Abstract

Introduction

The role of systemic marginalization in negatively impacting the health and wellbeing of individuals and populations is well-established. Although the profession has begun to address the impact of colonialism in clinical and educational contexts, these topics are less represented in the underpinning theories, models, and frameworks that guide research, practice, and education.

Objective

To identify and analyze peer-reviewed journal articles about professional theories, models, and frameworks describing justice-oriented constructs.

Method

We searched for journal articles published between 1971 and 2021 as indexed in PubMed/Medline, EMBASE, Scopus, PsycInfo, CINAHL, and Web of Science. We used the Levac et al. methodology and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews extension (PRISMA-ScR) and the JBI Scoping Review Network. Included articles featured theories, models, frameworks that described justice-oriented constructs.

Results

Forty-five articles published from 1987 to 2021 met inclusion criteria. These included 19 models, 19 frameworks, five theories, and two paradigms. The majority of articles originated in Canada, the United States, and Australia and within the past 20 years. The most commonly described constructs were inclusion, culture, and occupational justice.

Conclusion

This scoping review provides an overview of publications describing theories, models, and frameworks in occupational therapy literature that include justice-oriented constructs. Although justice-oriented constructs were the central topic in 35 articles, the context was not explicitly connected to professional activity. Only seven articles discussed research, which reveals a major concern considering its foundational role in the profession.

Keywords:
Social Justice; Professional Ethics; Colonialism

Resumo

Introdução

O papel da marginalização sistémica no impacto negativo na saúde e no bem-estar dos indivíduos e das populações está bem estabelecido. Embora a profissão tenha começado a abordar o impacto do colonialismo em contextos clínicos e educacionais, estes tópicos estão menos representados nas teorias, modelos e enquadramentos subjacentes que orientam a investigação, a prática e a educação.

Objetivo

Identificar e analisar artigos de periódicos revisados ​​por pares sobre teorias, modelos e estruturas profissionais que descrevem construtos orientados para a justiça.

Método

Pesquisamos artigos de periódicos publicados entre 1971 e 2021 indexados em PubMed/Medline, EMBASE, Scopus, PsycInfo, CINAHL e Web of Science. Usamos o Levac et al. metodologia e seguiumos a extensão Preferred Reporting Items for Systematic Reviews and Meta-Analyses para extensão Scoping Reviews (PRISMA-ScR) e a JBI Scoping Review Network. Os artigos incluídos apresentavam teorias, modelos e estruturas que descreviam construções orientadas para a justiça.

Resultados

Quarenta e cinco artigos publicados de 1987 a 2021 preencheram os critérios de inclusão. Estes incluíram 19 modelos, 19 estruturas, cinco teorias e dois paradigmas. A maioria dos artigos teve origem no Canadá, nos Estados Unidos e na Austrália nos últimos 20 anos. Os construtos mais comumente descritos foram inclusão, cultura e justiça ocupacional.

Conclusão

Esta revisão de escopo fornece uma visão geral das publicações que descrevem teorias, modelos e estruturas na literatura de terapia ocupacional que incluem construtos orientados para a justiça. Embora os construtos orientados para a justiça tenham sido o tema central em 35 artigos, o contexto não estava explicitamente ligado à atividade profissional. Apenas sete artigos discutiram a pesquisa, o que revela uma grande preocupação considerando o seu papel fundacional na profissão.

Palavras-chave:
Justiça Social; Ética Profissional; Colonialismo

Introduction

Theories, models, and frameworks (TMFs) are increasingly used across health care professions to understand behavior, guide intervention, and predict health outcomes (Kivunja, 2018Kivunja, C. (2018). Distinguishing between theory, theoretical framework, and conceptual framework: a systematic review of lessons from the field. International Journal of Higher Education, 7(6), 44-53.). Occupational therapy providers use conceptual theories and models to understand the scope of occupational therapy, and practice models may provide more direct intervention guidance (Fisher, 1998Fisher, A. G. (1998). Uniting practice and theory in an occupational framework. The American Journal of Occupational Therapy, 52(7), 509-521.). Thus, while there is frequent confusion and overlap in the use of the terms theory, model, and framework, TMFs collectively are a critical component of applying clinical reasoning and organizing clinical practice (Nilsen, 2015Nilsen, P. (2015). Making sense of implementation theories, models and frameworks. Implementation Science: IS, 10(1), 53.). A theory is a set of logically related principles that describes and explains a certain phenomenon (Bailer-Jones, 2009Bailer-Jones, D. M. (2009). Scientific models in philosophy of science. Pittsburgh: University of Pittsburgh Press. ). Theories assist scientists and professionals in predicting and testing various factors within any given phenomenon. A model is not explanatory; rather it attempts to describe a phenomenon as a visual representation of theory. Models often simplify or translate theoretical constructs for use in practice, often serving as the venue for theory-testing (Bailer-Jones, 2009Bailer-Jones, D. M. (2009). Scientific models in philosophy of science. Pittsburgh: University of Pittsburgh Press. ). Frameworks provide theories with general classes of explanatory variables and the relationships among them (Bailer-Jones, 2009Bailer-Jones, D. M. (2009). Scientific models in philosophy of science. Pittsburgh: University of Pittsburgh Press. ). Frameworks express points of emphasis, on what one should pay attention to, but not what to do or how to do it.

Theories, models, and frameworks (TMFs) in occupational therapy

In essence, TMFs provide boundaries, coherence, and guidance for occupational therapy providers’ focus and actions as they practice. While TMFs are used mostly in occupational therapy research and practice, they also feature prominently in occupational therapy education, particularly in curricula (what to teach), instruction (how to teach; e.g., guiding best practices in teaching strategies), and assessment (ways to obtain evidence of learning (Grenier et al., 2020Grenier, M.-L., Zafran, H., & Roy, L. (2020). Current landscape of teaching diversity in occupational therapy education: a scoping review. The American Journal of Occupational Therapy, 74(6), 7406205100p1.)). As society changes, the profession must develop to meet the needs of a fully global context (Hammell, 2011Hammell, K. W. (2011). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33., 2019Hammell, K. W. (2019). Building globally relevant occupational therapy from the strength of our diversity. World Federation of Occupational Therapists Bulletin, 75(1), 13-26.). TMFs in occupational therapy must continuously evolve to include new knowledge and fully consider the complexity and intersection of the factors influencing human health in today’s ever-changing world. As such, occupational therapy providers, educators, and scientists must consider the contemporary applicability of TMFs broadly and train future generations to translate and apply the most up-to-date TMFs to their work (American Occupational Therapy Association, 2018American Occupational Therapy Association – AOTA. (2018). Occupational therapy education research agenda: revised. The American Journal of Occupational Therapy, 72(Suppl. 2), 7212420070p1-7212420070p5.; Heeb et al., 2020Heeb, R., Hooper, B., & Taff, S. D. (2020). Representation of theory in occupational therapy education: an international systematic mapping review 1940–2015. Journal of Occupational Therapy Education, 4(4), 1-16.).

TMFs abound in the profession of occupational therapy, too many to discuss in any detail in one paper (Chien et al., 2022Chien, C.-W., Mo, C., Lin, C.-Y., Chan, W. H., Chan, C. W., Tang, W. H., Siu, C. P., & Yip, H. S. (2022). Evaluation of the effect of using online database to enhance students’ learning of occupational therapy theories in occupational therapy education. Hong Kong Journal of Occupational Therapy, 35(1), 96-104.). The most prevalent TMFs offer initial signals to what extent they include and/or use constructs related to justice, equity, diversity, and inclusion. Here, we very briefly examine some commonly occurring TMFs used widely in occupational therapy (although varying in different professional and cultural contexts): environmental press theory, the Model of Human Occupation (MOHO), and the AOTA Practice Framework. Lawton & Nahemow’s (1973)Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer & M. P. Lawton (Eds.),The psychology of adult development and aging(pp. 619-674). Washington, DC: American Psychological Association. environmental press theory is foundational to occupational therapy’s understanding of how a person’s occupational choices and engagement level are impacted by the fit between environmental demands and individual competence in meeting or adapting to those stressors. Environmental press is most informative in terms of task analysis and modification of built environments; what is missing, however, is specific consideration of the social and ethical aspects of occupational performance and how health inequities and vulnerabilities created and sustained by systemic structures provide additional stressors affecting human health beyond the individual. The MOHO is extensively taught and used in occupational therapy practice (Kielhofner & Burke, 1980Kielhofner, G., & Burke, J. P. (1980). A model of human occupation, part 1. Conceptual framework and content. The American Journal of Occupational Therapy, 34(9), 572-581.; Kielhofner, 2008Kielhofner, G. (2008). Model of human occupation: theory and application. Philadelphia: Lippincott Williams & Wilkins.) and focuses on occupational performance and participation as influenced by the constructs of volition, habituation, occupational identity, and occupational competence, with the ultimate goal of occupational adaptation. Although the environment is an element, the MOHO is, at its core, about supporting individual construction of positive occupational identity and competence without clear or deep consideration of larger factors that may act as barriers, such as systemic oppression, lack of access, sociopolitical issues, or climate change (Kielhofner, 2008Kielhofner, G. (2008). Model of human occupation: theory and application. Philadelphia: Lippincott Williams & Wilkins.). The AOTA Practice Framework (4th edition) is meant to be used as a comprehensive guide to occupational therapy practice that forwards the profession’s core beliefs, outlines professional language, and delineates the process, scope, and context of occupational therapy services in the United States (American Occupational Therapy Association, 2020American Occupational Therapy Association – AOTA. (2020). Occupational therapy practice framework: domain and process. The American Journal of Occupational Therapy, 74(Suppl.2), 7412410010p1-7412410010p87.). As a guiding document and lexicon for occupational therapy, the Practice Framework is extremely valuable, although it generally does not explore the influence of justice, equity, diversity, or inclusion beyond advocacy as intervention and occupational justice as an outcome. The point of our present discussion is not to dismiss or minimize the significant positive impact that environmental press theory, the MOHO, and the AOTA Practice Framework each have had on the profession, but rather to point out that none of the three explicitly includes justice, equity, diversity, or inclusion as critically important core elements.

Contextualizing justice-oriented constructs within occupational therapy

As we slowly emerge from the COVID-19 pandemic, the world remains in uncertain times. Globally, we face multiple challenges that impact human health, including post-pandemic reemergence and residual trauma, systemic racism and colonial oppression of marginalized identities, resource scarcity, ideological polarization, mis/disinformation, conflict, nationalism, and the existential emergency of climate change (Garcia, 2022Garcia, M. (2022). This is America: systemic racism and health inequities amidst the COVID-19 pandemic. Social Work in Public Health, 37(2), 105-121.; Njoku, 2021Njoku, A. U. (2021). COVID-19 and environmental racism: challenges and recommendations. European Journal of Environment and Public Health, 5(2), em0079.). For many decades, these challenges have affected people’s ability to engage in desired occupations but simultaneously force us to consider the intersection of our collective occupations with global values, systems, structures, and the environment in its entirety. Additionally, these emerging and growing threats to occupational engagement disproportionately impact populations that have been historically and presently excluded, specifically people of color, the economically deprived, people with disabilities, and other minoritized groups (Adelman, 2007Adelman, L. (2007). Unnatural causes: is inequality making us sick? Preventing Chronic Disease, 4(4), 1-2.; Johnson-Agbakwu et al., 2022Johnson-Agbakwu, C. E., Ali, N. S., Oxford, C. M., Wingo, S., Manin, E., & Coonrod, D. V. (2022). Racism, COVID-19, and health inequity in the USA: a call to action. Journal of Racial and Ethnic Health Disparities, 9(1), 52-58.). Occupational therapy has an important opportunity to be at the forefront of addressing these complex threats to human health and well-being but only if we choose to do so with intentionality (Brown et al., 2021Brown, K., Lamont, A., Do, A., & Schoessow, K. (2021). Increasing racial and ethnic diversity in occupational therapy education: the role of Accreditation Council for Occupational Therapy Education (ACOTE®) Standards. The American Journal of Occupational Therapy, 75(3), 7503347020.). The actions required must be sweeping and swift, not simply broad policy statements. The professional praxis necessary begins with the very foundations of the profession, in the philosophical epistemologies and ethical principles underpinning the TMFs that guide occupational therapy practice, research, and education.

Originating in the United States, occupational therapy’s history includes not only the community focus of Hull House, but also a persistent individualist and reductionist lens and resilient ties to medicine for legitimacy (Taff & Babulal, 2021Taff, S. D., & Babulal, G. M. (2021). Reframing the narrative on the philosophies influencing the development of occupational therapy. In S. D. Taff (Ed.), Philosophy and occupational therapy: informing education, research, and practice (pp. 7-22). New Jersey: Slack Incorporated.). Traces of this evolution manifest as theoretical imperialism embedded in professional lexicon, practice, education, and research (Taff & Putnam, 2022Taff, S. D., & Putnam, L. (2022). Northern philosophies and professional neocolonialism in occupational therapy: a historical review and critique. Cadernos Brasileiros de Terapia Ocupacional, 30, e2986.). The TMFs underpinning the profession (many of which are narrowly focused on Northern/Western perspectives), therefore, bear neocolonial features that need to be identified, critiqued, disrupted, and dismantled (Taff & Putnam, 2022Taff, S. D., & Putnam, L. (2022). Northern philosophies and professional neocolonialism in occupational therapy: a historical review and critique. Cadernos Brasileiros de Terapia Ocupacional, 30, e2986.). Thus, there is a need for the profession to reframe its priorities, systems, processes, research, and training around a foundation of basic human rights, core values, and justice. A preliminary step toward such a paradigm shift is to comprehensively explore the existing literature for evidence on whether and how constructs related to justice, equity, diversity, and inclusion are evoked in professional TMFs. Therefore, the purpose of this scoping study was to search international literature from the past 50 years to explore the presence, use, and historical evolution of justice-oriented constructs in occupational therapy. The review focused on TMFs that were influential to the field of occupational therapy as indicated by a clear focus on occupation. TMFs were explored that were relevant for clinicians, researchers, and/or educators within the occupational therapy profession and described occupation as either a means or ends of various outcomes. Within these occupation-based TMFs, we identified if they were justice-oriented by whether or not they incorporated concepts that critically considered the effects of social, cultural, political, institutional, or other systems-level factors on health, well-being, opportunity, and other outcomes (e.g., determinants of health, access to resources, education, employment, equity, ability to participate). The research question guiding this scoping review was to identify what theories, models, and frameworks in occupational therapy include constructs related to justice, equity, diversity, and inclusion. The ultimate purpose of this review was to develop a greater understanding of approaches to integrating occupation, justice and health as evidenced in professional TMF’s.

Method

A preliminary search of MEDLINE, the Cochrane Database of Systematic Reviews, and JBI Evidence Synthesis was conducted, and no current or underway systematic reviews or scoping reviews on the topic were identified. Malfitano et al. (2016)Malfitano, A. P. S., Souza, R. G. M., & Esquerdo Lopes, R. (2016). Occupational justice and its related concepts: an historical and thematic scoping review. OTJR: Occupational Therapy Journal of Research, 36(4), 167-178. completed a scoping review on occupational justice and its related concepts, but not in relation to TMFs or justice-oriented constructs more broadly conceived. The methodological framework suggested by Levac et al. (2010)Levac, D., Colquhoun, H., & O’Brien, K. K. (2010). Scoping studies: advancing the methodology. Implementation Science : IS, 5(1), 69. guided this scoping review. The standards and guidelines for conducting and reporting scoping reviews set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR; (Tricco et al., 2018Tricco, A. C., Lillie, E., Zarin, W., O’Brien, K. K., Colquhoun, H., Levac, D., Moher, D., Peters, M. D. J., Horsley, T., Weeks, L., Hempel, S., Akl, E. A., Chang, C., McGowan, J., Stewart, L., Hartling, L., Aldcroft, A., Wilson, M. G., Garritty, C., Lewin, S., Godfrey, C. M., MacDonald, M. T., Langlois, E. V., Soares-Weiser, K., Moriarty, J., Clifford, T., Tuncalp, O., & Straus, S. E. (2018). PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Annals of Internal Medicine, 169(7), 467-473.) and the JBI Scoping Review Network (Peters et al., 2022Peters, M. D. J., Godfrey, C., McInerney, P., Khalil, H., Larsen, P., Marnie, C., Pollock, D., Tricco, A. C., & Munn, Z. (2022). Best practice guidance and reporting items for the development of scoping review protocols. JBI Evidence Synthesis, 20(4), 953-968.) guided the creation of the search strategies and process criteria for the review. This scoping review was registered under OSF Registries (Center for Open Science, 2023Center for Open Science. (2023). Scoping review of occupational therapy theories, models and frameworks. Retrieved in 2023, August 28, from osf.io/f7djn
osf.io/f7djn... ).

Identifying relevant studies

This study explored English-language peer-reviewed publications in the timeframe of the years 1971–2021. A 50-year timeframe was selected because it would not only include publications relevant to modern-day health care and social policy, but also assist with identifying trends over time. A research librarian assisted with developing and running the search strategy.

The literature was searched using standardized subject terms, keywords, and wildcard searching for concepts including occupational therapy, culture, justice, equity, inclusion, and theory. These strategies were executed in the PubMed/Medline 1946-, EMBASE 1947-, Scopus 1823-, PsycInfo 1800-, Cumulative Index of Nursing and Allied Health Literature (CINAHL 1937-), and Web of Science (WOS 1900-) databases. The full search strategy is available in the supplemental materials.

Selecting studies

Identified publications were reviewed with the following inclusion criteria: (1) discussed an explicitly stated theory, model, or framework; (2) have a focus on occupation (to include those connected in context to either occupational science or occupational therapy); and (3) described broad constructs of justice, equity, diversity, or inclusion. Although many viable choices exist regarding the semantics of inclusion criteria, we opted for wide-ranging terms in contrast to more specific, interpersonal constructs such as racism or bias. We excluded clinical trials, basic science research, theses/dissertations, book chapters, conference abstracts, systematic reviews, interviews, and policy statements. To be included, publications had to describe occupation as core component contributing to, or influenced by various outcomes, thereby focusing on TMFs used in the field of occupational therapy. Although book chapters undergo an editorial process that provides feedback, that process is not equivalent to the peer-review required for refereed journals. Clinical trials were excluded because they did not meet our inclusion criteria and rarely (Colquhoun et al., 2013Colquhoun, H. L., Brehaut, J. C., Sales, A., Ivers, N., Grimshaw, J., Michie, S., Carroll, K., Chalifoux, M., & Eva, K. W. (2013). A systematic review of the use of theory in randomized controlled trials of audit and feedback. Implementation Science, 8(1), 66.) evoke theory in study design, measurement, implementation, or interpretation.

Charting the data

Two authors independently reviewed each title and extracted data items using the Covidence^® systematic review management system (Veritas Health Innovation, Melbourne, Australia). The data extraction team met as a group to discuss any discrepancies and came to consensus. Two rounds of review were conducted, first to review the title and abstract, followed by the full text to determine final inclusion. Based on the research question, the authors developed a data extraction tool to guide analysis. All authors reviewed the full-text versions of included articles through a basic content analysis approach (Elo & Kyngäs, 2008Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107-115.; Hsieh & Shannon, 2005Hsieh, H.-F., & Shannon, S. E. (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277-1288.).

Collating, summarizing, and reporting the results

Data points extracted included: (1) geographic location, (2) type (theory, model, or framework), (3) professional context (clinical, research, or education), (4) specific constructs represented, and (5) central or peripheral focus of justice, equity, diversity, or inclusion. Instances of each of the data points were summarized, and frequency was calculated.

Results

The database search yielded 4,036 articles, and 1,885 duplicates were removed. The titles and abstracts of the remaining 2,151 articles were screened, and 174 full texts were reviewed (Figure 1). Four additional articles that met inclusion criteria were identified in a supplementary search guided by the reference lists of included articles, resulting in 45 total articles for full-text content analysis. Constructs were defined as “central” when they clearly served as the main focus of the article; constructs were “peripheral” when another topic was central and they were included or mentioned but not in a detailed or integrated fashion.

The majority of articles originated in Canada (n = 14, 31%; (Benjamin-Thomas & Rudman, 2018Benjamin-Thomas, T. E., & Rudman, D. L. (2018). A critical interpretive synthesis: use of the occupational justice framework in research. Australian Occupational Therapy Journal, 65(1), 3-14.; Grenier, 2020Grenier, M. L. (2020). Cultural competency and the reproduction of White supremacy in occupational therapy education. Health Education Journal, 79(6), 633-644.; Hammell, 2011Hammell, K. W. (2011). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27-33., 2013Hammell, K. R. (2013). Occupation, well-being, and culture: theory and cultural humility. Canadian Journal of Occupational Therapy, 80(4), 224-234., 2016Hammell, K. R. W. (2016). Empowerment and occupation: a new perspective. Canadian Journal of Occupational Therapy, 83(5), 281-287.; Iwama et al., 2009Iwama, M. K., Thomson, N. A., Macdonald, R. M., Iwama, M. K., Thomson, N. A., & Macdonald, R. M. (2009). The Kawa model: the power of culturally responsive occupational therapy. Disability and Rehabilitation, 31(14), 1125-1135.; King et al., 2006King, G. A., Tucker, M. A., Baldwin, P. J., & LaPorta, J. A. (2006). Bringing the Life Needs Model to life: implementing a service delivery model for pediatric rehabilitation. Physical & Occupational Therapy in Pediatrics, 26(1), 43-70.; Law, 1993Law, M. (1993). Evaluating activities of daily living: directions for the future. The American Journal of Occupational Therapy, 47(3), 233-237.; Martins & Reid, 2007Martins, V., & Reid, D. (2007). New-immigrant women in urban Canada: insights into occupation and sociocultural context. Occupational Therapy International, 14(4), 203-220.; Restall et al., 2018Restall, G. J., MacLeod Schroeder, N. J., & Dubé, C. D. (2018). The Equity Lens for occupational therapy: a program development and evaluation tool. Canadian Journal of Occupational Therapy, 85(3), 185-195.; Townsend et al., 2003Townsend, E., Galipeault, J. P., Gliddon, K., Little, S., Moore, C., & Klein, B. S. (2003). Reflections on power and justice in enabling occupation. Canadian Journal of Occupational Therapy, 70(2), 74-87., 2011Townsend, E., Polatajko, H. J., Craik, J. M., & von Zweck, C. M. (2011). Introducing the Leadership in Enabling Occupation (LEO) model. Canadian Journal of Occupational Therapy, 78(4), 255-259.; Vrkljan, 2005Vrkljan, B. H. (2005). Dispelling the disability stereotype: embracing a universalistic perspective of disablement. Canadian Journal of Occupational Therapy, 72(1), 57-60.; Wieringa & McColl, 1987Wieringa, N., & McColl, M. (1987). Implications of the model of human occupation for intervention with native Canadians. Occupational Therapy in Health Care, 4(1), 73-91.), the United States (n = 12, 27%; (Agner, 2020Agner, J. (2020). Moving from cultural competence to cultural humility in occupational therapy: a paradigm shift. The American Journal of Occupational Therapy, 74(4), 7404347010p1-7404347010p7.; Causey-Upton, 2015Causey-Upton, R. (2015). A model for quality of life: occupational justice and leisure continuity for nursing home residents. Physical & Occupational Therapy in Geriatrics, 33(3), 175-188.; Clifton & Taff, 2021Clifton, M., & Taff, S. D. (2021). The FOCUUS model: facilitating occupational performance on campus: uplifting underrepresented students. Journal of Occupational Therapy Education, 5(3), 1.; Grady, 1995Grady, A. P. (1995). Building inclusive community: a challenge for occupational therapy. The American Journal of Occupational Therapy, 49(4), 300-310.; Gupta, 2006Gupta, J. (2006). A model for interdisciplinary service-learning experience for social change. Journal, Physical Therapy Education, 20(3), 55-60.; Jaegers et al., 2020Jaegers, L. A., Dieleman, C., Dillon, M. B., Rogers, S., Muñoz, J. P., & Barney, K. F. (2020). Justice-Based occupational therapy initiative: advancing occupational justice in criminal justice systems. Annals of International Occupational Therapy, 3(4), 200-208.; Muñoz, 2007Muñoz, J. P. (2007). Culturally responsive caring in occupational therapy. Occupational Therapy International, 14(4), 256-280.; Schaber, 2002aSchaber, P. L. (2002a). FIRO Model: a framework for family-centered care. Physical & Occupational Therapy in Geriatrics, 20(3-4), 1-18.; Taff et al., 2014Taff, S. D., Bakhshi, P., & Babulal, G. M. (2014). The accountability-well-being-ethics framework: a new philosophical foundation for occupational therapy. Canadian Journal of Occupational Therapy, 81(5), 320-329.; Taff & Blash, 2017Taff, S. D., & Blash, D. (2017). Diversity and inclusion in occupational therapy: where we are, where we must go. Occupational Therapy in Health Care, 31(1), 72-83.; Talero et al., 2015Talero, P., Kern, S. B., & Tupé, D. A. (2015). Culturally responsive care in occupational therapy: an entry-level educational model embedded in service-learning. Scandinavian Journal of Occupational Therapy, 22(2), 95-102.; Wood et al., 2017Wood, W., Lampe, J. L., Logan, C. A., Metcalfe, A. R., & Hoesly, B. E. (2017). The Lived Environment Life Quality Model for institutionalized people with dementia. Canadian Journal of Occupational Therapy, 84(1), 22-33.), Australia (n = 7, 16%; (Frew et al., 2008Frew, K. M., Joyce, E. V., Tanner, B., & Gray, M. A. (2008). Clinical reasoning and the international classification of functioning: a linking framework. Hong Kong Journal of Occupational Therapy, 18(2), 68-72.; Goh et al., 2019Goh, N. C. K., Hancock, N., Honey, A., & Scanlan, J. N. (2019). Thriving in an expanding service landscape: experiences of occupational therapists working in generic mental health roles within non-government organizations in Australia. Australian Occupational Therapy Journal, 66(6), 753-762.; Hitch & Pepin, 2021Hitch, D., & Pepin, G. (2021). Doing, being, becoming and belonging at the heart of occupational therapy: an analysis of theoretical ways of knowing. Scandinavian Journal of Occupational Therapy, 28(1), 13-25.; Nelson, 2007Nelson, A. (2007). Seeing white: A critical exploration of occupational therapy with Indigenous Australian people. Occupational Therapy International, 14(4), 237-255.; Pereira, 2017Pereira, R. B. (2017). Towards inclusive occupational therapy: introducing the CORE approach for inclusive and occupation-focused practice. Australian Occupational Therapy Journal, 64(6), 429-435.; Pereira et al., 2020Pereira, R. B., Whiteford, G., Hyett, N., Weekes, G., Di Tommaso, A., & Naismith, J. (2020). Capabilities, Opportunities, Resources and Environments (CORE): using the CORE approach for inclusive, occupation‐centered practice. Australian Occupational Therapy Journal, 67(2), 162-171.; Whiteford et al., 2018Whiteford, G., Jones, K., Rahal, C., & Suleman, A. (2018). The participatory occupational justice framework as a tool for change: three contrasting case narratives. Journal of Occupational Science, 25(4), 497-508.), South Africa (n = 3, 7%; (du Toit, 2008du Toit, S. (2008). Using the Model of Human Occupation to conceptualize an occupational therapy program for blind persons in South Africa. Occupational Therapy in Health Care, 22(2-3), 51-61.; Janse van Rensburg, 2018Janse van Rensburg, E. (2018). A framework for occupational enablement to facilitate social change in community practice. Canadian Journal of Occupational Therapy, 85(4), 318-329.; Mthembu, 2021Mthembu, T. G. (2021). A commentary of occupational justice and occupation-based community development frameworks for social transformation: the Marikana Event. South African Journal of Occupational Therapy, 51(1), 72-75.); and Brazil (n = 2, 4%, (Malfitano & Lopes, 2018Malfitano, A. P. S., & Lopes, R. E. (2018). Social occupational therapy: committing to social change. New Zealand Journal of Occupational Therapy, 65(1), 20-26.; McInerney et al., 2007McInerney, C. A., McInerney, M., Rodrigues, P., & Rocha Miranda, C. (2007). Programa Integrando: applications of the occupational therapy practice framework in Brazil. World Federation of Occupational Therapists Bulletin, 55(1), 34-41.) with the remaining seven articles each representing a single country including Croatia (Bartolac & Jokić, 2019Bartolac, A., & Jokić, C. S. (2019). Understanding the everyday experience of persons with physical disabilities: building a model of social and occupational participation. Journal of Occupational Science, 26(3), 408-425.), Namibia (Chichaya et al., 2018Chichaya, T. F., Joubert, R. W. E., & McColl, M. A. (2018). Analysing disability policy in Namibia: an occupational justice perspective. African Journal of Disability, 7, 1-11.), Jordan (Darawsheh et al., 2015Darawsheh, W., Chard, G., & Eklund, M. (2015). The challenge of cultural competency in the multicultural 21st century: a conceptual model to guide occupational therapy practice. The Open Journal of Occupational Therapy, 3(2), 1-22.), New Zealand (Emery-Whittington, 2021Emery-Whittington, I. G. (2021). Occupational justice-Colonial business as usual? Indigenous observations from Aotearoa New Zealand. Canadian Journal of Occupational Therapy, 88(2), 153-162.), Ireland (McCormack & Collins, 2012McCormack, C., & Collins, B. (2012). The affirmative model of disability: a means to include disability orientation in occupational therapy? British Journal of Occupational Therapy, 75(3), 156-158.), Scotland (Millar et al., 2013Millar, F., Doherty, M., Forster, G., McFarlane, A., & Ogilvie, P. (2013). Managing waiting times and providing equitable, family-centred care: a description of four key initiatives from NHS Fife Child Health Occupational Therapy Service (2006-11). British Journal of Occupational Therapy, 76(8), 379-383.), and Sweden (Nilsson & Townsend, 2010Nilsson, I., & Townsend, E. (2010). Occupational justice-bridging theory and practice. Scandinavian Journal of Occupational Therapy, 17(1), 57-63.). Publication frequency increased over time, with the majority of articles being published since the year 2000 (n = 42, 93%; Figure 2). Most publications described a model (n = 19, 42%) or framework (n = 19, 42%) for occupational therapy. Only five (11%) were classified as theories, and two (4%) were described by the authors as paradigms. Although many publications described concepts that could guide more than one domain of occupational therapy (practice, education, or research), the majority (n = 33, 73%) targeted clinical practice, whereas 23 (51%) included educational purposes, and only seven (16%) described components related to research. Of those seven, only two of the articles were primarily focused on research.

Many of the TMFs addressed multiple justice-oriented constructs in varying levels of detail; therefore we connected each included article to one primary construct of focus. The most frequently described constructs across publications were inclusion (n = 17, 38%), culture (n = 10, 22%), and occupational justice (n = 11, 24%). Other frequently described themes included human rights, social determinants of health, diversity, occupational deprivation, social justice, human rights, and community. Of the 45 articles, 35 (78%) had a central theme related to justice-oriented constructs. A summary of each study is included in Table 1.

Discussion

Geographic location

We identified 45 publications exploring TMFs in occupational therapy that incorporated constructs related to justice, equity, diversity, and inclusion. Critically, we identified that publications have increased in recent years and originate mostly from Western countries including Canada (14; 31%), the United States of America (12; 27%), and Australia (7; 16%). The remaining 12 articles originated from Brazil (2), Croatia, Ireland, Jordan, Namibia, New Zealand, Scotland, South Africa (3), and Sweden. Journals represented included the American, British, Canadian, and South African Journals of Occupational Therapy, Occupational Therapy International, Physical & Occupational Therapy in Geriatrics, the Journal of Occupational Science, and the World Federation of Occupational Therapists Bulletin. Despite calls to action from the international occupational therapy community, the dearth of current TMFs addressing these issues indicates that words have not always been followed with action. Certainly, work on and within justice-oriented TMF’s is occurring in locations that fell outside the parameters of this review. However, given the continued influence of Northern/Western ways of thinking, doing, and being in occupational therapy globally, we must remain aware of how those historicized neocolonial elements impact the development of justice-oriented TMF’s and if those manifest in applied action or remain inert.

Date of publication

Surprisingly, we found that the majority (93%) of articles were published in the past 20 years, with only three articles published prior to 2000. Although the spike in discussion in recent challenging times is understandable, the disparate number of earlier publications suggests that recent scholarship and theory-building has been reactive to current events instead of generating proactive and intentional ideals. Instead, we found that these topics were not significantly explored until recently, which hints at a historical pattern of reluctance in acknowledging and explicitly addressing the impact of socially contextualized issues in research, education, and practice. Some watershed moments in health care since 2000 may have provided the impetus for ensuing professional discussions on justice-oriented constructs and phenomena (Barksdale et al., 2014Barksdale, C. L., Kenyon, J., Graves, D. L., & Jacobs, C. G. (2014). Addressing disparities in mental health agencies: strategies to implement the national class standards in mental health. Psychological Services, 11(4), 369-376., 2017Barksdale, C. L., Rodick III, W. H., Hopson, R., Kenyon, J., Green, K., & Jacobs, C. G. (2017). Literature review of the National CLAS Standards: policy and practical implications in reducing health disparities. Journal of Racial and Ethnic Health Disparities, 4(4), 632-647.), only to be accelerated by the Black Lives Matter Movement and Covid-19 pandemic in 2020. Correspondingly, we identified that justice-oriented terminology was first introduced as directly connected to TMFs in the early 2000s (Nilsson & Townsend, 2010Nilsson, I., & Townsend, E. (2010). Occupational justice-bridging theory and practice. Scandinavian Journal of Occupational Therapy, 17(1), 57-63.; Townsend et al., 2003Townsend, E., Galipeault, J. P., Gliddon, K., Little, S., Moore, C., & Klein, B. S. (2003). Reflections on power and justice in enabling occupation. Canadian Journal of Occupational Therapy, 70(2), 74-87.) and that nearly 20% of the included articles were published in the most recent 2020-2021 timeframe.

TMFs and area of focus

Of the 45 included publications, the majority described a model (42%) or framework (42%). Only five (11%) were classified as theories, and two were described by the authors as paradigms (4%). Of these TMFs, several were described in more than one publication, including Critical Race Theory (e.g., (Grenier, 2020Grenier, M. L. (2020). Cultural competency and the reproduction of White supremacy in occupational therapy education. Health Education Journal, 79(6), 633-644.; Nelson, 2007Nelson, A. (2007). Seeing white: A critical exploration of occupational therapy with Indigenous Australian people. Occupational Therapy International, 14(4), 237-255.), the Kawa River Model (e.g., (Iwama et al., 2009Iwama, M. K., Thomson, N. A., Macdonald, R. M., Iwama, M. K., Thomson, N. A., & Macdonald, R. M. (2009). The Kawa model: the power of culturally responsive occupational therapy. Disability and Rehabilitation, 31(14), 1125-1135.; Nelson, 2007Nelson, A. (2007). Seeing white: A critical exploration of occupational therapy with Indigenous Australian people. Occupational Therapy International, 14(4), 237-255.), and Occupational Justice as a Framework (e.g., (Benjamin-Thomas & Rudman, 2018Benjamin-Thomas, T. E., & Rudman, D. L. (2018). A critical interpretive synthesis: use of the occupational justice framework in research. Australian Occupational Therapy Journal, 65(1), 3-14.; Chichaya et al., 2018Chichaya, T. F., Joubert, R. W. E., & McColl, M. A. (2018). Analysing disability policy in Namibia: an occupational justice perspective. African Journal of Disability, 7, 1-11.; Mthembu, 2021Mthembu, T. G. (2021). A commentary of occupational justice and occupation-based community development frameworks for social transformation: the Marikana Event. South African Journal of Occupational Therapy, 51(1), 72-75.). Most of the publications were focused on clinical practice (71%), followed by education (52%) and research (18%). Our findings indicate that theories that address constructs related to justice, equity, diversity, and inclusion are particularly lacking in the research literature. This is of concern, as theories serve as the foundational explanation and guiding principles from which the profession’s scientific questions are developed, and ultimately the evidence, translational practice, and curricular content that follow. Although occupational therapy practitioners, scholars, and teachers are enacting work using justice-oriented TMF’s from other disciplines, the potential for integrating and creating novel approaches that feature the unique intersection with occupational engagement holds great promise. Future work in occupational therapy TMF development should include research to ensure that our science and evidence are developed with a lens that considers constructs focused on justice, equity, diversity, and inclusion.

Constructs represented

The most frequently described justice-oriented construct across publications was inclusion (38%). However, many instances were related specifically to disability inclusion rather than the broader range of cultural aspects of inclusion (McInerney et al., 2007McInerney, C. A., McInerney, M., Rodrigues, P., & Rocha Miranda, C. (2007). Programa Integrando: applications of the occupational therapy practice framework in Brazil. World Federation of Occupational Therapists Bulletin, 55(1), 34-41.; Schaber, 2002bSchaber, P. L. (2002b). Qualitative evaluation of a management course project: creating new job possibilities for occupational therapy. Occupational Therapy in Health Care, 15(1-2), 177-192.). The application of inclusion with a focus on disability is an important finding from this study, since we must also consider inclusion within the broader context of life factors that include the breadth and depth of human experiences. Although a strong focus on disability inclusion and advocacy are core to the profession of occupational therapy and meeting societal needs, it is imperative that occupational therapy cultivate inclusion beyond disability status to consider and address other life factors for clients and the occupational therapy workforce. Constructs such as anti-racism, culturally and linguistically appropriate services, and health disparities have had limited exploration and theoretical development in the occupational therapy literature.

The other most frequently described constructs in the review included culture (24%) and occupational justice (21%). Articles that discussed culture included constructs such as cultural competence, cultural awareness, cultural humility, cultural safety, cultural differences, cultural responsiveness, culturally responsive caring, cultural preparedness, and cultural readiness. The expansive variety of terminology demonstrates the complexity of culture; however, this can lead to challenges in building a coherent body of knowledge and supporting evidence. The construct of occupational justice appeared multiple times in the literature as related to disability, marginalization, human rights, social justice, occupational deprivation, enablement, equity, and accountability. Publications related to inclusion, culture, and occupational justice highlight a need for more inclusive terminology, constructs, and thematic guidance to move the profession forward in meeting society’s diverse occupational needs and to promote humanizing occupational therapy for all people, populations, and groups. That said, Hammell (2017)Hammell, K. R. W. (2017). Critical reflections on occupational justice: toward a rights-based approach to occupational opportunities: réflexions critiques sur la justice occupationnelle: vers une approche des possibilités occupationnelles fondée sur les droits. Canadian Journal of Occupational Therapy, 84(1), 47-57. notes the lack of a clear definition of occupational justice and confusion with the broader construct of social justice; suggesting instead the clarity offered through a rights-based approach congruent with existing TMF’s informed by the capabilities approach and the United Nations Universal Declaration of Human Rights.

Central or peripheral focus

The majority of publications featured a central focus on justice-oriented constructs (n = 35), including decolonization (Emery-Whittington, 2021Emery-Whittington, I. G. (2021). Occupational justice-Colonial business as usual? Indigenous observations from Aotearoa New Zealand. Canadian Journal of Occupational Therapy, 88(2), 153-162.), critical disability theory (Chichaya et al., 2018Chichaya, T. F., Joubert, R. W. E., & McColl, M. A. (2018). Analysing disability policy in Namibia: an occupational justice perspective. African Journal of Disability, 7, 1-11.), and culturally responsive care (Muñoz, 2007Muñoz, J. P. (2007). Culturally responsive caring in occupational therapy. Occupational Therapy International, 14(4), 256-280.). Although a central focus is a positive finding, the constructs as described rarely served to connect the TMF to interventions, educational strategies, or research questions. For example, Bartolac & Jokić (2019)Bartolac, A., & Jokić, C. S. (2019). Understanding the everyday experience of persons with physical disabilities: building a model of social and occupational participation. Journal of Occupational Science, 26(3), 408-425. propose a comprehensive model to enable social and occupational participation of persons with physical disabilities authentically derived from personal lived narratives. Although it clarifies the nature of participation (a justice-oriented construct), the model is not applied to any specific aspect of research, practice, or education. This is not meant as a criticism of the model itself (which is extremely valuable in identifying enablers for participation), but rather to present it as just one of many examples of how even TMFs which feature a central focus, justice-oriented construct often do not translate to everyday practice and, even more importantly, can fail to problematize the Eurocentric assumptions behind the very concepts they describe (in this case, ‘occupation’ and ‘participation’). Explicit and intentional integration and translation of TMF constructs to the everyday practices of occupational therapy providers, educators, and scholars is critical to transforming and reforming the profession. The TMFs that described justice-oriented constructs in a peripheral manner (n = 10) did so indirectly through larger discussions of accessibility for activities of daily living (Law, 1993Law, M. (1993). Evaluating activities of daily living: directions for the future. The American Journal of Occupational Therapy, 47(3), 233-237.) or affirmative disability orientation (McCormack & Collins, 2012McCormack, C., & Collins, B. (2012). The affirmative model of disability: a means to include disability orientation in occupational therapy? British Journal of Occupational Therapy, 75(3), 156-158.).

Limitations

This review was limited by the parameters of the search focusing on electronic databases, peer-reviewed literature, and including only articles published in English. We recognize that there is an emerging body of non-English literature on justice-oriented topics, particularly associated with the social occupational therapy perspective in South America as well as related movements in South Africa, among other locations. As a next step for future research, we plan on completing another review, but do so including the grey literature, book chapters, and with non-English speaking collaborators so we can reasonably analyze more international resources. In addition, articles that did not specifically include occupational therapy were excluded. As a result, interprofessional topics that relate to occupational therapy and potentially impact practice were not reflected in these results. The complexity of clearly extracting contextual or attitudinal barriers prevented from us from including those as elements of full-text coding, but we acknowledge their potential influence. Chronologically, the study was limited to the past 50 years, which may have prevented a more complete illustration of trends and patterns across the profession’s full history. Closely following scoping review methodology maintains objectivity in the search process, however, decisions about what data to extract during coding could be influenced by author identities and their experiences as occupational therapists practicing in Northern/Western contexts. Indeed, the review methods used here, while commonly accepted globally, feature colonial elements that may minimize or neglect certain minoritized perspectives. Finally, we acknowledge that, while unlikely, the combination of the complexity of inclusion criteria, inconsistent use or definition of justice-oriented terminology and TMFs in the literature, and unclear connections to professional practice, research, or education could have resulted in pertinent articles being unduly excluded.

Conclusions

This review indicates that there are a limited number of TMFs in the peer-reviewed occupational therapy literature from the past 50 years that evoke justice-oriented themes. Our findings suggest that when justice-oriented constructs have been represented in the literature, they are narrow in focus, not applicable to the depth and breadth of the human experience, and often fail to make direct, applied connections to specific practice, research, or educational contexts; this narrows the profession’s scope and potential value to the clients we serve. In addition, a disparity exists in the connection of occupational therapy literature to current paradigms relevant to health care and societal needs, thus limiting the translation of research to practice and educational contexts. There is no progress without reflection and change, and we must consider where we have been unsuccessful as a profession in adequately addressing justice-oriented constructs in the TMFs that help us to understand behavior, guide intervention, and predict health outcomes. Without addressing these core principles that influence basic human rights, we risk failing to address critical factors that profoundly impact health, well-being, and engagement in occupation. As a profession, we serve to benefit from taking a deep look at the foundational ideologies and principles of occupational therapy and considering where and how we may have missed opportunities to proactively address and prioritize these concepts. Moreover, we may consider looking to our colleagues in other professions who have paved the way by addressing social justice and other justice-oriented concepts in their TMFs, and consider where and how these are relevant to our own practice, research, and education. In a world of continued uncertainty and global unrest, we must rise to the occasion and focus our lens more in depth on the concepts of justice, equity, diversity, and inclusion which largely influence systemic and social structures and policy that impact health and occupation, particularly among the most vulnerable and minoritized populations. Growing and emerging challenges and experiences throughout the globe should serve as a call to action to develop the infrastructure to facilitate change within the profession. Specifically, we propose the need for deeper theoretical exploration and the development of TMFs that will take into consideration the intersection of occupation with a vast and complex context in mind—considering global values, systems, structures, and the environment in its entirety.

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