Abstract
The World Health Organization’s (WHO’s) new focus on rehabilitation offers great opportunities for occupational therapy. Recognizing that the problems in daily function created by the aging of the world’s population and the increasing prevalence of chronic health conditions require rehabilitation to be a vital part of health systems, the World Health Organization brought a variety of stakeholders together in 2017 and 2019 to help them develop the Rehabilitation 2030 initiative. Occupational therapy was represented by the World Federation of Occupational Therapists, the American Journal of Occupational Therapy, the Canadian Journal of Occupational Therapy, editorial board members of several occupational therapy journals, and other occupational therapy researchers. A major challenge to meeting the goal of sufficient rehabilitation services to meet global need is the worldwide shortage of occupational therapists. This shortage can be attributed to a paucity of knowledge about occupational therapy as a health care profession, lack of understanding of the occupational therapy scope of practice, the cost of education required to become an occupational therapist, and the need for occupational therapy salaries to offset educational costs. Nonetheless, ongoing success in research and clinical outcomes will increase knowledge of the value of occupational therapy and increase the size of the profession. WHO’s focus on function is to be lauded. Yet, occupational therapists must not be content with an emphasis on function. They also need to advocate for contextual changes that eliminate barriers to participation and engagement experienced by people with disability.
Lorie Gage Richards, PhD, OTR/L, FAOTA
Catherine Vallée, PhD, OT
We have entered an exciting era for occupational therapy! In 2017, the World Health Organization (WHO) launched its new initiative in rehabilitation, Rehabilitation 2030, by bringing together stakeholders from a large variety of areas to assist them in creating this vision. To build consensus, create a realistic action plan, and gain the commitment of various stakeholders, WHO organized two meetings (in 2017 and 2019). Health ministers, health profession educators and researchers, journal editors, nonprofit organization staff, program and research funders, and consumers were invited to comment on and validate the directions prioritized by WHO.
Occupational therapy was represented throughout this process by the World Federation of Occupational Therapists; editorial board members from the American Journal of Occupational Therapy, the Canadian Journal of Occupational Therapy, and the Scandinavian Journal of Occupational Therapy; and several occupational therapy researchers. The objectives of this initiative can be summarized as follows: (1) to create strong leadership and political support for rehabilitation; (2) to improve rehabilitation planning, implementation, governance, and investment; (3) to expand high-quality rehabilitation workforces and services; (4) to enhance rehabilitation data collection; and (5) to build research capacity and expand the availability of quality evidence for rehabilitation (WHO, 2019).
Why Rehabilitation? Why Now?
Health and demographic trends are changing globally. The world’s population is aging, and more people will be in their later years of life than younger than age 24 yr by 2050 (United Nations, Department of Economic and Social Affairs, Population Division, 2017). Aging is associated with increasing risk of disability (Federal Interagency Forum on Aging-Related Statistics, 2016; Gregory & Fried, 2003). In addition, the prevalence of noncommunicable diseases is increasing (WHO, 2018b). Noncommunicable diseases remain the leading cause of death in the world (WHO, 2018a). However, equally important, they often result in many years of decreased functioning and occupational engagement.
In addition, advancements in acute medical care have reduced the likelihood of death for many health conditions, such as stroke (Kunst et al., 2011; Seminog et al., 2019). Thus, the number of people with disabling conditions has risen considerably since 1990 (Global Burden of Disease 2015 Disease and Injury Incidence and Prevalence Collaborators, 2016). It is estimated that more than 1 billion people (or about 15% of the global population) live with a disability, and these numbers are expected to grow (WHO, 2011). This increase produces a large burden for society and a lower quality of life for people with a disability and their caregivers.
New Shift in Envisioning Health
In a striking new direction, WHO has endorsed the concept of function as a third health indicator, along with mortality and morbidity (Stucki & Bickenbach, 2017). Because current medical treatment cannot, for the most part, prevent or cure the decline in body structures and functions associated with aging or noncommunicable diseases, WHO has recognized that rehabilitation is the fundamental health care strategy for reducing or eliminating barriers to function. WHO (2019) has argued that rehabilitation should be offered for people with a wide range of health conditions; throughout all stages of the life course; and during all phases of acute, subacute, and long-term care, including primary care. Moreover, WHO has invited international and national leaders to prioritize rehabilitation and to include rehabilitation services in universal health coverage.
Occupational therapy is a critical part of rehabilitation because of the profession’s focus on enhancing the ability to perform and engage in the occupations that are critical to a person’s life roles (American Occupational Therapy Association, 2014). By focusing on client-centered enablement of occupations, occupational therapy practitioners assist people with engaging in meaningful occupations, achieving a variety of roles, and creating occupational justice in their communities (Townsend & Polatajko, 2007). Practitioners are experts in understanding how the interactions among people’s current abilities, the demands of the occupations in which they want or need to engage, and the demands of the contexts in which these occupations occur influence occupational performance and participation. Identifying a variety of strategies targeting any or all of these three areas allows practitioners to help people achieve successful occupational engagement, act as change agents, and reduce occupational injustices (Dhillon et al., 2010, 2016; Finlayson, 2013; Kielhofner et al., 2011).
There is growing research showing that occupational therapy interventions are effective for people with health conditions across the life course, decreasing health care utilization (Rogers et al., 2017), improving the ability to complete daily life activities independently or with reduced assistance (Aghajanzade et al., 2019; Ahn, 2019; Burgess & Jensen, 2019; Uruma et al., 2019), and increasing quality of life (Levasseur et al., 2019; Yang et al., 2020).
Meeting the Needs: Some Challenges Await
Despite the evidence that occupational therapy positively affects the health and quality of life of people with disabling or potentially disabling conditions, there is a large unmet need for occupational therapy services around the world. The extent of and reasons for the unmet need vary among countries.
One reason for unmet occupational therapy need is the lack of understanding within health care systems of the importance of occupational engagement to health and the subsequent broad scope of occupational therapy practice. Because of this limited view, occupational therapy practitioners can become pigeonholed into narrow roles, such as handwriting or bathing-and-dressing experts. Therefore, occupational therapy organizations and practitioners still have much work to do to communicate and advocate for occupational therapy’s ability to address the full gamut of occupational performance and engagement problems; moreover, occupational therapy researchers must continue to build evidence for the effectiveness of occupational therapy services for a variety of problems and outcomes.
A second reason for the insufficient amount of occupational therapy services relates to access. Many people have limited or no access to occupational therapy services because of limited or no funding for rehabilitation in general or specifically for occupational therapy. This particular problem is highly prevalent in low- and middle-income countries. However, it also remains an issue for higher income countries, especially for countries that rely primarily on expensive private health insurance. Other people cannot access occupational therapy because they live in rural areas where there are limited health care services. Urbanization across the globe has led to more services in urban areas, with fewer or no resources within a reasonable distance in rural areas. Although telehealth holds much promise for helping to ameliorate this problem, such systems can be expensive, and not all reimbursement systems will pay for tele–occupational therapy.
A third reason relates to the availability of occupational therapists. The World Federation of Occupational Therapists estimated that there should be approximately 750 occupational therapists per 1 million people (Bo et al., 2008; Landry et al., 2007; WHO, 2017). Yet, the number of practitioners falls well below that estimate even in high-income countries, which have just over 420 occupational therapists per 1 million people. In low- and middle-income countries, the number ranges from fewer than 25 to approximately 75 occupational therapists per 1 million people (WHO, 2017).
Part of the problem is the requirement of a bachelor’s or higher degree to enter the occupational therapy profession. Although such education ensures that occupational therapy practitioners have the critical reasoning and technical skills to operate at the cutting edge of the profession, such education is expensive, and practitioners who obtain this level of education also need sufficient salaries to justify the cost of and time devoted to their education. When health systems do not fund practitioners well, the limited number of jobs and potentially low salaries—combined with the cost of obtaining a bachelor’s, or higher, degree—likely eliminate many people from pursuing occupational therapy.
A model that may be more financially feasible for many countries is one with many occupational therapy practitioners at the technician level and with a smaller number of occupational therapists who supervise them. A practitioner at the technician level would require less training and could carry out many of the daily interventions, particularly with people with simpler health barriers to function. General rehabilitation technicians who assist all the rehabilitation professions might be an approach, but it is not clear that this kind of person would have enough training in the profession-specific knowledge and skills to be effective.
One example model exists in the United States. U.S. occupational therapists require at least a master’s degree in occupational therapy, must pass a national certification exam, and must obtain a state license to practice. Occupational therapy assistants must have at least an associate’s degree (usually a 2-yr degree) in occupational therapy, must pass a national certification exam, and must obtain a state license to practice. Occupational therapy assistants carry out the intervention plan that the registered occupational therapist develops and may also collaborate with the therapist in developing the plan. Because occupational therapy assistants are not independent practitioners and must work under the supervision of a registered occupational therapist, they require a smaller amount of education, which costs the health system less.
An Opening for Change and the Need to Voice Concerns
WHO (2017) defined rehabilitation as “a set of measures that assist individuals, who experience or are likely to experience disability, to achieve and maintain optimum functioning in interaction with their environments” (p. 2). The current action plan states,
Rehabilitation addresses the impact of a health condition on the person’s life by focusing primarily on improving their functioning and reducing the experience of disability. Rehabilitation focuses on the functioning of an individual and not the disease. It does this through a strong emphasis on educating and empowering people to manage their health conditions, adapt to their situation and remain as independent and active as possible. (WHO, 2019, p. 2)
Moreover, WHO is developing different packages of rehabilitation interventions (PRIs) to support decision makers in planning, budgeting, and integrating rehabilitation interventions into health systems. As a starting point, WHO selected 20 health conditions on the basis of their prevalence rates, burden of care, and level of disability (Rauch et al., 2019). The PRIs will describe the best evidence available for implementing effective rehabilitation services for specific conditions.
WHO’s current approach is a good start. It is phenomenal that the world is now focusing attention on rehabilitation needs to promote better occupational engagement and quality of life through better functioning for the millions of people with disabling or potentially disabling health conditions. Yet, as occupational therapy practitioners, we need to go further. We need to remember that contextual interventions are also needed to affect the social participation of different groups, such as interventions focusing on stigma reduction, employment, education, and access to housing.
In the International Classification of Functioning, Disability and Health, WHO (2001) acknowledged that removing body structure and function impairments does not necessarily ensure one’s ability to perform activities, and one’s ability to perform activities does not necessarily translate into social participation; contextual factors are an important consideration. Evidence-based practice in the domains of social participation is often established for large populations or with evidence across populations. Thus, as some participants pointed out in the last round of consultation in July 2019, the best approach may actually be a multiple-pronged approach that includes such contextual interventions. Occupational therapy practitioners will need to stay vigilant about advocating for such changes and work to provide population-based approaches that address contextual barriers, in addition to addressing interventions at the individual level.
As occupational therapy practitioners, we salute this initiative: Building meaningful lives as a key outcome of health services, across the continuum of care, will enhance health and quality of life for millions of people. It will likely also create opportunities for the profession and allow the benefits of occupational therapy to reach greater numbers of people. New roles and emergent practices could flourish if we strategically advocate for the Rehabilitation 2030 initiative. We must be diligent in taking advantage of this new WHO focus on rehabilitation to advocate for inclusion of occupational therapy services in health plans, institutions, and agencies where practitioners’ unique skills can make a difference in the lives of clients. Moreover, to help address the unmet needs of the population with or at risk for disability, practitioners need to voice clearly that functioning is just the start. Because clients and consumers want to live fuller lives, in which social participation and occupational engagement are enabled, practitioners also need to advocate for contextual changes that eliminate barriers to participation and engagement.