Exploring Canadian Occupational Therapists’ Perceptions on Health Disparities: An Interpretative Descriptive Study

Data Generation Tools

Data were generated using semistructured virtual interviews to allow participants to provide in-depth descriptions of their experiences, in a safe and private environment of their choosing (Morse, 2008). Field notes and analytic memos from the research team were used to support data analysis (Saldana, 2020).

Data Generation Procedures

Participants interested in this study were emailed by or emailed the lead researcher (RD) and completed written consent (Morse, 2008). After completing written consent and prior to the interview, participants completed a brief demographic questionnaire. The demographic questionnaire asked about age, sex, gender, sexual orientation, race, ethnicity, presence of disability, language spoken, years of clinical experience, province of residence, and clinical setting practiced. The purpose of the demographic questionnaire was to contextualize the findings of the study, as experiences with health disparities may be influenced by demographic characteristics (e.g., gender). Additionally, experiences with health disparities and equity-oriented care may be influenced by participants’ social and professional characteristics (e.g., gender, years in practice, setting). Including this information supports a richer interpretation of the data and enhances transparency regarding the composition of the sample. A semistructured interview guide was used to support the interview (see Appendix B for example). Memos were taken during and after each interview by the first author. All interviews were audio recorded through Zoom (Zoom, 2024) and lasted approximately one hour. Participants did not receive any honorariums but were thanked for their time.

Theme 1: Health Equity is a Core Principle of Occupational Therapy

Participants described that trust, reflexivity, and respectful client-centered care were core components of occupational therapy. These components facilitated considerations of inclusivity and equity-centered principles in clinical practice, as noted by a participant:

“And I think the occupational therapy model is very much about getting to know your client as an individual. So, our model lends itself really well, in the first place, to really looking at that person as an individual” (P6).

Participants described that reflexivity, a skill reinforced in occupational therapy educational curriculum, is an essential component of practice and necessary to provide equity and client-centered care. Reflexivity, that is reflecting on one's actions and thoughts and their impacts on others, was reported to influence occupational therapists’ ability to provide equitable care by acknowledging assumptions that might impact access to care.

“It [reflexivity] makes me more aware that I'm probably missing a mark in a lot of things. And it makes me driven a lot more to kind of like, try really hard to be careful with my language, and be careful with what I have and what I don't know, trying to ask questions and seek support in those areas…I come from a very privileged background. There's no way that that does not influence how I practice” (P2).

Additionally, recent initiatives regarding cultural humility promoted by the Canadian Association of Occupational Therapists, further reinforces the importance of considering the impacts of personal biases on client interactions and outcomes:

“When we used to just talk about cultural competence, it might not have occurred to me to take that step, to sit down with them and learn from it. But that whole concept of cultural humility, I knew that I needed to acknowledge my lack of knowledge. I've missed something. Bottom line whatever way you slice it and dice it, I missed something” (P6).

Participants also believed that the context in which occupational therapists practice requires a more personal understanding of clients’ values to establish rapport and achieve positive health outcomes. For example, occupational therapists must spend time understanding clients’ unique goals, everyday tasks, home environment, support system, and occupation; all of which provide an in-depth understanding of how individual values and circumstances impact healthcare. They opined that this client-centered approach helps occupational therapists consider equity-centered principles in practice, in a manner that other types of healthcare professionals might not have the time or resources to consider. To illustrate, one participant noted that occupational therapists require more trust when working intimately with people's personal lives and values:

“If you're going in people's homes or having to work with them in their communities, you need… trust like even to open the door…but I think occupational therapy is probably a little bit more (needs more trust)-like relative to maybe other professions” (P5).

Overall, there are fundamental components of occupational therapy which inherently support equity-centered principles.

Theme 2: Systemic Barriers are Central to the Occupational Therapy Process and Can Affect the Delivery and Access of Equity-Centric Care

While participants believed that the profession of occupational therapy is aligned with equity-centered principles, they acknowledged that there are systemic factors affecting both the delivery and accessibility of occupational therapy services. These external barriers not only complicate the delivery of care but also deepen existing inequities by limiting access to culturally sensitive resources and appropriate communication, making it more difficult to engage clients from marginalized groups in meaningful and effective treatment, as highlighted by this participant:

“Yeah, I sometimes feel that what we do is in practice it's almost easier to overcome…But it's the larger systemic ones where it's kind of…even if you, as an individual, want to do something differently…some of these barriers make it harder to” (P4).

Participants also noted that validated outcomes currently used in practice have lacked cultural sensitivity and often do not for cultural nuances in client behavior, communication, and needs. This could lead to potential misinterpretations of a client's abilities and challenges and can result in suboptimal treatment outcomes. To illustrate, one participant recalled an experience using a standardized assessment, which led to the client feeling uncomfortable:

“He was taught, you never say no to people, and a perceived position of power which I was as a healthcare professional, a white person…I thought I, there was nowhere in our standards of practice, or anything that you know, you can get down to that kind of level of detail… We need all our standardized assessments to get re-standardized” (P6).

In this example, the occupational therapists recognized how their position of power and use of standardized assessments can impact people of various cultures. Participants also described language discordance as one of the biggest challenges toward providing equity-centered care, as it hindered clinician client rapport. Language discordance not only hinders communication but also impacts the therapeutic alliance, trust, and the ability to gather critical client information. While language accessibility tools and family support are useful, these solutions may not always be available, leaving many clients at a disadvantage in their care. Overall, participants described that external factors affecting the delivery and access of care were more likely to impact those who do not speak the dominant language, newcomers, living in rural communities, have mobility challenges, and are unhoused. In these instances, occupational therapists described that providing clients with educational materials and having personal conversations was an important component to addressing health disparities but also noted the importance of addressing issues at a larger systemic level.  

Theme 3: Occupational Therapists as Advocates Against Health Disparities

Participants described that part of their roles was advocating for the needs of their clients within the respective systems that they operate. Occupational therapists working within the insurance sectors described specific challenges when providing care for clients involved in a workplace or motor vehicle accident including: (1) building rapport with clients who had developed a sense of mistrust of healthcare and insurance systems, (2) providing care within the time and funding constraints of insurance coverage, and (3) needing to advocate on behalf of their clients who may be unable or unempowered to advocate for their needs:

“Yeah, like, our practice doesn't change too much. But… what our clients have access to is, it's unfortunately dependent on what the insurer is agreeing to pay” (P3).

Occupational therapists described that advocating for extended insurance coverage can help mitigate funding constraints, ensuring that marginalized populations receive the care they need without facing financial barriers. Next, occupational therapists working within public and community funding systems also experienced challenges with funding, limiting their time and resources to address long waitlists of clients in need of services. As an example, one occupational therapist providing supports for Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ+) individuals in rural Alberta stated that their clientele had difficulty accessing support due to the political climate and clients fear of being open with their identity:

“LGBTQ2 + clientele, a lot of people seeking assistance with transitioning. Which is not very well accepted in this part of the country. So not a lot of resources in our city here. So that was one group that I think benefited quite a bit from having access to free OT services” (P8).

Lastly, occupational therapists working within hierarchies in larger clinical systems described difficulty explaining the importance of considering health disparities to other clinicians:

“Yeah, like, psychologists are on the mental health like hierarchy. They always will override you…. All I can say is just like advocate for the client the best I can” (P9).

It is imperative to acknowledge that participants also described instances of advocating for their clients to other occupational therapists, demonstrating that while the profession is making progress there is still work to be done:

“Some of the occupational therapists, my colleagues and people I've worked with the least understanding of anybody regarding disabilities” (P7).

Participants also described the importance of working as advocates to increase awareness of occupational therapy and the differences in perceptions of occupational therapy across communities. Participants described that the current lack of awareness of occupational therapy directly impacting clients’ access to care and ability to navigate the Canadian healthcare system:

“We're still not well known across the community at large…So I know friends who work in PAEDS, they will say, they will often not get timely referrals, you know, from families, because they think, Oh, this is just a problem we have to deal with not thinking, oh, this is a problem that could be dealt with as a health issue or can be, you know, they could receive services, right” (P1).

One participant also described educating their colleagues on the value of occupational therapy, which ultimately led to an increase in the number of occupational therapists working in that clinic over time. In addition to the issue of lack of awareness, individuals might have a general distrust of the healthcare system and therefore may be hesitant to seek supports:

“One thing I've noticed going into work with Indigenous clients is that it is very difficult to gain trust as someone like me. Who's, you know, like white, middle-aged person? There is a level of suspicion there, and that completely justified suspicion. So, it's more about meeting people where they're at and not trying to force anything on them” (P8).

Mistrust with the healthcare system may occur due to clients being continuously ignored or overlooked by healthcare professionals, risk of privacy breaches, or not being comfortable expressing vulnerability to healthcare professionals that may not understand their situation. Further, some cultures might have a stigma associated with accessing care, particularly pertaining to mental health or dementia care. Last, while some individuals view the client-centered and function focused perspective of occupational therapy as an asset, this is a deviation from the traditional medical model that might create some hesitancy in individuals who are familiar and comfortable with that perspective:

“In general, most people don't know what we are and what we do and what our purposes are. But I think, I've found people of like some backgrounds kind of feeling like it's not very, it's not productive. It's not like it's not that medical model, or it's not valid. It's a little bit too kind of out there and holistic kind of doesn't seem like it” (P2).

The lack of awareness about the scope and benefits of occupational therapy often leads to delayed referrals or a failure to consider occupational therapy as part of a comprehensive treatment plan. This not only affects access to care but also perpetuates health disparities by limiting opportunities for early intervention and preventive care. Overall, participants viewed lifelong education and advocacy as vital to addressing health disparities in occupational therapy.

Theme 4: Health Disparities Must be Considered When Hiring and Retaining Occupational Therapists in Practice

Along with challenges that clients might face, participants remarked that occupational therapists also need opportunities to have safe spaces and be protected. While many participants described the important role they played in advocating for their clients, some occupational therapists stated that they often experienced backlash:

“And also, when I had to address with the PSW (personal support worker), who was making all sorts of comments in the nursing station one day that were inappropriate. Then I heard later that she told someone else that she just wanted to…she wanted to slap me” (P8).

Participants also described having difficulty navigating and providing care when they were experiencing discrimination from their clients:

“Of course I'm in a position of power over the clients, right? But there's a really strange grey area when you have like microaggressions” (P9).

Some participants thought that it would be helpful to have a safe space to deal with some of these concerns. Examples of possible safe spaces include mentorship, peer groups, mental health resources, online chat groups, or continuing education courses illustrating disparities occupational therapists might experience while working. Participants also believed that increasing diversity in occupational therapists was important for both the profession and clients:

“You know I'm not white, which is like something that can really help with some of the, you know, like that rapport building for-for people who have been, you know, who have been terribly marginalized, terribly sort of discriminated against for and-and race is absolutely like a predictor as well for-for some of these outcomes” (P10).

Participants described the need for supports at an individual practice level. They stated that for equity-centered principles to be fully implemented, there needs to be systemic changes at the leadership level. For example, participants stated that courses on health disparities should either be mandated or occupational therapists should be given protected time to learn it to help reinforce its importance to the profession. Next, participants believed that there was a need to increase accessibility and inclusivity at the professional training level, potentially including equitable admission practice or retention supports (e.g., financial supports). This was described to be especially needed in western provinces, in which there is a shortage of occupational therapy programs. Last, some participants described the difficulty of internationally trained occupational therapists to practice in Canada or receive access to resources about health disparities within the Canadian context. To summarize, supports for occupational therapy at the direct clinical level and within larger systems were described as important to participants in this study.