Background: In high-income countries, such as Canada, 50% of health outcomes are attributable to social determinants. Occupational opportunities are also structurally determined, yet these inequities are obscured by the White, Western assumptions and ableist neoliberal ideology in which the profession is deeply rooted. Purpose. To highlight the impact of structural injustices and other social determinants of health and occupation; explore the occupational therapy profession's structural competence; and build on existing knowledge to advance an agenda for action on injustice and inequity for the occupational therapy profession. Key issues. Occupational therapy's failure to prioritize education, research and action on systemic injustices and other social determinants of health and occupation reflects a lack of commitment to achieving the World Federation of Occupational Therapists' Minimal Standards. Implications. If occupational therapy is to advance knowledge and practices that address inequities in the social and structural determinants of health and occupation, we must strive towards structural competence.
AllsoppK.KindermanP. (2017). A proposal to introduce formal recording of psychosocial adversities associated with mental health using ICD-10 codes. The Lancet Psychiatry, 4, 664–665. https://doi.org/10.1016/S2215-0366(17)30318-8
2.
AnnammaS. A.FerriB. A.ConnorD. J. (2018). Disability critical race theory: Exploring the intersectional lineage, emergence, and potential futures of DisCrit in education. Review of Research in Education, 42(1), 46–71. https://doi.org/10.3102/0091732X18759041
BeaganB. L. (2007). Experiences of social class: Learning from occupational therapy students. Canadian Journal of Occupational Therapy, 74(2), 125–133. https://doi.org/10.2182/cjot.06.012x
6.
BeaganB. L.EtowaJ. (2009). The impact of everyday racism on the occupations of African Canadian women. Canadian Journal of Occupational Therapy, 76(4), 285–293. https://doi.org/10.1177/000841740907600407
7.
Bergan-GanderR.Von KürtheyH. (2006). Sexual orientation and occupation: Gay men and women's lived experiences of occupational participation. British Journal of Occupational Therapy, 69(9), 402–408. https://doi.org/10.1177/030802260606900903
8.
BjörnsdóttirK.TrausdóttirR. (2010). Stuck in the land of disability? The intersection of learning difficulties, class, gender and religion. Disability and Society, 25(1), 49–62. https://doi.org/10.1080/09687590903363340
9.
Bonilla-SilvaE. (1997). Rethinking racism: Toward a structural interpretation. American Sociological Review, 62(3), 465–480.
10.
BuchananI. (2010). Oxford Dictionary of critical theory. Oxford University Press.
11.
Canadian Medical Association (2013). Health care in Canada: What makes us sick?Author. https://www.cma.ca/Assets/assets-library,/…/What-makes-us-sick_en.pdf.
12.
CollinsP. H. (1991). Learning from the outsider within. The sociological significance of black feminist thought. In FonowM. M.CookJ. A. (Eds.), Beyond methodology: Feminist scholarship as lived research (pp. 35–59). Indiana University Press.
13.
CrawfordE. (2017). Continuing the dialogue: A rights-approach in occupational therapy. Australian Occupational Therapy Journal, 64(6), 505–509. https://doi.org/10.1111/1440-1630.12416
14.
De MaioF.AnsellD. (2018). “As natural as the air around us”: On the origin and development of the concept of structural violence in health research. International Journal of Health Services, 48(4), 749–759. https://doi.org/10.1177/0020731418792825
15.
DowersE.WhiteC.KingsleyJ.SwensonR. (2019). Transgender experiences of occupation and the environment. Journal of Occupational Science, 26(4), 496–510. https://doi.org/10.1080/14427591.2018.1561382
16.
Emery-WhittingtonI. (2021). Occupational justice—Colonial business as usual? Indigenous observations from Aotearoa New Zealand. Canadian Journal of Occupational Therapy, 88(2), 153–162. https://doi.org/10.1177/0008417421005891
17.
FarmerP. (2009). On suffering and structural violence: A view from below. Race/Ethnicity: Multidisciplinary Global Contexts, 3(1), 11–28.
18.
FassinD. (2003). The embodiment of inequality. EMBO, 4(S1), S4–S9.
ForondaC.BaptisteD.-L.ReinholdtM. M.OusmanK. (2016). Cultural humility: A concept analysis. Journal of Transcultural Nursing, 27(3), 210–217. https://doi.org/10.1177/1043659615592677
21.
FrierA.BarnettF.DevineS. (2017). The relationship between social determinants of health, and rehabilitation of neurological conditions: A systematic review. Disability and Rehabilitation, 39(10), 941–948. https://doi.org/10.3109/09638288.2016.1172672
22.
FrierA.BarnettF.DevineS.BarkerR. (2018). Understanding disability and the ‘social determinants of health’: How does disability affect peoples’ social determinants of health?Disability and Rehabilitation, 40(5), 538–547. https://doi.org/10.1080/09638288.2016.1258090
23.
FrohlichK. L.AbelT. (2014). Environmental justice and health practices: Understanding how health inequities arise at the local level. Sociology of Health and Illness, 36(2), 199–212. https://doi.org/10.1111/1467-9566.12126
24.
FyffeD. C.BotticelloA. L.MyaskovskyL. (2011). Vulnerable groups living with spinal cord injury. Topics in Spinal Cord Injury Rehabilitation, 17(2), 1–9. https://doi.org/10.1310/sci1702-01
25.
GalheigoS. M. (2011). What needs to be done? Occupational therapy responsibilities and challenges regarding human rights. Australian Occupational Therapy Journal, 58(2), 60–66. https://doi.org/10.1111/j.1440-1630.2011.00922
26.
GalheigoS. M. (2018). Concepts and assumptions of a critical perspective in occupational therapy. Paper presentation. WFOT Congress, Cape Town, South Africa.
27.
GallagherM. B.PettigrewJ.MuldoonO. (2015). Occupational choice of youth in a disadvantaged community. British Journal of Occupational Therapy, 78(10), 622–629. https://doi.org/10.1177/0308022615583065
28.
GalvaanR. (2015). The contextually situated nature of occupational choice: Marginalised young adolescents’ experiences in South Africa. Journal of Occupational Science, 22(1), 39–53. https://doi.org/10.1080/14427591.2014.912124
29.
GamieldienF.van NiekerkL. (2017). Street vending in South Africa: An entrepreneurial occupation. South African Journal of Occupational Therapy, 47(1), 24–29. https://doi.org/10.17159/2310-3833/2017/vol47n1a5
30.
GaryK. W.NichollsE.ShamburgerA.StevensL. F.Arango-LasprillaJ. C. (2011). Do racial and ethnic minority patients fare worse after spinal cord injury? A critical review of the literature. NeuroRehabilitation, 29(3), 275–293. https://doi.org/10.323/NRE-2011-0704
31.
GerlachA.BrowneA.SutoM. (2014). A critical reframing of play in relation to Indigenous children in Canada. Journal of Occupational Science, 21(3), 243–258. https://doi.org/10.1080/14427591.2014.908818
32.
GerlachA. J. (2015). Sharpening our critical edge: Occupational therapy in the context of marginalized populations. Canadian Journal of Occupational Therapy, 82(4), 245–253. https://doi.org/10.1177/0008417415571730
33.
GibsonC. (2020). When the river runs dry: Leadership, decolonisation and healing in occupational therapy. New Zealand Journal of Occupational Therapy, 67(1), 11–20.
34.
GoldenbergM. J. (2006). On evidence and evidence-based medicine: Lessons from the philosophy of science. Social Science and Medicine, 62(11), 2621–2632.
35.
GonçalvesM. V.MalfitanoA. P. S. (2020). Brazilian youth experiencing poverty: Everyday life in the favela. Journal of Occupational Science, 27(3), 311–326. https://doi.org/10.1080/14427591.2020.1757495
36.
GretschelP.GalvaanR. (2017). Using a client-centred approach in occupational therapy. In DsouzaS. A.GalvaanR.RamugondoE. L. (Eds.), Concepts in occupational therapy. Understanding southern perspectives (pp. 237–247). Manipal University Press.
37.
GroceN.KettM.LangR.TraniJ.-F. (2011). Disability and poverty: The need for a more nuanced understanding of implications for development policy and practice. Third World Quarterly, 32(8), 1493–1513. https://doi.org/10.1080/14427591.2012.659169
38.
HammellK. W. (2004). Dimensions of meaning in the occupations of daily life. Canadian Journal of Occupational Therapy, 71(5), 296–305. https://doi.org/10.1177/000841740407100509
39.
HammellK. W. (2008). Reflections on…well-being and occupational rights. Canadian Journal of Occupational Therapy, 75(1), 61–64. https://doi.org/10.2182/cjot.07.007
40.
HammellK. W. (2009a). Sacred texts: A sceptical exploration of the assumptions underpinning theories of occupation. Canadian Journal of Occupational Therapy, 76(1), 6–13. https://doi.org/10.1177/000841740907600105
41.
HammellK. W. (2009b). Self-care, productivity and leisure, or dimensions of occupational experience? Rethinking occupational “categories”. Canadian Journal of Occupational Therapy, 76(2), 107–114. https://doi.org/10.1177/000841740907600208
42.
HammellK. W. (2011). Resisting theoretical imperialism in the disciplines of occupational science and occupational therapy. British Journal of Occupational Therapy, 74(1), 27–33. https://doi.org/10.4276/03080221X12947686093602
43.
HammellK. W. (2015). Respecting global wisdom: Enhancing the cultural relevance of occupational therapy's theoretical base. British Journal of Occupational Therapy, 78(11), 718–721. https://doi.org/10.1177/0308022614564170
44.
HammellK. W. (2019). Building globally relevant occupational therapy from the strength of our diversity. World Federation of Occupational Therapists’ Bulletin, 75(1), 13–26. https://doi.org/10.1080/14473828.2018.1529480
45.
HammellK. W. (2020a). Engagement in living: Critical perspectives on occupation, rights and wellbeing. CAOT Publications ACE.
46.
HammellK. W. (2020b). Making choices from the choices we have: The contextual—embeddedness of occupational choice. Canadian Journal of Occupational Therapy, 87(5), 400–411. https://doi.org/10.1177/0008417420965741
47.
HammellK. W. (2020c). Action on the social determinants of health: Advancing occupational equity and occupational rights. Cadernos Brasileiros de Terapia Ocupacional, 28, https://doi.org/10.4322/2526-8910.ctoARF2052
48.
HammellK. W.IwamaM. K. (2012). Well-being and occupational rights: An imperative for critical occupational therapy. Scandinavian Journal of Occupational Therapy, 19(5), 385–394. https://doi.org/10.3109/11038128.2011.611821
HooperM. W.NápolesA. M.Pérez-StableE. J. (2020). COVID-19 and racial/ethnic disparities. JAMA, 323(24), 2466–2467. https://doi.org/10.1001/jama.2020.8598
51.
IngvarssonL.EgilsonS. T.SkapdottirU. D. (2016). “I want a normal life like everyone else”: Daily life of asylum seekers in Iceland. Scandinavian Journal of Occupational Therapy, 23(6), 416–424. https://doi.org/10.3109/11038128.2016.1144787
52.
IwamaM. (2003). Toward culturally relevant epistemologies in occupational therapy. American Journal of Occupational Therapy, 57(5), 582–588.
53.
IwamaM. (2007). Embracing diversity: Explaining the cultural dimensions of our occupational therapeutic selves. New Zealand Journal of Occupational Therapy, 54(2), 18–25.
54.
IwamaM. K. (2006). The Kawa model: Culturally relevant occupational therapy. Churchill Livingstone Elsevier.
55.
JonesR.CrowshoeL.ReidP.CalamB.CurtisE.GreenM.EwenS., … (2019). Educating for Indigenous health equity: An international consensus statement. Academic Medicine, 94(4), 512–519. https://doi.org/10.1097/ACM.0000000000002476
56.
JoubertR. (2010). Exploring the history of occupational therapy's development in South Africa to reveal the flaws in our knowledge base. South African Journal of Occupational Therapy, 40(3), 21–26.
57.
JullJ. E.GilesA. R. (2012). Health equity, aboriginal peoples and occupational therapy. Canadian Journal of Occupational Therapy, 79(2), 70–76. https://doi.org/10.2182/cjot.2012.79.2.2
58.
KinchloeJ. L.McLarenP. (2005). Rethinking critical theory and qualitative research. In DenzinN. K.LincolnY. S. (Eds.), The sage handbook of qualitative research (3rd edition, pp. 303–342). Thousand Oaks, CA: Sage.
KinébanianA.StomphM. (1992). Cross-cultural occupational therapy: A critical reflection. American Journal of Occupational Therapy, 46(8), 751–757.
61.
KirbyT. (2020). Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities. Lancet: Respiratory Medicine, 8(6), 547–548. https://doi.org/10.1016/S2213-2600(20)30228-9
62.
KriegerN. (2012). Methods for the scientific study of discrimination and health: An ecosocial approach. American Journal of Public Health, 102(5), 936–945. https://doi.org/10.2105/AJPH.2011.300544
63.
LevackW.ThorntonK. (2017). Opportunities for a meaningful life for working-aged adults with neurological conditions living in residential aged care facilities: A review of qualitative research. British Journal of Occupational Therapy, 80(10), 608–619. https://doi.org/10.1177/0308022617722736
64.
LimK. H.DuqueR. L. (2011). The challenge for occupational therapy in Asia; becoming an inclusive, relevant, and progressive profession. In KronenbergF.PollardN.SakellariouD. (Eds.), Occupational therapies without borders. Volume 2. Towards an ecology of occupation-based practices (pp. 103–112). Churchill Livingstone Elsevier.
65.
LondonL. (2008). Human rights: A professional responsibility and an institutional obligation. South African Journal of Occupational Therapy, 38(1), 1.
66.
LukachkoA.HatzenbuehlerM. L.KeyesK. M. (2014). Structural racism and myocardial infarction in the United States. Social Science and Medicine, 103, 42–50. https://doi.org/10.1016/j.socscimed.2013.07.021
67.
MarmotM. (2004). The status syndrome. London: Bloomsbury.
68.
MarmotM. (2015). The health gap. The challenge of an unequal world. London: Bloomsbury.
69.
MarmotM. G.BellR. G. (2011). Improving health. Social determinants and personal choice. American Journal of Preventive Medicine, 40, S73–S77. https://doi.org/10.1016/j.amepre.2010.10.010
70.
MarmotM.FrielS.BellR.HouwelingT. A. J.TaylorS., on behalf of the Commission on Social Determinants of Health. (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet (London, England), 372, 1661–1669. doi:10.1080/14427591.2012.659169
71.
MarmotM.AllenJ.BellR.BloomerE.GoldblattP.on behalf of The Consortium for the European Review of Social Determinants of Health and the Health Divide. (2012). WHO European review of social determinants of health and the health divide. Lancet (London, England), 380(9846), 1011–1029. https://doi.org/10.1016/S0140-6736(12)61228-8
72.
MartínI. Z.MartosJ. A. F.MillaresP. M.BjörklundA. (2015). Occupational therapy culture seen through the multifocal lens of fieldwork in diverse rural areas. Scandinavian Journal of Occupational Therapy, 22(2), 82–94.
73.
MasudaJ. R.PolandB.BaxterJ. (2010). Reaching for environmental health justice: Canadian experiences for a comprehensive research, policy and advocacy agenda in health promotion. Health Promotion International, 25(4), 453–463. https://doi.org/10.1093/heapro/daq041
74.
McCollM. A. (2021). What can occupational therapy & disability studies contribute to one another?Canadian Journal of Occupational Therapy, 88(1), 4–11. https://doi.org/10.1177/0008417211003473
75.
McNeillH. N. (2017). Māori and the natural environment from an occupational justice perspective. Journal of Occupational Science, 24(1), 19–28. https://doi.org/10.1080/14427591.2016.1245158
76.
MetzlJ. M.HansenH. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133. https://doi.org/10.1016/j.socscimed.2013.06.032
77.
MurthiK.HammellK. W. (2021). “Choice” in occupational therapy theory: A critique from the situation of patriarchy in India. Scandinavian Journal of Occupational Therapy, 28(1), 1–12. https://doi.org/10.1080/11038128.2020.1769182
78.
NelsonA. (2007). Seeing white: A critical exploration of occupational therapy with Indigenous Australian people. Occupational Therapy International, 14(4), 237–255. https://doi.org/10.1002/oti.236
79.
NelsonA. (2009). Learning from the past, looking to the future: Exploring our place with Indigenous Australians. Australian Occupational Therapy Journal, 56(2), 97–102. https://doi.org/10.1111/j.1440-1630.2009.00781
80.
NixonS. A. (2019). The coin model of privilege and critical allyship: Implications for health. BMC Public Health, 19, 1637. https://doi.org/10.1186/s12889-019-7884-9
81.
NjelesaniJ.TeachmanG.DurocherE.HamdaniY.PhelanS. K. (2015). Thinking critically about client-centred practice and occupational possibilities across the life-span. Scandinavian Journal of Occupational Therapy, 22, 252–259. https://doi.org/10.3109/11038128.2015.1049550
82.
OkashaS. (2002). Philosophy of science: A very short introduction. Oxford: Oxford University Press.
83.
OliverM. (1996). Understanding disability: From theory to practice. Basingstoke, UK: Macmillan.
84.
OttersenO. P.DasguptaJ.BloiunC.BussP.ChongsuvivatwongV.FrenkJ., … (2014). The Lancet-University of Oslo Commission on Global governance for Health. The political origins of health inequity: Prospects for change. Lancet (London, England), 383, 630–667. https://doi.org/10.1016/S0140-6736(13)62407-1
85.
OwensL. (2017). Our professional existence is political: Critical reflections on ‘seeing white’ in occupational therapy. In SakellariouD.PollardN. (Eds.), Occupational therapies without borders, 2nd edn. Integrating justice with practice (pp. 194–202). Elsevier.
86.
ParadiesY.BenJ.DensonN.EliasA.PriestN.PieterseA., … (2015). Racism as a determinant of health: A systematic review and meta-analysis. PLoS ONE, 10(9), e0138511. https://doi.org/10.1371/journal.pone.0138511
87.
PihamaL. (2019). Colonization and the importation of ideologies of race, gender, and class in Aotearoa. In McKinleyE. A.SmithL. T. (Eds.), Handbook of Indigenous education (pp. 1–20). Springer Nature.
88.
PitonyakJ. S.MrozT. M.FogelbergD. (2015). Expanding client-centred thinking to include social determinants: A practical scenario based on the occupation of breastfeeding. Scandinavian Journal of Occupational Therapy, 22(4), 277–282. https://doi.org/10.3109/11038128.2015.1020865
89.
PurserR. E. (2019). McMindfulness. How mindfulness became the new capitalist spirituality. Repeater.
90.
QuesadaJ.HartL. K.BourgoisP. (2011). Structural vulnerability and health: Latino migrant laborers in the United States. Medical Anthropology, 30(4), 339–362. https://doi.org/10.1080/01459740.2011.576725
91.
ReadingC. (2018). Structural determinants of Aboriginal peoples’ health. In GreenwoodM.de LeeuwS.LindsayN. M. (Eds.), Determinants of Indigenous Peoples’ health; beyond the social (2nd edn, pp. 3–17). Canadian Scholars.
92.
RestallG.GerlachA.ValavaaraK.PhenixA. (2016). The Truth and Reconciliation Commission's Calls to Action: How will occupational therapists respond?Canadian Journal of Occupational Therapy, 83(5), 264–268. https://doi.org/10.1177/0008417416678850
93.
RobertsD. E. (2019). Foreword: The promise of structural competency. In HansenH.MetzlJ. M. (Eds.), Structural competency in mental health and medicine: A case-based approach to treating the social determinants of health (pp. v–viii). New York, NY: Springer.
RudmanD. L. (2013). Enacting the critical potential of occupational science: Problematizing the “individualizing of occupation”. Journal of Occupational Science, 20(4), 298–313. https://doi.org/10.1080/14427591.2013.803434
96.
SherryK. (2010). Culture and cultural competence for occupational therapists. In AlersV.CrouchR. (Eds.), Occupational therapy: An African perspective (pp. 60–77). Johannesberg, RSA: Sarah Shorten.
97.
StienstraD. (2012). About Canada disability rights. Halifax, NS: Fernwood.
98.
SutherlandA. (1981). Disabled we stand. London: Souvenir.
99.
TeghtsoonianK. (2009). Depression and mental health in neoliberal times: A critical analysis of policy and discourse. Social Science and Medicine, 69, 28–35. https://doi.org/10.1016/j.socscimed.2009.03.037
100.
TervalonM.Murray-GarciaJ. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117–125.
101.
ThoitsP. A. (2010). Stress and health: Major findings and policy implications. Journal of Health and Social Behavior, 51(1), S41–S53. https://doi.org/10.1177/0022146510383499
102.
TownsendE. A.PolatajkoH. (2013). Enabling occupation II: Advancing an occupational therapy vision for health, well-being & justice through occupation (2nd edn). Ottawa, ONT: CAOT Publications ACE.
103.
van DornA.CooneyR. E.SabinM. L. (2020). COVID-19 exacerbating inequalities in the US. Lancet (London, England), 395(10232), 1243–1244.
104.
Viruell-FuentesE. A.MirandaP. Y.AbdulrahimS. (2012). More than culture: Structural racism, intersectionality theory, and immigrant health. Social Science and Medicine, 75(12), 2099–2106. https://doi.org/10.1016/socscimed.2011.12.037
105.
WilkinsonR. G.MarmotM. (2006). Social determinants of health: The solid facts. Copenhagen, Denmark: World Health Organization Regional Office for Europe.
106.
World Federation of Occupational Therapists (2014). Position Statement: Human displacement (revised). Retrieved from www.wfot.org.
107.
World Federation of Occupational Therapists (2016). Minimal standards for the education of occupational therapists. (revised). Retrieved from www.wfot.org.
108.
World Federation of Occupational Therapists (2019). Position Statement: Occupational therapy and human rights (revised). Retrieved from www.wfot.org.
109.
World Health Organization (2018). The social determinants of health. Retrieved March 17, 2108, from www.who.int/social_determinants/sdh_definition/en.
YazdaniF. (2017). Owning occupational therapy theories and concepts: Wearing your own coat!. In SakellariouD.PollardN. (Eds.), Occupational therapies without borders. Integrating justice with practice (2nd edition, pp. 95–101). Edinburgh: Elsevier.
