Abstract
Introduction
We write in in Kjipuktuk (Halifax area) in Mi’kma’ki, the unceded territory of the Mi’kmaw on the East coast of what is now known as Canada. We first presented on the ideas contained in this paper in May 2025 at the annual conference of the Canadian Association of Occupational Therapists in amiskwacîwâskahikan (Edmonton, Alberta) in Treaty 6 Territory, home of the Nehiyaw (Cree), Niitsitapi (Blackfoot), the Métis, Denesuliné (Dene), Nakota Sioux (Stoney), and Anishinaabe (Saulteaux). We write from a sense of urgency, an awareness that social inequities, oppressions of multiple types, are increasing with frightening speed. We write to urge occupational therapists across Canada to find ways to enact those core professional competencies that require all of us to engage in anti-oppressive practice.
The 2021 professional competencies for occupational therapists in Canada (ACOTRO, ACOTUP & CAOT, 2021)—particularly in section C—require therapists to promote equity, work to reduce power inequities, challenge social structures that privilege or marginalize, and engage in anti-oppressive practice (defined in the Glossary as “taking action to challenge oppression and discrimination” [p. 19]). Anti-oppressive practice asks all of us to not only examine how we may be reproducing oppression and privilege within workplaces and therapeutic spaces, but also work to transform harmful social conditions “out there” in the real world (Kirsh, 2015; Picotin et al., 2021). Competency C1.3 for example, asks us to, “Challenge biases and social structures that privilege or marginalize people and communities” (ACOTRO, ACOTUP & CAOT, 2021). Oppression is, by definition, systemic, involving social structures such as such as media, education, legal systems, housing, health care, and the economy (Pooley & Beagan, 2021). It pertains to social groups rather than individuals, reaching beyond instances of harm or grievance to imbalanced power relations at a societal level.
Thus, the work of anti-oppression addresses systems, not just individuals. It seeks to dismantle power imbalances, not simply help clients who face social harms to survive or “build resilience.” Anti-oppression demands that we work to create change, not just in our workplaces, but in the social world around us. It demands not just analysis and critique, but also strategies to change power relations that sustain inequities (Emery-Whittington, 2021) including colonialism, racism, classism, ableism, saneism, and cis-hetero-sexism. It usually means working with others, not on our own, and ideally with members of groups experiencing oppression.
Advocacy has long been accepted as a component of competent practice in many of the health professions (e.g., Townsend & Polatajko, 2007) but in Canada activism has typically been seen as violating professionalism (Beagan et al., 2024). Professionals like occupational therapists are exhorted to remain politically “neutral” or risk losing patient/client trust, and more broadly public trust and professional reputation (see Alterio, 2025; DeIuliis, 2017; Lefkowitz et al., 2025; Hubinette et al., 2024). In this paper, we examine the distinctions and common ground between the terms advocacy and activism, while also introducing a third term: agitating. We explore how these three approaches contribute to justice-oriented change-making, linking them to the essential competencies of occupational therapy. We interrogate the ways in which activism can be understood as a valuable component of professionalism, rather than violating it. We invite readers to consider different change-making approaches to some scenarios relevant to occupational therapy. Finally, we end with an invitation to collectively theorize how justice-oriented change happens.
Who Are We in This Work?
We have among us about 70 years of activism, in social justice struggles including anti-racism (particularly anti-Black racism and anti-Indigenous racism); Indigenous rights and sovereignty; anti-poverty; disability rights; 2SLGBTQ + rights; feminism and reproductive rights; anti-violence; as well as peace movements. Some of us identify as Indigenous, some as African Nova Scotian, and some as white settlers. Some of us identify as 2SLGBTQ+, and some as having working class family backgrounds.
We have organized and attended protests and demonstrations. We have engaged in direct action, and community-based education. We have organized conferences and disrupted conferences that needed disrupting. We have established peer support networks, community groups and non-profits. We have done social justice work through artistic creation, research and writing, policy analysis, and pitching proposals to governments. In hallways, staffrooms and numerous other places, we have had difficult conversations with colleagues, bosses, patients/clients, students, teachers, and administrators. We have drafted terms of reference, and solidarity commitments. We have all been in settings that seemed to feel so neutral to everyone else, yet so loaded to us. All of us have had the experience—countless times—of being the only one to speak up about something, of hearing the silence that fell in response, of having our words ignored or dismissed. We have had to learn when and how to express anger, and when that is not strategic. All of us have had the soul-destroying experience of trying to make change in isolation, and known the joy of working with like-minded, like-hearted others to make change. It is from these perspectives we write, intending to share experiences, ideas, and reflections, rather than prescribe singular approaches.
Advocacy, Activism, and Agitating
Advocacy is generally understood as supporting a cause, working on behalf of some person, group, or cause (Parsons, 2016; Ryan et al., 2020). It typically involves working within existing systems, existing frameworks, attempting to persuade others, especially key decision-makers (Flavell, 2023). Advocates employ dialogue, lobbying, educating, and amplifying the voices of others to influence policy and changes in practice. Models of advocacy emphasize building consensus around directions, focusing efforts with specific decision-makers, presenting the case and monitoring change (e.g., Smart Advocacy, 2023). Advocacy is typically more reactive, motivated by individual cases or concerns. It is important to note, however, that access to decision-makers may not always equate to influence over those decision-makers (Canadian Friends Service Committee [CFSC, 2023], p. 20).
Activism is typically more proactive, working to effect broader social/political change. It usually involves working with others, not individually, ideally members of the groups experiencing oppression. Activists employ direct action and public displays of dissent, deliberately seeking to draw public attention to bring something to visibility or shift public perceptions (Flavell, 2023; Parsons, 2016; Ryan et al., 2020). Activism is not accidentally disruptive, it deliberately disrupts the status quo as a change-making strategy. Activism need not seek to overthrow a government; it can be big actions, but also small actions.
Activists are often grassroots community members, working outside existing systems. Their goals extend beyond ameliorative action to transformative system/structure change. Strategies may include protests, sit-ins, demonstrations and rallies, but may also be highly creative, such as street theater (e.g., Lakey, 2024). For example, in 1970 abortion rights activists chained themselves to the seats in the House of Commons in Ottawa; when they began disrupting formal debate, security staff were unable to remove them and had to shut everything down (Sethna & Hewitt, 2009). The AIDS Coalition to Unleash Power staged “die ins” all over Canada and the US, demanding medical research and access to treatment for people with HIV/AIDS (Brown, 1997; Schulman, 2021). Indigenous Peoples have successfully used blockades of bridges and roads to alter planned development and resource extraction (Obomsawin, 1993; Kwetasel'wet Wood, 2023). In Kjipuktuk (Halifax) in the 1980s, a group of single mothers (Mothers United for Metro Shelter) advocated for 2 years for better income assistance rates, and more affordable housing. Finally, they erected a very prominent “tent city.” They also invaded the provincial legislature: We went to the legislature, and we formally gave the MLAs their eviction notice. Then we started measuring the Legislature windows for curtains. We brought our kids with us, and these kids were running around everywhere. It was great! The police were called and they brought the paddy wagon, but they weren’t going to arrest a bunch of mothers with strollers. (Devet, 2017)
We would add “agitating” to the range of change-making approaches. We think of an agitator as someone who stirs things up, who keeps raising the unpopular perspective, who keeps an issue front and center, despite discomfort (Mitra, 2021). An agitator invites others to think differently about something, raises consciousness and critical thinking. Agitators strive to articulate concerns in ways that create common purpose, though they may not always have a clear direction for change. For example, the Occupy movement, a non-violent movement that swept around the globe in 2011, drew attention to the massive economic injustices that accompany capitalism, and advanced participatory democracy, but did not have consistent goals for change. Agitating can be a key role in professional settings like occupational therapy: sometimes an agitator can get things on the agenda. The agitator is the person who asks that something go in the meeting minutes, so it does not disappear. The agitator raises the hard questions, sometimes repeatedly. The agitator may not have solutions, but too often change-makers get shut down by those who say, “Don’t complain if you don’t have a solution.” Complaining about injustices is agitating, stirring things up, raising consciousness.
Advocacy, activism, and agitation intertwine in justice-oriented change-making. Sometimes different people take up different strategies, sometimes the same people employ different strategies in different contexts. The “radical flank” theory of social movements argues that the more extreme activism of one group may help more moderate advocates to make otherwise-impossible gains, as decision-makers see them as reasonable and open to negotiation (Freeman, 1975; Rowe & Carroll, 2014). Sometimes when agitating is unsuccessful it gives way to advocacy. Sometimes advocacy gives way to direct action and activism, when more pressure is needed. Sometimes activism has results, and activists can slide into advocacy roles, helping to shape policy and practices as a result of sought-after change. As conditions change, tactics may need to change—relentlessness is a helpful attribute. In any given situation, a key decision is whether to engage, disrupt or stir things up? (see Figure 1).
Advocacy, Activism, Agitating.
Activism in Occupational Therapy
The Canadian Model of Client-Centered Enablement (Townsend & Polatajko, 2007) calls on occupational therapists to be advocates: to raise critiques, to lobby and engage with key decision-makers, and to speak up on behalf of others. The 2012 Profile of Practice of Occupational Therapists in Canada stated that therapists should be “change agents,” “advocating on behalf of, and with clients, working toward positive change to improve programs, services, and society, within health and other systems” (Canadian Association of Occupational Therapists, 2012, p. 3). The closest it came to activism was, “Advocate appropriately for the vulnerable or marginalized clients to enable participation through occupation” (p. 9), and “Advocate for needed changes related to the determinants of health, well-being, and equity for clients served, including organizations and populations” (p. 12). Though “advocate” was mentioned 14 times in the profile of practice, it was never mentioned in the essential competencies in use at that time (Canadian Association of Occupational Therapists, 2012, Appendix B). Activism was not even on the radar.
From a disability rights perspective, Georgia Vine notes, “As occupational therapists, we often say that as part of our role we advocate for our patients and clients, but do we act as activists?” (Vine, 2024). In her 2015 Muriel Driver lecture, Bonnie Kirsch makes an impassioned case for occupational therapists to engage in change-making at the level of systems and structures: If occupational justice and social inclusion are our goals, we must not only analyze and critique the social, institutional, economic, and political constraints that impede people's ability to participate fully in their communities; we must also take steps to dismantle them. (Kirsh, 2015, p. 216)
Nick Pollard and Sakellariou (2014) have also called for the development of a “political occupational therapy,” noting that “if the role of the occupational therapist is catalytic … there is potential for an occupation-based activism” (p. 645). They also warn that, “The idea of the clinical practitioner as an activist is controversial” (p. 646). Karen Whalley Hammell (2020) urges a politicized occupational therapy when she suggests that the appropriate focus of the profession is “action on the social determinants of health” (p. 392), specifying “poverty, class, caste and gender inequities, sexism, colonialism, racism, disablism, homophobia and transphobia, that are well-documented determinants of health, [and] are also determinants of occupational opportunity and engagement” (p. 390).
In their review of literature on political action in occupational therapy, Solángel García Ruiz and Malfitano (2024) found there is surprisingly little discourse, with most of it emerging from South America (Argentina, Chile, Colombia and Brazil). They urge therapists to “assume their political role within the practice, participating in social transformation processes … in the movements and struggles of society, in the construction of new social relationships” (p. 12). This requires historical and political analysis of the context of real people's lives, enabling the development of appropriate responses to people's needs. Social occupational therapy in Brazil takes up this direction as central to practice, based on a “a critical understanding of social issues, social inequalities that limit the participation and citizenship of vulnerable groups” (García Ruiz & Malfitano, 2024, p. 11). They also note that the “political dimensions of the profession” (p. 12) may be controversial; nonetheless, “it is necessary to break the limits of professional practices and seek coherence with the needs of the people and groups with whom one interacts” (García Ruiz & Malfitano, 2024, p. 10).
Mobilizing Power
Agitating, activism, and advocacy all rely on the mobilization of some form of power to engage in change-making. Battilana and Kimsey (2017) argue that people use whatever form of power they have available:
Personal, including charisma, effort, experience, passion, expertise, creativity Positional, connected to a job, organizational role, or general social regard Relational, through connections with others, influence on others
Gitxsan child welfare activist Cindy Blackstock argues for leveraging the power of being small, a distinct form of power she calls “mosquito advocacy.” The approach of the small four-person First Nations Child and Family Caring Society was effective because their efforts were “inspired by the following mosquito-like characteristics: 1) small and agile; 2) goal oriented; 3) infectious; 4) buzzing; 5) swarming; and 6) biting” (Blackstock, 2016, p. 219; or see https://www.youtube.com/watch?v=OAB-Phb-2Po). The mosquito, though tiny, is relentless and driven, able to slide through the smallest cracks in an edifice.
A General Approach to Justice-Oriented Change-Making
There are as many ways to approach activism as there are activists. Having reviewed literature inside and outside of academia regarding social justice and change-making, and after discussing our own experiences in activism, we would suggest activism typically involves these general processes, usually working with others:
See an inequity, an injustice Analyze the reasons for it Envision a desired future Believe the situation could be different Map (a) path(s) to get from here to there Take action in the direction of the change desired Assess how actions are working and circle back as needed
This is not intended as a linear set of steps to follow, but more as a retrospective analysis of patterns we have experienced. The process differs not only by what justice issue is being tackled, but also by who is engaged, where we enter into the process, and who we are working alongside. Seeing injustice and leaping directly to action can be tempting, but without strong analysis of the “how and why” of injustice—analysis that gets at roots of problems rather than symptoms—action may be misdirected. Without a vision for a different future and belief that it is possible, we may bog down in cynicism or angry flailing. Analysis of injustice plus a future vision enables us to map a direction—or series of directions—to increase the effectiveness of actions. At the same time analysis, even commitment, without action does not bring about change (see Wark, 2021).
We have mentioned power several times already. What do we mean by this? Power has often been understood as authority backed by the use or potential use of force, including violence or threat of violence. Yet power also operates in less obvious ways. It may operate through ideology, establishing the norms, beliefs, and values of dominant groups as the only acceptable ones, even the only imaginable ones. In these situations, power operates more through consent than force. Power may be structured into institutional positions, such as the power employers hold over employees; it may also be encoded into laws, policies, and institutional procedures. Economic power facilitates access to resources and services, but beyond this, symbolic forms of power establish the ways of being, doing, knowing, and thinking of dominant groups as superior to others, to be emulated. In contemporary Western societies governance may mean internalizing dominant perspectives, monitoring and disciplining ourselves and each other to ensure we meet prevailing expectations. Power even shapes (and is shaped by) whose truths become socially accepted as “real.” Resisting oppressive power requires understanding what kind of power is operating. As Wyatt and colleagues (2024) argue in the context of medical education, some power hierarchies are upheld through violence and punishment, others through obedience and conformity; they do not require the same forms of resistance (Two highly accessible starting places for power analysis are the books of Anne Bishop (2005, 2015) and the Powercube website (n.d.)).
Possible Roles in Change-Making
Not everyone doing justice-oriented change-making sees themselves yelling into a bullhorn in front of a crowd. And not everyone needs to! One of the delights of working collectively, working with others, is that each person brings their own strengths and inclinations. There are lots of ways to engage.
Four widely cited roles articulated by Bill Moyer (2001), and later revised slightly by George Lakey (2016), are the helper, advocate, organizer, and rebel. The
The
Ideally, all four roles co-exist in any justice-oriented change-making. They are mutually beneficial. They can, however, raise strong tensions within or between groups. Numerous on-line sites expand on those classic four roles in change-making (see Figure 2), allowing people to see where their particular gifts and abilities may contribute, drawing on their strengths, skills, and talents to enhance collective work. It also allows those on the frontlines of change-making to consider whether they need to engage in different roles for a while, to rest and restore.
Skills in technology, communications, and social media have become vital roles in justice-oriented change-making. For example, they have been essential to the #MeToo movement, and to Black Lives Matter. At the same time, there is a risk that social media creates more performative activism, where statements become stand-ins for action, and “likes” and followers supplant concrete actions for change. Parsons (2016) calls this “slacktivism,” supporting a cause at virtually no cost. He also, however, suggests it may be a “potential gateway to more substantive activism and advocacy” (p. 3).
But Isn’t Activism Unprofessional?
While advocacy is clearly accepted (expected) within occupational therapy, it is less clear whether activism is considered acceptable (Beagan et al., 2024). Professional regulators have been vague about whether protest and civil disobedience which might lead to arrest would be considered actionable violations. The College of Occupational Therapists of Nova Scotia (COTNS) gave a typical response to that question: Occupational therapists play a critical role in advocating for the needs of individuals and their communities… COTNS recognizes that responsible advocacy is a fundamental aspect of client-centred practice… Regulated professionals maintain their right to freedom of expression; however, this right is limited by their professional obligations. Occupational therapists have a duty to the public and to the profession to conduct themselves in a way that is consistent with professional standards and ethics. Failing to do so creates a risk of harm to the public by undermining trust in the profession… (COTNS Newsletter March 2024, emphasis added)
We question whether the notion of “duty to the profession” tends to trump the notion of duty to the public, or in fact engaging in the morally and ethically right thing to do. We question who is envisioned when invoking “the public.” Arguably, public trust in the profession is undermined when therapists do not engage in activism, failing to confront the social structures and conditions that create social injustices and hinder equitable occupational participation. Regulator vagueness about possible consequences is in direct tension with national professional competencies that require anti-oppressive practice and thus justice-oriented change-making.
In other fields, activism is also construed as dubious in relation to professionalism (Costa et al., 2021; Levins & Dunn, 2008; Parsons, 2016). Yet, in medicine, Tasha Wyatt et al. (2024) and colleagues argue that resistance to injustice—activism—can clearly be professional. They found that when medical residents risked resisting injustices they engaged in thoughtful, well-reasoned actions that considered power, costs and benefits, context and directions. They pondered what kind of power was being used, in order to choose the right form of resistance. They engaged in cost/benefit calculations, to determine who would bear costs, how serious those costs were, and who would reap the benefits. They carefully considered contextual power relations, including their own positions and the power held by others. And they debated directions and strategies for resistance, what to say/do, who to direct action toward, and how to say/do it best. Pondering when/whether/how to make a message more palatable to those in power is a highly strategic skill.
Such nuanced analysis of complex factors epitomizes critically reflexive and ethical decision-making, arguably an embodiment of ethical professional practice (Wyatt et al., 2024). If we think about professionalism as enacting respect, integrity, and responsibility (rather than checklists of behaviors), increasing public trust by thoughtfully challenging social inequities is entirely professional. Cindy Blackstock argues, “Moral courage is often punished and framed as insubordination, unpatriotic, blowing the whistle, or rocking the boat. Moral courage is the act of standing up for your values in risky situations” (2016, p. 224). Unwavering commitment to values is critical, she argues, to successful change-making. We invite readers to think (or talk) through the scenarios posed in Figure 3 to envision engaging in justice-oriented change-making, as people, as professionals, as occupational therapists.
Scenarios for Imagining Change-Making.
Making it Work! Tips for Change-Making
Earlier we noted that accurate analysis of injustice is critical, otherwise actions may take unhelpful directions. Equally important is how the message about the issue is constructed: it needs to resonate with others. In social movement scholarship, this is called “framing” (Gamson & Meyer, 1996). In a “diagnostic frame,” activists convey what is the problem, the injustice and its cause(s). A “prognostic frame” identifies desirable solutions, directions, or strategies. A “motivational frame” articulates a “call to arms” encouraging people to take action. Blackstock (2016) emphasizes the importance of finding a frame that people can easily support, making it “infectious,” motivating others to join in. She suggests drawing on widely shared, deeply held values and language. For example, the student resistance movement that eventually overthrew Serbian dictator Slobodan Milosevic emphasized a message of hope: “What we were focused on was whether people had a need for hope—and they did. They desperately wanted to hope” (Lakey, 2024). Within a year, the movement grew from a dozen people to tens of thousands.
Unwavering commitment to clearly articulated moral values is also critical. For the First Nations Child and Family Caring Society, this included peaceful non-violence, and avoiding personal gain/self-interest from movement work (Blackstock, 2016). Interestingly, the student movement in Serbia committed to the same moral principles (Lakey, 2024). They implemented rotating leadership to minimize personal political gain and held to non-violence even during widespread arrests and detentions. Non-violence proved powerful, as local police were forced to arrest peaceful demonstrators who expressed respect and empathy for the police: “Morale was in shatters… All of a sudden the police officers started calling in sick. They didn’t want to come to work” (Lakey, 2024).
Blackstock (2016) also advises activists to give clear guidance to those who wish to support the cause, identifying concrete actions that are specific, cost free, and meaningful. Dismantling capitalism is a tall order, guaranteed to immobilize most supporters! Petitioning a municipal counselor for higher income assistance rates might be a concrete, free way to engage. Simple, free support activities allow smaller groups to take advantage of “swarming” like mosquitoes, with roles for all.
Though individual activism can absolutely make a change happen (see e.g., Métis National Council, 2014), from our own experience, activism, agitating, and advocacy are always better when working with others. It's more effective, and more enjoyable—ultimately more sustainable. Join a group, create a group, even a small one. The comradeship of like-minded, like-hearted others is invaluable. Within groups, there will always be internal tensions, not least because rebels see advocates as “sell outs” and helpers see organizers as dismissive! Those tensions are inevitable, but they can also cause a group to implode or dissolve. Embracing and assuming a generosity of spirit can reduce internal policing and “cancel culture.” Establish clear processes to manage conflict in advance (CFSC, 2023; Lakey, 2024). Direct the energy saved outward, toward the group's goals.
The range of roles available to those who engage in justice-oriented change-making allow people to work to their own strengths and skills, feeding instead of draining energy. At the same time, there is room to grow; sometimes we feel compelled to step up, to do or say the thing that needs doing or saying, despite our own discomfort, uncertainty. Those are hard, but important moments: “Activism often involves forgiving yourself for your imperfections and inability to do more to heal the world, while also not shying away from taking meaningful action” (CFSC, 2023, p. 13). Sometimes even just speaking up in support of another person, being the second voice, can be a critical contribution, reducing isolation and exhaustion plus building connections.
Connections across different justice-movements are frequently spoken about as allyship, in which I may use my resources or privilege to support your cause. Existing power and resources do not get redistributed; I am helping you, I am altruistic (Levins Morales, 2019). In contrast, solidarity—a term long used among activists—focuses on connections and commonalities between your struggle and mine. We build ways to work together because the systems of oppression that affect us overlap, and because our histories of harms and resistance intersect (Building Movement Project, 2024; in occupational therapy, see García Ruiz & Malfitano, 2024; Restall, 2024). I support your work against ableism not because I am a generous person, but because I see the links to my work against poverty: colonial capitalism measures people's worth by individual productivity. Clarifying the basis of unity when working together—where struggles connect and where they do not—can avoid later disintegration.
What is Your Theory of Change?
Whether you stage a sit in, write a letter to a government official, ask the hard question (over and over again), craft a petition, or mount a piece of street theater, you are operating with a (often unarticulated) theory of change. A theory of change posits anticipated cause–effect relationships in an “If ___ then ___ because ___” format (Forrest & Legge, 2023). Unangax̂ scholar Eve Tuck (2022) urges everyone to converse about this: “Let us be curious enough about the world and the future to ask What is your theory of change these days?” She urges us to make this everyday conversation with friends, family, and strangers. Avoiding this dialogue leaves us assuming we are operating with the same theory of change. It may also leave us working with a theory of change that no longer fits the circumstances: “When I say that I want the discussion of our theories of change to be among the most mundane, regularly-occurring discussions across our many relations, it is so that we are not reliant on a broken theory of change.” The social and political world around us is changing quickly. Inequities are deepening, structures of power are intensifying. Theories of change help us to articulate—together with others—how we understand power to operate, where change might happen, what collective resources we share, and possible strategies for ethical action.
Conclusion
The national competencies for the occupational therapy profession require engagement in anti-oppressive practice. They require therapists to, “Challenge biases and social structures that privilege or marginalize people and communities” (ACOTRO, ACOTUP & CAOT, 2021). The moment is perhaps more urgent than it has been in many decades for all of us to be talking on a regular basis about injustices, how power structures uphold those, and how change might happen. Occupational therapy has long been committed to equity and justice; anti-oppressive practice asks us to take that commitment further, working to transform harmful social conditions in the world around us. Working with others, we can analyze causes of injustice, envision change, identify directions guided by ethical commitments, and then act. There are many roles we can take in justice-oriented change-making, and we can take up different ones in different situations. Advocacy, agitating and activism are ways to embody anti-oppressive practice. This work can even be fun!
Key Messages
With professional competencies requiring Canadian occupational therapists to promote anti-oppressive practice, strategies for making change need to move beyond advocacy to agitating and activism.
Numerous potential roles in the work of effecting social change enable individual therapists to identify approaches that fit for them and suit the circumstances.
Social change-making requires careful analysis, ethical decision-making, commitment to expressed values, understanding of multiple forms of power, a theory of change, and the moral courage to act.
Footnotes
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
