Focusing on “what matters”: the Occupation, Capability and Wellbeing Framework for Occupational Therapy

Abstract Introduction Critical occupational therapists have challenged models from the Global North that have dominated occupational therapy and informed ableist practices focused on appraising dysfunctions, classifying deviations from bodily “norms”, and remedying individuals’ “deficits” in performing three occupations (self-care, productive, leisure). This indicated the need for a new conceptual framework; one grounded in research evidence derived from a diversity of people and contexts. Objectives To outline the imperative for, and genesis and features of an evidence-informed conceptual framework for occupational therapy, centred on occupations, capabilities and wellbeing. Methods This paper draws from the work of critical occupational therapists; outlining the conception and process of building a flexible framework by linking concepts identified through extensive review of multidisciplinary research from both the Global South and North. Results Building on evidence that occupation is a determinant of wellbeing, the Occupation, Capability and Wellbeing Framework for Occupational Therapy (OCWFOT, Hammell, 2020a) encourages a strengths-based approach to occupational therapy: assessing and building on individual, collective and community assets, abilities and resources; focusing on occupations that “matter most”; and fostering a relational view of people as interdependent and embedded within families and communities. Conclusion Focused unequivocally on the wellbeing needs and aspirations of individuals, families, groups, communities and populations that are met or unmet by current patterns of occupational engagement; on both abilities and opportunities; and on occupation as a human right, the OCWFOT is theoretically defensible, provides conceptual clarity, and has utility as an evidence-informed structure around which future research and practices may be oriented.


Introduction
Since the 1970s, a group of Brazilian occupational therapists working "from a critical standpoint" (Galheigo, 2005, p. 91) has been advancing socially-focused approaches to occupational therapy designed to address the structural inequities that shape people's occupational opportunities and their lives (Ambrosio et al., 2022;Barros et al., 2005;Barros et al., 2011;Galheigo, 2011aGalheigo, , 2011bGalheigo, , 2014Galheigo, , 2018Galheigo, , 2021;;Malfitano, 2022;Malfitano et al., 2014a;Malfitano et al., 2014b;Malfitano et al., 2019).Central to these endeavours has been a sustained effort to challenge the myriad ways in which sociallystructured problems are portrayed as personal matters (Barros et al., 2011), and to promote social occupational therapy: practices focused on assuring occupational engagement, social inclusion and participation, and the individual and collective autonomy necessary to envision and enact choices (Malfitano, 2022).In South Africa, too, occupational therapists were advancing practices informed by a social justice perspective; emphasising the right of all people to occupational engagement, and addressing structural inequities negatively impacting the wellbeing and quality of life of marginalised people (Watson & Swartz, 2004).These critically-informed, epistemologically-innovative, and socially-relevant approaches to practice provided exemplars and guidance from which the rest of the occupational therapy world has had the opportunity to educate itself.
Unfortunately, the overwhelming dominance and presumed superiority of occupational therapy in the Global North (appropriately also referred to in this paper as the "minority world") enables many within the Anglophone profession to ignore, dismiss or remain oblivious to forms of practice developed in the Global South: the majority world (Hammell, 2015a(Hammell, , 2019)).Although a few Anglophone occupational therapy theorists in the minority world have been striving to raise profound concerns about Northern occupational therapy's abiding preoccupation with individuals and their ascribed deficits, and simultaneous disregard (concealment) of all the structural injustices that impact the health and wellbeing, not just of individuals, but of collectives (e.g.Farias & Rudman, 2019;Gerlach et al., 2018;Hammell, 2019Hammell, , 2020a;;Hammell & Iwama, 2012;Rudman, 2013), the profession in the minority world has been remarkably slow to embrace radical, evolutionary change.This is exemplified in McColl's (2021) recent assertion, that within Canadian occupational therapy, "Occupational performance problems are mostly viewed as personal and family issues, to be addressed on an individual basis" (McColl, 2021, p. 5), and that, "Despite increased attention in recent years to the role of the environment in occupational therapy, the emphasis is still on understanding the components of the individual responsible for occupational problems, and where possible, remediating those; or where not possible, compensating or re-framing" (McColl, 2021, p. 5).
The premise that individuals are wholly responsible for their own health, wellbeing and occupational "performance" is central to a neoliberal political rationality (Gerlach et al., 2018) and epitomises the way in which socially-structured problems are depicted within Northern occupational therapy as personal matters (Barros et al., 2011).This wilfully ignores the wealth of evidence indicating that factors such as poverty and social exclusion cause physical and mental ill-health (Marmot, 2004).The profoundly problematic nature of the profession's promotion of this toxic, ableist ideology is explored further, below.
Regrettably, McColl's observation also indicates that the victim-blaming portrayal of any and all problems encountered by disabled and other marginalised people as "personal matters" caused by their own flawed "components" remains ubiquitous in the minority world, providing additional support -if more was needed -for Galheigo's (2011a) lament: that within the occupational therapy profession, "contemporary history has witnessed the North and the West being positioned or positioning themselves both as the source of inspiration and provider of guidance or assistance for the South and the East" (Galheigo, 2011, p. 65).Of course, the reverse of this equation would assert that the South and East are positioned by those in the Global North as having nothing of importance to inspire, guide or assist their Northern and Western colleagues.The implicit racism at the core of this Eurocentric assumption (Hammell, 2015a) needs to be widely acknowledged and universally deplored.
The term "Global South" is used in this paper to refer to those regions of the world that continue to endure inequalities of wealth, power and cultural influence due to the dominance and ongoing impact of European colonialism and North American imperialism (Connell, 2007).Although located in the Southern hemisphere, Australia and Aotearoa New Zealand are included within the parameters of the Global North due to their power, wealth and Anglophone privilege, because this term pertains to power, not geography.Furthermore, Valderrama Núñez (2019) notes that "in each North there is a South and in each South there is a North" (Valderrama Núñez, 2019, p. 672).Structural inequalities ensure that some in the Global South enjoy disproportionate wealth and occupational opportunities, while numerous people in the Global North endure poverty and severely limited occupational opportunities (Hammell, 2021a).
Because theorists formulate their ideas within specific socio-cultural, political, economic and geographic contexts, cross-cultural dialogues are necessary to identify and foreground perspectives that have been overlooked, obscured and omitted by Northern occupational therapy theories.It is self-evident that occupational therapy's theories, models and practices have to incorporate multiple worldviews and values if they are to be relevant and inclusive rather than irrelevant, ethnocentric, and potentially culturally unsafe (Hammell, 2019).Responsibility lies with occupational therapists in the Global North to challenge the North-centric and Eurocentric knowledges and practices that have dominated the profession, and educate themselves from the insights, knowledges and radical practices of Southern occupational therapists.Egan & Restall (2022) believe that an "evolution" is finally detectable within the Northern occupational therapy profession in the minority world; contending that this evolution "can be traced from promoting function (independently carrying out activities, particularly activities of daily living), to enabling occupational performance (accomplishing self-care, productivity, or leisure occupations), to occupational engagement (active, satisfying participation in occupations)" (Egan & Restall, 2022 p. 5).Unfortunately, it is apparent that this evolution has been unevenly accomplished, with considerable professional attention in the Global North remaining fixated on facilitating functions, promoting independence, and "enabling" the performance of three specific forms of occupation -self-care, productive and leisure -described as the "purposes" of occupation (Townsend & Polatajko, 2013).
These, and other inadequacies of the Anglophone profession's status quo pointed to the requirement for a new conceptual framework for occupational therapy: one firmly grounded in evidence and explicitly focused on occupational therapy's unique domain of concern -the enhancement of human wellbeing through occupational engagement.The aim of this paper is to outline the impetus for, evolution of, and potential for the Occupation, Capability and Wellbeing Framework for Occupational Therapy ["OCWFOT", Hammell (2020a)].
The author identifies as a White, temporarily non-disabled, class-privileged, straight cis-female holding citizenship status in two Anglophone nations within the Global North; currently living as a settler on the traditional, ancestral and unceded territory of Coast Salish people in Canada.She acknowledges the unearned benefits, advantages and privileges she has always derived from her white skin, able body and proximity to socially-constructed and valued Western "norms" of being and doing.

Occupational Therapy's Ableist Status Quo: Promoting Function, Independence, and Occupational "Performance"
As part of their ongoing attempts to focus the attention of the international occupational therapy profession on the culturally-specific, ableist, White, Anglophone, Judeo-Christian, Western, heteronormative middle-class norms and values that infuse its dominant Northern models and that have informed its practices, a few critical occupational therapy scholars in the Global North have tried to draw attention to the fit between occupational therapy practices focused on modifying individuals and exhorting them to become self-reliant, and the ableist neoliberal political and economic agenda that dominates the minority world (Gerlach, 2015;Hammell, 2009aHammell, , 2009bHammell, , 2011Hammell, , 2015aHammell, , 2020a;;Iwama, 2003Iwama, , 2006)).
"Critical" occupational therapy scholarship critiques the status quo, questions conventional practices, and exposes and challenges the profession's taken-for-granted values, beliefs, assumptions and ideologies (Farias et al., 2016;Galheigo, 2018;Gerlach, 2015;Gerlach et al., 2018;Hammell, 2015b;Hammell & Iwama, 2012).Critical scholars seek to expose the linkages between ideologies and structures of power, highlighting the ways in which the status quo unfairly advantages certain social groups while disadvantaging others (Felluga, 2015).By exploring alternative ways of thinking and doing, critical theorists strive to suggest how a more just and equitable society might be achieved (Bronner, 2011).
"Ableism" is an ideology that advances the notion that certain bodies are "normal", appropriate and desirable, and that upholds as "natural" the inequitable opportunities and advantages that flow to those with usual bodies.An ableist ideology portrays those with impairments as both flawed and inferior, and requires its adherents to assess and classify "abnormal" bodies, functions and performances, and to use this information to inform interventions designed to "norm" non-standard bodies, eradicate "ab-normal" ways of being and doing (Hammell, 2023), and induce social conformity (Sandahl, 2003;Stiker, 1999).
"Neoliberalism" is an economic and political ideology that upholds a system of globalised capitalism concerned with fostering consumerism and maximizing private profit, and that has effectively widened inequalities both within and between nations (Rotarou & Sakellariou, 2017).Within a neoliberal ideology, people are valued according to their productivity and contribution to economic growth (Gruber & Scherling, 2020), thus neoliberalism promotes individualism, independence and selfreliance; valuing individuals who strive to improve their abilities and become more employable (Hammell, 2021a).Of particular relevance to the occupational therapy profession is the understanding that "Participation within a human rights framework seeks to address structural changes; but in a neoliberal climate, participation for citizens necessitates individual change" (Harris et al., 2012, p. 826).The imprint of a hegemonic neoliberal ideology on occupational therapy in the minority world is illustrated by the reality that, since the 1980s, the profession has been preoccupied with promoting function and independence in activities of daily living, and with enabling the performance of self-care and productive occupations (Egan & Restall, 2022).
Critical occupational therapy scholars have challenged the profession to acknowledge that its focus on assessing, minimising and, if possible eliminating physical and functional differences supports an ableist neoliberal ideology that equates human value with "normal" (typical, usual) bodies, abilities, functions and performances; and that such practices actively contribute to an ableist narrative -that disability is an inferior and deficient state of being (Hammell, 2023).Moreover, by uncritically promoting the neoliberal belief that independence is admirable, aspirational and universally valued (Hammell, 2020a(Hammell, , 2023;;Kristensen et al., 2017), the occupational therapy profession has actively reinforced ableist stereotypes that devalue all those who are unable to achieve independence, who choose to accept the help extended by others, or those for whom independence is neither a valued nor aspirational state of being (Hammell, 2006).And by focusing on the "components" of individuals deemed "responsible" for "occupational performance problems" (McColl, 2021, p. 5), occupational therapists have frequently overlooked, not only the socially-structured constraints on people's occupations and lives, but also the abilities, skills, strengths, experience, knowledge, social capital and resources possessed by these "individuals", both as individuals, and as members embedded within collectives.Indeed, the dominance of an individualistic ideology, which posits individuals as responsible for their own accomplishments, distracts occupational therapy from perceiving, contesting and changing those "structural inequalities -economic, religious, socio-cultural, political -that constrain occupational opportunities and occupational rights, not only of individuals, but of entire communities" (Hammell, 2015a, p. 719).
Neoliberalism's ableist premise -that people's value lies in their ability independently to perform self-care and engage in productive occupations (Burgin, 2014;Gerlach et al., 2018) -is infused throughout occupational therapy's educational and clinical practices (Santos, 2022;Grenier, 2021).Indeed, collusion with neoliberalism's ableist values; unabashed aspirations to eliminate bodily differences, "normalise" functions and performances, and promote self-reliance, independence and productivity have all contributed to the perception -articulated by critical disability scholars -that occupational therapy is a disabling profession that actively contributes to the exploitation (Hammell, 2006) and oppression of disabled people [for review, see Hammell (2023)].Coleridge (1993) observed that rehabilitation therapists, although usually well-intentioned, are "unwitting cogs" in an oppressive system in which they "relate to disabled people from a position of power and dominance, not equality" (Coleridge, 1993, p. 75).The premise that therapists are unwitting cogs is inordinately generous, not least because they are "the beneficiaries of a status quo that accords them social status, prestige and power over those who must use their services" (Hammell, 2006, p. 149).Nicholls (2022) has pointed out that the rehabilitation professions have derived enormous social privilege and economic gain from disabling practices that include compiling hierarchical categorisations (on the basis of physical ability and function), the use of humiliating assessments, and ongoing efforts to induce "normality".Thus, while individual clinicians may strive with individual patients to renegotiate the possible parameters of "normality" in the context of disability (Bermez et al., 2021), this represents a disruptive and unsanctioned form of practice; one that counters the principles ardently promoted by the profession itself.
That an ableist neoliberal ideology continues to energise occupational therapy in the Global North is evidenced by the profession's enthusiastic collusion with the cost-saving agenda of neoliberal austerity (College of Occupational Therapists, 2011; Green & Lambert, 2017;Hayes et al., 2023;Morley & Smyth, 2013), and ongoing commitment to assessing and addressing the occupational performance of just three forms of occupationself-care, productive and leisure (Townsend & Polatajko, 2013) despite more recent developments within the profession [e.g.Egan & Restall (2022); Hammell (2020a)], and as if these are the only occupations worthy of professional attention.These three specific categories betray the neoliberal-inspired priorities shared among theorists in the Global North, being neither informed by, nor supported by empirical evidence (Hammell, 2009b(Hammell, , 2020a)).Importantly, occupational therapy's ubiquitous tripartite categorisation obscures, devalues and ignores many of the occupations that are important to the quality of people's lives and essential to their wellbeing (Hammell, 2019(Hammell, , 2020a)), and has effectively diverted attention from the profession's core concern: the promotion of wellbeing through occupation (Jonsson, 2008;World Federation of Occupational Therapists, 2012).
Highlighting the dearth of evidence-informed support for occupational therapy's dominant models, a number of critics have advocated for the profession to ground its models, theories and practices in evidence derived from multiple contexts and from a diversity of sources (Gerlach, 2015;Hammell, 2009aHammell, , 2009bHammell, , 2011Hammell, , 2015a;;Iwama, 2003Iwama, , 2006)).Indeed, Grenier (2020) contends that it is time to "radically dismantle and rebuild the 'biased' frameworks and models on which the profession has relied for over a century" (Grenier, 2020, p. 640).

Radically Rethinking the Profession's Practice Frameworks
The World Federation of Occupational Therapists' Revised Position Statement on Occupational Therapy and Human Rights (World Federation of Occupational Therapists, 2019) might be taken as a useful basis for radically rebuilding the frameworks that inform the practices of occupational therapists.This Statement asserted occupational therapists' obligation to promote occupational rights."Occupational rights" pertain to the right of all people to engage in the occupations they need to survive, define as meaningful, and that contribute positively to their own wellbeing and the wellbeing of their communities (Hammell, 2008;World Federation of Occupational Therapists, 2019).Importantly, WFOT has not asserted the profession's obligation as being the enablement of self-care, productive and leisure occupations, nor as the elimination of physical differences and maximisation of functions, performances and independence, but as enablement of the right to occupational participation (Hammell, 2019(Hammell, , 2020a)).
The WFOT Revised Position Statement on Occupational Therapy and Human Rights (World Federation of Occupational Therapists, 2019) also asserted that "occupational rights are secured by identifying and addressing the capabilities (Sen, 2003), opportunities, and freedom of choice for individuals, communities and populations to participate in society".This envisions an occupational therapy practice no longer preoccupied exclusively with people already living with impairments or illnesses, but one concerned with the equitable enlargement of occupational opportunities for all people experiencing injustice.From a capabilities and human rights perspective, enhancing the capabilities of people who are refugees or who live in communities enduring environmental injustice, for example, is of no less importance than enhancing the capabilities of disabled people (Hammell, 2020a).Thus, when World Federation of Occupational Therapists (2010) declared that "the primary goal of occupational therapy is to enable people to participate in occupation" (World Federation of Occupational Therapists, 2010, p. 1), this mandate was not limited to "the participation of disabled people" or to "the participation of people with mental illness".Rather, the World Federation explicitly stated that occupational therapy's primary concern and mandate is with people's participation in occupation (Hammell, 2017).Clearly, this highlights the need for occupational therapists to radically rethink the nature of their practices and the forms of assessment they employ in perpetuating these practices.

Occupational Therapy Assessment: Time for a Radical Rebuild
Occupational therapists will inevitably target for intervention those issues they have identified as problematic during their assessment process; thus, assessments matter.If the assessment process focuses on cataloguing individuals' deficits, dysfunctions and deviations from "normality; it is unlikely that subsequent interventions will be focused on the enhancement of meaningful occupational engagement or on the structural changes required to achieve equity of occupational opportunity.Because occupational therapy is situated within a hegemonic neoliberal political environment that advances and rewards specific modes of governance, the profession has demonstrated considerable enthusiasm for "standardised", quantitative forms of assessment (Kristensen et al., 2017).These types of assessment enable occupational therapists to identify and document the deficits, dysfunctions and individual "components" (McColl, 2021, p. 5) deemed responsible for occupational performance problems, consistent with a neoliberal agenda.But for a profession that ostensibly stands against ableism, such practices are both ill-conceived and inappropriate.
Occupational therapy's assessments -that are almost exclusively "standardised" on the basis of the standards ("norms") shared among straight, well-educated, class-privileged, culturally-Christian White people living in urban areas of the minority world (Hammell, 2021a;White & Beagan, 2020) -must be replaced by less oppressive and more culturally relevant tools (Hammell, 2006(Hammell, , 2020a;;White & Beagan, 2020).Assessments undertaken to compile catalogues of deficits and dysfunctions -information that can be used both to deny resources, equipment, services (Hammell, 2007) and life-saving therapies (Proulx et al., 2020;Thorneycroft & Asquith, 2021), and to impose interventions intended to induce social conformity -are inappropriate to a profession ostensibly concerned with equity and occupational rights.Moreover, "it is a common complaint of patients that rehabilitation services are always assessing or looking for failure" (Wade, 2009, p. 388); a process that may be both distressing and demeaning.An occupational therapy profession ideologically rooted, not in ableism, but in equity would employ forms of assessment amenable to identifying environmental resources and constraints, in addition to individual and collective resources and strengths, and be able to identify "what matters most": the capabilities that an individual, group or community values and that motivate them in the occupational choices they aspire to make (Hammell, 2020a).
This brief review of neoliberalism's ableist impact on occupational therapy's commitment to assessing and promoting individuals' functions, independence and performance of self-care and productive occupations suggests the need for a new framework for occupational therapy practice; one grounded in some fundamental principles.

Principles Underpinning the Framework
In the early decades of the 21 st century, profound social injustices -such as sexism, patriarchy, racism, poverty, class and caste inequities and the ongoing impacts of colonialism -could no longer be ignored as determinants of occupational participation, and occupational therapy practices focused on modifying individuals were widely recognised as inadequate responses to occupational injustices (Farias & Rudman, 2019;Gerlach, 2015;Gerlach et al., 2018;Hammell, 2019;Hammell & Iwama, 2012;Rudman, 2013).If a new framework was to be developed, this would have to reflect -and advance -some fundamental and overlapping principles, and to be centred explicitly on wellbeing.Understanding, and embracing these principles is a requisite for using the OCWFOT authentically and effectively.Ryan & Sapp (2007) observed that a "'well' being is able to maintain its vitality and to thrive within its everyday ecological context" (Ryan & Sapp, 2007, p. 71).Wellbeing has been defined within the occupational therapy literature as "a state of contentmentor harmony-with one's: physical/mental health; emotional/spiritual health; personal and economic security; self-worth (sense of being capable, and of being valued by others); sense of belonging (which includes the ability to contribute to others and to maintain valued roles and relationships, and which may include a sense of belonging and of connectedness to the land and nature); opportunities for self-determination (defined as the ability to enact choices and counteract powerlessness); opportunities to engage in meaningful and purposeful occupations; and sense of hope" (Hammell & Iwama, 2012, p. 387).Inherent to this definition of wellbeing is the importance of social inclusion and participation; the opportunity for meaningful social engagement (doing things with others), and having a sense of equality and meaningful belonging within one's community (Hammell, 2020a).Indeed, Ryff & Singer (1998) have claimed that "human well-being is ultimately an issue of engagement in living" (Ryff & Singer, 1998, p. 2).
Occupation is a clear determinant of human wellbeing and central to engagement in living.Thus, the framework had to focus attention on occupational engagement; a concept which has lacked definitional consensus within occupational science or occupational therapy (Black et al., 2019;Kennedy & Davis, 2017;Morris & Cox, 2017).Recently, occupational engagement has been defined as "active, satisfying participation in occupations" (Egan & Restall, 2022, p. 5), and this understanding of the term is shared within the OCWFOT.Because occupational engagement is dependent on both abilities and opportunities, the framework had to advance a strengths-based approach (Bryant et al., 2021) to occupational therapy, encouraging the assessment and enhancement of individual, family and collective capacities, capabilities and resources, and eschewing practices that contribute to a deficit-saturated view of people and communities.
Richards & Galvaan (2018) observed that if occupational therapy is to promote "a socially transformative focus in practice, the profession needs to embrace a broader interpretation of engagement in occupations, taking into account the structural and sociopolitical factors that affect the health and participation of people in communities" (Richards & Galvaan, 2018, p. 8).Because occupational therapists need to be competent in analysing "the forces that constrain decision making, frame choices, and limit life options" (Quesada et al., 2011, p. 342), the framework had to promote structural competence (Metzl & Hansen, 2014): the ability to discern, and the commitment to change inequitable social and structural determinants of health and occupation.Structural competence -advanced as a core competency for occupational therapists (Hammell, 2021b) -provides the foundation for understanding inequities that constrain and frame choices, and limit life options.Moreover, because sexism, patriarchy and misogyny, colonialism, racism, class and caste inequities, poverty, ableism and disablism, ageism, heteronormativity and gender binarism are determinants of occupational opportunity and engagement -because occupations are socially determined (Hammell, 2021b) -the framework needed to foster an equity-focus.To be equity-focused is to "surface, challenge and, ultimately, change unjust social conditions" (Phipps & Masuda, 2018, p. 381); refusing to overlook, accept or collude with the injustices that unfairly advantage specific groups of people while unfairly disadvantaging others.
Having real opportunities to engage in occupations that contribute positively to wellbeing is a human right (World Federation of Occupational Therapists, 2019).Thus, the framework had to reflect a rights-based, socially-focused approach to practice.Because "occupational rights are secured by identifying and addressing the capabilities (Sen, 2003), opportunities, and freedom of choice for individuals, communities and populations to participate in society" (World Federation of Occupational Therapists, 2019, p. 1), the framework had to focus on the expansion of people's capabilities -their opportunities as well as their abilities -to engage in valued occupations.
Sen's Capabilities Approach (Sen, 1999(Sen, , 2005) ) encourages a focus on wellbeing from a human rights perspective, being concerned both with people's abilities to do and be the things they value doing and being, and with their real opportunities to choose to act on these wishes.Sen's approach focuses attention both on the things that people currently have the ability and opportunity to do, and on the range of occupational choices they can envision themselves doing because these options are realistically available to them (Robeyns, 2005;Sen, 1999;Trani et al., 2009).The capabilities approach employs a multidimensional and contextual view of human wellbeing: one that attends to the linkages between physical, mental, social and material wellbeing; and the social, physical, political, economic, religious and cultural dimensions of people's lives (Crocker & Robeyns, 2010).For a thorough review of the capabilities approach for occupational therapy, see Hammell (2022).
Because environmental factors and systemic social forces sustain health inequities and determine occupational possibilities (Rudman, 2010), the new framework had to encourage the identification of contextual factors impacting the possibilities for people to expand their choices, convert their opportunities and resources into actions, actualise their values, and enjoy the real capability to achieve wellbeing through engagement in occupations they value: occupations that "matter" (Hammell, 2020a).Epidemiologists contend that because inequalities in opportunities for social participation produce a social gradient of health -in which the health and longevity of people closely match their economic and educational statuses -efforts at health promotion require a focus, not solely on individuals' biology and behaviour, but on the social, economic and political circumstances in which they live and work, and on their real abilities to choose among a range of equitably available opportunities: their capabilities (Marmot, 2004).Thus, occupational therapists have been urged to embrace a capabilities approach as a philosophical foundation for practice (Bailliard, 2016;Hammell, 2015bHammell, , 2017Hammell, , 2020bHammell, , 2022;;Pereira, 2017).
Congruent with both a capabilities approach and the ideals that underpin Southern approaches to occupational therapy, the OCWFOT is aligned with a commitment towards social justice.Kirkham & Browne (2006), who explored the implications of adding the word "social" to that of "justice", noted that, when placed together, the terms draw attention to the ways in which injustices are maintained through social institutions and relationships, and "highlight the embeddedness of individual experience in a larger realm of political, economic, cultural, and social complexities" (Kirkham & Browne, 2006, p. 325).The concept of social justice "provides a moral compass that refocuses us to see beyond an individualistic perspective" (Kirkham & Browne, 2006, p. 337), encourages collective action to address the root causes of inequities, and encourages occupational therapists to enquire into the nature of our own practices; whether, for example, services are prioritised towards underserved people and communities, or whether services are provided based on the ability to pay (Hammell, 2017).
Occupational therapy in the minority world has enthusiastically promoted individualistic, neoliberal consumerist ideas concerning "client-centred practice" (Hammell, 2013); focused on individual choice, personal responsibility, selfdetermination, the notion that autonomy equals agency, and the premise that individuals all wish to make decisions independently.This is potentially damaging for those people who do not share these aspirations and values, or for whom such aspirations are "biologically, socially or economically unattainable" (Tieu et al., 2022, p. 9).Tieu et al. (2022) affirm an understanding of people (known as "clients" within neoliberal consumer-speak) as "socially-embedded, relational and temporally extended subjects" (Tieu et al., 2022, p. 1) whose capacity for autonomy "is dependent on the quality of the relationship they have with their care provider(s) and their social networks" (Tieu et al., 2022, p. 4).Because people belong, and are interconnected within interdependent relationships and communities that shape, support and constrain the options they consider and the choices they have the opportunity to make (Galvaan, 2012(Galvaan, , 2015;;Hammell, 2014;Robeyns, 2005;Yap & Yu, 2016), the framework had to advance a relational ontology (Donchin, 2001;Hunt & Ells, 2011); one that also acknowledges the interconnected nature of relationships between occupational therapists and service users.A relational ontology is embedded within Sen's conceptualisation of capabilities (Robeyns, 2005;Terzi, 2005Terzi, , 2011)), such that capabilities are understood to be shaped -and partly constituted -by social circumstances (Entwistle & Watt, 2013).From this perspective, people's choices and actions are understood to derive from the interactions between individuals' abilities and their position in society (Smith & Seward, 2009).The importance of understanding autonomy as inherently relational has been emphasised by feminist theorists.Nedelsky (1989), for example, described autonomy, not as an individual attribute, but as a lifelong process of being and becoming autonomous within webs of relationships that support and nurture the capacity to make choices and act in ways that align with one's values.Indeed, Nedelsky (1989) contends that it is impossible to be autonomous and to feel able to exercise some control over one's life choices in the absence of supportive and nurturing social circumstances.Autonomy, then, is not an individual accomplishment, but inherently relational.
The new framework had to foster and reflect specific attitudes and behaviours.Because occupational therapists are required to build, foster, and sustain respectful, critically-conscious, culturally humble, collaborative relationships with service users (Hammell, 2020a;Nicholls, 2022;Restall et al., 2022), the framework needed to focus occupational therapists' attention on understanding and respecting the values and priorities of service users, while mitigating the imbalances of power that accompany different social positions (Fisher-Borne et al., 2015).
Finally, because occupational therapy is an international profession, the framework needed to be grounded in perspectives from both the Global South and North, and be articulated simply and clearly, and in terms that are easily understandable for those for whom English is not a first language (Hammell, 2020a).

Building a Conceptual Framework
Produced through a process of qualitative analysis, a conceptual framework is a network of linked concepts providing a comprehensive understanding of a phenomenon, and an empirical structure to inform subsequent research and practice (Jabareen, 2009).Because human engagement in occupation is inherently subjective and contextuallysituated it is a construct appropriate to a synthesis derived from qualitative rather than quantitative data (Jabareen, 2009).Northern models of occupation that have dominated the occupational therapy profession have demonstrated remarkable resistance to empirical data, critical appraisals, new insights or scholarly evolution, remaining largely unchanged for many decades (Hammell, 2020a).In contrast, a conceptual framework is deliberately flexible and dynamic, being continually re-considered, re-conceptualised and revised in light of new research, theoretical insights, and evolutions within the literature (Jabareen, 2009).This is my hope for the OCWFOT.In particular, I hope that the OCWFOT will be re-considered, re-conceptualised and revised using Southern epistemologies and by occupational therapists from the Global South.
The process of building a qualitative, conceptual framework comprises three phases: 1. an extensive review of multidisciplinary texts addressing the phenomenon of interest; 2. identification and naming of concepts; 3. synthesis of these concepts into a framework (Jabareen, 2009;Leamy et al., 2011).
The first phase entailed a review of research pertaining to human wellbeing and occupational engagement, published in English (due to the linguistic incompetence of the author).Considerable effort was expended to make sure that these studies derived from both the Global South and North.The review was extensive; employing studies undertaken within multiple academic disciplines and with a diversity of individuals, groups and communities.The studies were scanned for recurring themes in a qualitative process of analysis, and these themes were synthesised.The substantial empirical base used to inform the new conceptual framework is expansively described and justified in Engagement in living: Critical perspectives on occupation, rights and wellbeing (Hammell, 2020a).
In the second phase, the overarching concepts identified during the qualitative review were summarised within the following statements: • "Human health, wellbeing, participation and quality of life are significantly impacted by the occupations in which people engage.• Occupation is a determinant of human health and wellbeing.
• Specific human wellbeing contributors that have cross-cultural and crossdevelopmental relevance include: Surviving and thriving (taking care of self and others); Belonging, connecting and contributing; Having a sense of self-worth as valued and valuable, capable and competent, responsible and respected; Engaging in valued occupations that provide pleasure, purpose and meaning; Having real choice, and the opportunity for autonomy in enacting those choices; Having hope and a sense of coherence and continuity" (Hammell, 2020a, pp. 211-212).
The third phase saw the synthesis of empirical literature combined with the equity imperatives of the theoretical literature (i.e. the "principles", outlined above) to inform a new framework for practice.Figure 1 provides a visual representation of the Occupation, Capability, and Wellbeing Framework for Occupational Therapy [Occupation, Capability, and Wellbeing Framework for Occupational Therapy, Hammell (2020a)].

The Occupation, Capability, and Wellbeing Framework for Occupational Therapy
The OCWFOT encourages a four-phased approach to practice.

Identifying "what matters"
The problematic nature of traditional assessment practices, which focus on extracting specific information valued by therapists, and on cataloguing individuals' performance deficits, in-abilities, and bodily differences from valued "norms", have been alluded to, above.Reflecting the critiques of critical disability scholars, and responding to the imperative to embrace a strengths-based approach to practice, the OCWFOT encourages occupational therapists to engage in a process of identifying "what matters most" to service users; determining the outcomes that would be most valued following occupational therapy intervention.As Brown (2010) observed, "asking what is important to the person inserts the person's values into the assessment situation, helping to set the direction of treatment and to avoid paths that are irrelevant to the service recipient's life" (Brown, 2010, p. S35).Moreover, it is surely obvious that the occupational therapy assessment process ought to begin with an appraisal of desired outcomes, because "If we do not know where we wish to go, we shall not know how to get there or when we have arrived" (Hammell, 2020a, p. 214).
In assessing whether occupational therapy is likely to be relevant or useful, and in determining the possible foci for interventions, occupational therapists collaborate with service users to explore how their wellbeing and engagement in living might be enlarged through occupational participation.The process of striving to understand service users' wellbeing aspirations and unmet needs (their desired outcomes), and co-creating an assessment of strengths, available resources, structural barriers and constraints to achieving wellbeing through occupation demands some specific professional competencies.Foremost among these is a conscious process of active and engaged listening; a readiness to embrace others' knowledge; a willingness to critically challenge one's own position of power and privilege; a commitment to "cultural humility" (Tervalon & Murray-García, 1998); and an attitude of kindness, caring, and respect for service users' abilities, experience and strengths, and for their moral right to make choices concerning their lives (Hammell, 2013).
As a guide for exploring "what is important", the OCWFOT (Figure 1) includes a list of wellbeing contributors, identified through the extensive review process, that are demonstrated to have cross-cultural and cross-developmental relevance (Hammell, 2020a).This is neither a comprehensive nor a prescriptive list.Rather, it is an aide memoire: a reminder of the scope and breadth of factors that service users may find important and that they might identify if given the space to do so.In order to understand "what matters" to people -what roles they most value, what forms of occupational engagement they prioritise, with whom they wish to engage in occupations, what unmet occupational needs they wish to address -occupational therapists will need to employ qualitative modes of inquiry amenable to discerning the self-identified needs and wellbeing aspirations of service users, as individuals, groups and collectives.

Assessing capabilities
Once the occupational therapists have identified and understood the outcomes desired by the service user(s), assessment can be made of various elements that may contribute to transforming these aspirations and needs into expanded capabilities.As a profession committed to embracing a capabilities approach to practice, attention will focus both on people's real opportunities to engage in occupations "that matter", and on their abilities to do so.In seeking to understand who these service users are, a capabilities approach encourages consideration (a) of their personal characteristics, for example, their gender identities, ages, and illnesses or impairments; and (b) of the strengths, assets, knowledge and resources available to service users, as communities, groups and families, and as individuals embedded within these collectives.Integral to any assessment of capabilities is an appraisal both of (c) the barriers -inequitable structures and unfair constraints -and facilitators derived from their historical and environmental contexts (Mitra, 2006); social factors that determine the real occupational choices and opportunities available to this or these service users.
The OCWFOT is informed by a significant body of evidence demonstrating that engagement in occupations that matter and that enhance wellbeing is dependent, not solely upon volition and ability (as Northern, neoliberal-inspired theorists insist), but on the resources and real opportunities afforded by the environment.The figurative representation of the OCWFOT (Figure 1) thus deliberately locates the characteristics and resources of the environment on the same plane as the characteristics and resources of the individual/collective (Hammell, 2020a).
The OCWFOT encourages occupational therapists to understand the indivisibility of people and environments by considering those barriers and facilitators of occupational participation inherent to service users' situatedness within a complex environment.Dominant occupational therapy scholarship in the minority world has portrayed people and environments as divisible, and thereafter compartmentalised "the environment" into just four dimensions -physical, social, cultural, institutional (Townsend & Polatajko, 2013).The OCWFOT explicitly encourages consideration of multiple dimensions of service users' contexts, including, for example, political, legal, policy and economic contexts (such as the availability of specific government services and funding); geopolitical contexts (for example, war, territorial occupation); ancestral and historical contexts (such as the ongoing impacts of colonialism); contexts of religious, spiritual and cultural traditions; the local context of familiarity in home and community spaces; the built environment; the local climate and impacts of climate change; and the presence and availability of people who are to be relied on to provide support.Integral to consideration of potential barriers to occupation are those entrenched and socially-structured patterns of exclusion (for example, racism, ableism, disablism, patriarchy, sexism, misogyny, hetero-sexism, gender binarism, trans-phobia, caste and classism, ageism) that result in stigma, discrimination and inequitable access to occupational opportunities; unfairly disadvantaging some people while unfairly advantaging others.
The collaborative process of appraising resources and barriers empowers service users to identify "both 'What personal, family, group and community resources are realistically available for me to tap into, in order to be able to do what matters most to me?' and 'What are the barriers that limit my ability to access the resources I need or that thwart my opportunities to do what matters most?'" (Hammell, 2020a, p. 217).Once occupational therapists have gained a thorough understanding of the relevant material and nonmaterial circumstances shaping people's lives, and the contextual factors influencing the choices service users can envision and realistically make (Hammell, 2020c), intervention plans can be formulated.Clearly, standardised treatment protocols for specific diagnostic categories have no place within an evolved occupational therapy.

Interventions
Informed by knowledge of "what matters" (and thus what outcomes are desired following intervention), by evidence that occupational engagement contributes to health, wellbeing, participation and quality of life, and by assessment of current capabilities, interventions will be co-designed by service users and occupational therapists to target both the required abilities and the requisite opportunities for engagement in occupations that "matter".This should not be considered a linear process or algorithm (thus there are no straight lines or arrows implying causality in the OCWFOT Figure).Together, service users and occupational therapists will continually re-evaluate the progress being made toward accomplishing the things that matter to service users, identifying the need, perhaps, for new resources and skills and renewed efforts to challenge inequities and cocreate necessary structural changes.This process is informed by the understanding that occupational engagement depends upon having both abilities and opportunities.

Assessment of outcomes
The effectiveness of occupational therapy cannot be appraised by outcome measurement simplistically focused on physical functions or self-care independence because these provide little or no insight into whether people's wellbeing has been enhanced or whether their opportunities for occupational participation have expanded.Rather, the outcome of occupational therapy must be appraised through examination of the degree to which the service users' desired outcomes, identified at the outset, have been achieved.Thus, the OCWFOT encourages a form of outcome assessment amenable to appraising "the achieved expansion of people's capabilities to achieve their wellbeing aspirations and realise their unmet wellbeing needs through engagement in occupations that matter" (Hammell, 2020a, p. 215).If the occupational therapy outcome measures currently in use are not amenable to providing this important level of analysis, new forms of measurement are required.

Using the OCWFOT to Inform Practice
It has long been recognised that considerable time and resources are wasted when rehabilitation professionals strive to induce service users to achieve goals they do not value (Brown, 2010;Fischer et al., 1999;Towle & Godolphin, 1999).By focusing on identifying "what matters" to service users, and by formulating goals based on a full appraisal of their capabilities, the OCWFOT should enable occupational therapists to achieve both a more appropriate use of time and resources, and, more importantly, a more ethical, socially-relevant approach to practice.
The OCWFOT advances practices designed both to address the abilities, knowledge, strengths and resources of service users -as individuals and collectives -and to address (challenge, change, contest, resist, refuse) the inequities of the social, economic and political status quo; inequities that dictate the availability of choices and occupational opportunities.For example, employing the mode of assessment promoted by the OCWFOT, an occupational therapist might learn during a home visit that a service user, who has a spinal cord injury and uses a wheelchair for mobility, lives in a multistorey building in one of the city's most economically deprived neighbourhoods; that the only elevator in the building has not functioned for several weeks; and that they are therefore unable to get to the accessible shower (located on the ground floor) or to their job at a local community kitchen.Knowing that the occupations that currently "matter most" to this service user -showering and earning money through working -are unattainable due to inequitable social conditions, the occupational therapist and service user collaborate in contacting the non-profit organisation that owns the building, the local fire department, the city bylaw officers, local councillors, the mayor, the Human Rights' Commission, the local media; whatever it takes to resolve this injustice and ensure that the service user can access the occupational rights to which they are entitled.
Use of the OCWFOT thus encourages a capabilities, equity and rights-based approach to practice, as advocated by the profession's World Federation (World Federation of Occupational Therapists, 2019), and provides occupational therapists with a tool that might enable them to align their practices with their rhetoric.

Using the OCWFOT to Inform Research and Education
Because the OCWFOT requires occupational therapists to be able to embrace complexity, educators are required to incorporate critical social theories that foster critical thinking among students.Clearly, "students -the occupational therapists of tomorrow -require the skills to challenge ideological assumptions, contest the inequities of the status quo and to work in partnership with individuals, families, groups and communities in contextually-appropriate ways" (Hammell, 2020a, p. 221).Such critical thinking requires exposure to the work of Indigenous, Southern, postcolonial, critical feminist, queer, critical race and critical disability theorists (among others), and a willingness to challenge the assumptions inherent to the profession's status quo.
The OCWFOT provides a renewed agenda for research, and for developing relevant forms of assessment and equity-focused outcome measures.For example, while occupational therapy has long proclaimed the importance of enhancing wellbeing through occupational participation, little effort has been expended to develop measures amenable to assessing wellbeing.Further, few occupational therapy assessments have facilitated the identification and documentation of service users' strengths, assets, abilities and the resources available to them both as individuals and community members; and few measures have collated information concerning the sociallystructured barriers inherent to service users' environmental contexts.
If the occupational therapy profession is, indeed, evolving -as Egan & Restall (2022) have hopefully postulated -it requires priority-driven research that can begin the work of closing the current gaps in our knowledge base.In so doing, the profession needs "to employ critical approaches that are theoretically sophisticated, politically astute and attuned to structural inequalities, in recognition that research and professional practices are never politically neutral" (Hammell, 2020a, p. 254).If occupational therapy's practices, education, and the OCWFOT itself are to evolve in response to empirical, cross-cultural evidence, the profession's researchers must commit to generating the requisite knowledge.
Critical scholars have recognised the imperative for occupational therapists to consider complex social structures and practices and their inequitable impact on people's real opportunities for occupational participation and social inclusion [e.g.Galheigo (2021); Hammell (2020a); Hammell & Iwama (2012); Rudman (2021)].Although there are a few exemplars of occupational therapy research focused explicitly on understanding the social determinants of, and structural barriers to occupational participation [exemplars include Bailliard (2013); Ingvarsson et al. (2016); Pitonyak et al. (2015)], there are currently few assessment tools that enable and require occupational therapists to appraise and document this information.The OCWFOT might usefully become one tool to facilitate this important endeavour.

Conclusion
This paper has sought to sketch some of the factors that informed the development of the Occupational, Capability and Wellbeing Framework for Occupational Therapy (Hammell, 2020a).This conceptual framework focuses explicitly on the inherently contextual nature of occupational engagement, and on identifying the wellbeing aspirations and unmet needs that might be enlarged through occupational engagement.It encourages a practice of occupational therapy that begins, not with an assessment of individuals' bodily dysfunctions and performance flaws, but with striving to understand "what matters" to those whom occupational therapists seek to serve.
The OCWFOT is a flexible framework that does not rely upon a priori assumptions about the three occupations individuals ought to value, and does not delimit occupational therapy attention to individuals' "components", deficits or dysfunctions -or, indeed, to individuals.Embracing a relational perspective on human occupation, the OCWFOT foregrounds the reality that individuals belong within families and collectives, and that this belonging informs, shapes, enhances and limits their occupational choices, opportunities and engagement (Hammell, 2014).Occupational therapists in the Global South have provided exemplars of what is possible when therapists eschew individualistic, health-based modes of practice and focus instead on enlarging the occupational opportunities that contribute to the wellbeing of entire communities (Alburquerque et al., 2011;Brodrick, 2004;Lopes & Malfitano, 2021).The OCWFOT is offered as a tool to assist occupational therapists fulfil their obligation to assure the rights to occupational participation and social inclusion to which all people are equally entitled.
Portraying people's strengths, assets and abilities as neither more nor less important than the resources of the environment, the OCWFOT encourages consideration of interventions that address both people's abilities and their opportunities to "do" the occupations they value.This requires a willingness and ability to cope with complex realities, and to understand the contextually-embedded nature and diversity of humans and their occupations (Hammell, 2020a).
It is hoped that the OCWFOT will become a useful tool for those practitioners committed to embracing socially-focused approaches to occupational therapy; approaches that seek to enlarge both the possibilities for occupational engagement, social inclusion and participation, and the requisite opportunities for individuals and collectives to envision and enact their occupational choices (Malfitano, 2022).Although the OCWFOT was informed by perspectives articulated in the literatures of those in both the Global North and South, the author's specific positioning in the Global North, coupled with her inability to read anything that is not published in English, has undoubtedly led to an imbalance of perspectives.However, the OCWFOT is offered up to occupational therapists globally as a flexible, non-prescriptive tool for research and practice; a tool it is hoped will be re-considered, re-conceptualised and revised by occupational therapists -especially by those in the Global South.
Unusual, in being informed by a significant body of multidisciplinary perspectives from a broad diversity of participants in both the Global South and North, the OCWFOT "is theoretically defensible, provides conceptual clarity and may be used as a resource and structure around which future research, practice and outcome strategies may be oriented" (Hammell, 2020a, p. 214).