou (2019, p. 407) proposes to view education as a place “[...] where people enact different realities and dream possibilities [...]” of such complexities. Provided with skills to identify contextual factors of occupational participation and engagement, such as sociopolitical, economic, and cultural factors, occupational therapists and students could gain awareness of the power relations at play between the individuals and collectivities and engage in reasoning the complexity and uncertainties of everyday collective living. Kantartzis (2019) posits that occupational therapists have an ethical, moral, and social responsibility to shift their focus to shape key relations within the collective systems people engage. Critical and occupational justice frameworks, as explored in this study, ought to equip students to consider how collective living and emancipation are fostered or hindered by sociopolitical structures. In occupational therapy, the issue of being, doing, becoming, and belonging in everyday life is not recent (Fidler & Fidler, 1978). Zask (2011), a philosopher specialized in human activities, emphasizes that democratic participation through doing is participatory: to become a citizen, one needs to take part, play a part, and gain from participation in society. As a result, citizens can belong to a common human social story and promote their health, self-realization, moral progress, and gain a sense of worth.

Limitations of the study

The small sample of participants might appear as an apparent limitation of the study (Krefting, 1991). However, a small group of participants was needed to ensure engagement in in-depth dialogue and discussion of their practices. In addition, participants were selected from different locations to allow for a broader examination of practices and experiences. Nonetheless, the findings are based on a particular sample of participants, providing insights into the tensions that this group face while developing community practice in specific locations in France. The design of the study, based on discussion, allowed for triangulation of the first author’s ongoing interpretations and data analysis. The purpose of using community development and occupational justice frameworks was to conceptually support the dialogue. Yet, two out of three documents were in English, leading to difficulties with comprehension and allocating enough time for reading the documents. This limited further development of practical occupational concepts that could have been used to articulate the possibilities for community development in France. Nevertheless, the findings of this study raise awareness about these tensions that may be shared by other occupational therapists in other locations.

Conclusion

According to Kemmis et al. (2014), a critical perspective on the specific arrangements of a professional practice allows for its transformation into a more rational, productive, fair, sustainable, and inclusive practice. To design health promotion services in community development, occupational therapists need to engage in political reasoning on occupation-related health and engage collaboratively with all stakeholders. A critical perspective will enhance their contribution to a participatory healthcare and their application of occupational justice. Future quantitative, longitudinal, multi-method research should aim to understand how occupational justice informs the application of justice in public policies.

Acknowledgements

This article is based on the first author’s master thesis, supervised by the second author, and a special thank you is therefore extended to colleagues and examiners that have reviewed the work. The authors would also like to thank all the participants for sharing their experiences and time. With their permission and in alphabetical order: Aïchatou Camara, co-head and project director of the French South-Eastern Region for education and health promotion at Comité départemental d’éducation et de promotion de la santé des Bouches du Rhône; Hélène Clavreul, occupational therapist and educator, specializing in psychosocial rehabilitation; Valérie Giaume, private practitioner and then a member of the French Association of Occupational Therapists’ ethical committee; Anne-Laurie Pilar, co-founder of a youth organization for self-determination and community coordinator; and Mathilde Roux, an occupational therapist in community development and social engineering.

• How to cite: Albuquerque, S., & Farias, L. (2022). Occupational therapists’ perceptions of the need to enact health promotion in community development through occupational justice. Cadernos Brasileiros de Terapia Ocupacional, 30(spe), e3070. https://doi.org/10.1590/2526-8910.ctoAO23253070

References

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Edited by

Guest Editor

Dr. Michael Palapal Sy

Publication Dates

• Publication in this collection
  08 June 2022
• Date of issue
  2022

History

• Received
  29 June 2021
• Reviewed
  15 Oct 2021
• Reviewed
  03 Dec 2021
• Accepted
  14 Dec 2021