Impact of Occupational Therapy Education on Students’ Disability Attitudes: A Longitudinal Study

Disability Attitudes and Occupational Therapy Education

Occupational therapy curricula can influence attitudes and behaviors that inform how students think about disability, interactions with clients, and the focus of the interventions. People’s attitudes operate on two different levels: explicit and implicit (Amodio & Mendoza, 2011). Explicit attitudes are conscious attitudes, whereas implicit attitudes are unconscious attitudes. Explicit measures do not capture all attitudes because people may be unaware that they hold biased attitudes, or they may feel pressure to conceal their biases because of social desirability (Amodio & Mendoza, 2011). In contrast, implicit attitudes can be useful to examine learned associations and internalization of society’s prejudice (Amodio & Mendoza, 2011). Because of the differences in how they operate and because of response bias (regardless of whether it is intentional), it is common for people’s explicit and implicit attitudes to not align.

Despite the differences between explicit and implicit biases, most research about occupational therapy students’ disability attitudes has focused exclusively on explicit attitudes. In fact, there is a dearth of research on occupational therapy and other allied health professional measures of implicit bias across disenfranchised groups. The research on explicit bias that does exist has also often resulted in conflicting findings. For example, Sullivan and Mendonca (2017) found that Level II fieldwork, compared with 2 yr of coursework, significantly improved students’ explicit attitudes toward people with intellectual disability. In another study, Penny et al. (2001) found that coursework lowered occupational therapy students’ explicit bias toward people with mental illness; however, after Level I fieldwork, students’ negative attitudes toward mental illness significantly increased. Conversely, Lee et al. (1994) found that participation in professional education across years in a curriculum had a positive impact on reducing students’ biased disability attitudes that were maintained during fieldwork experience.

In a systematic review of the literature on attitudes of health care students, including occupational therapy students, toward people with disabilities (PWDs), student attitudes became more favorable from Year 1 to Year 4 of professional education (Satchidanand et al., 2012). Lee et al. (1994), Tervo et al. (2004), White and Olson (1998), and Satchidanand et al. (2012) found that occupational therapy students’ explicit biases were lower than those in other professional programs; however, Lyons (1991) found that occupational therapy students’ explicit biases did not significantly differ from business students’ disability attitudes. Taken together, the findings from these studies offer conflicting evidence on how professional education affects explicit bias of students, and the findings offer even less evidence regarding implicit bias.

Exploring occupational therapy education programs’ influence on attitudes provides invaluable information to the profession during a paradigm shift from traditional deficit-based models to biopsychosocial models and strengths-based methods of interventions for clients and changes in educational standards (Accreditation Council for Occupational Therapy Education [ACOTE®], 2018). A gap exists in the literature, with little research exploring occupational therapy students’ implicit disability bias. For this reason, the aim of this study was to explore the impact of occupational therapy graduate education on occupational therapy students’ disability attitudes, specifically how occupational therapy students’ disability attitudes change throughout their graduate education.

We had two research questions:

To explore these research questions, we conducted a longitudinal analysis of occupational therapy students’ (N = 67) disability attitudes just before beginning and throughout their occupational therapy graduate education. Answering these questions will help the profession better understand whether, and how, occupational therapy curricula affect students’ implicit bias as they move through their professional education.

Method

Results

Across the years of the study, participants’ explicit disability attitudes ranged from 0.05 (no explicit bias) to 0.58 (strong explicit preference for people without disabilities). Participants’ implicit disability attitudes across the years ranged from −0.91 (strong implicit preference for PWDs) to 1.39 (strong implicit preference for people without disabilities). Table 2 outlines the students’ explicit and implicit attitudes at the four time points of their education.

Explicit Attitudes

A repeated-measures ANOVA was conducted to determine whether a difference occurred in students’ explicit disability attitudes throughout their education. Mauchly’s test of sphericity indicated that the assumption of sphericity was met, χ²(5) = 3.24, p = .66. The analysis revealed statistically significant differences in the students’ explicit attitudes at the four time points, F(3, 108) = 7.27, p < .001, η_p ² = .17 (large effect). Post hoc analyses (Bonferroni correction, p = .02) revealed a reduction in explicit disability attitudes from when students began their occupational therapy program (M = 0.35, SD = 0.08, moderate explicit bias) to when students graduated from their program (M = 0.29, SD = 0.09, slight explicit bias; p < .001; Table 3 and Figure 1).

OPEN IN VIEWER

Table 3.

Repeated-Measures ANOVA: Post Hoc

Measure	M	SD	M difference
			1	2	3
Explicit attitudes
1. Beginning of occupational therapy program	0.35	0.08
2. After Year 1	0.33	0.09	0.02
3. After Year 2	0.33	0.10	0.03	0.003
4. Graduation	0.29	0.09	0.07*	0.04	0.04
Implicit attitudes
1. Beginning of occupational therapy program	0.52	0.40
2. After Year 1	0.54	0.43	−0.02
3. After Year 2	0.53	0.47	−0.01	0.01
4. Graduation	0.42	0.52	0.10	0.11	0.10

Note. ANOVA = analysis of variance.

*

p < .001.

OPEN IN VIEWER

Figure 1.

Occupational therapy (OT) students’ explicit and implicit disability attitudes during their occupational therapy education.

Discussion

AOTA (2020a) recently acknowledged that discrimination, stigma, and implicit biases can negatively affect the provision of occupational therapy services. To reduce biases among occupational therapy practitioners, it is necessary to assess how organizational policies and procedures might reinforce or reduce prejudices, including appraisal of occupational therapy educational programs’ impact on their students’ attitudes. In response to concerns regarding bias, occupational therapy education programs are being called on by professional organizations to incorporate cultural competence and humility into educational curricula as a means to reduce bias and a means to develop empathetic, client-centered practitioners (Agner, 2020; Tyminski et al., 2019). For this reason, and to better understand the attitudes of occupational therapy students, the aim of this study was to explore students’ explicit and implicit attitudes throughout their graduate education.

Our findings revealed that occupational therapy students’ explicit disability attitudes significantly decreased between entering their occupational therapy program and their graduation, becoming more positive overall. Because responses to explicit measures may be motivated by concerns with the consequences of being seen as prejudiced, the students’ reduction in explicit attitudes may be a result of students becoming more aware of socially and politically appropriate concepts during their educational program or becoming culturally competent on issues pertaining to disability (Suarez-Balcazar et al., 2009).

Despite students’ explicit prejudice decreasing, their implicit disability attitudes did not significantly change throughout their education. In fact, 68% of students were implicitly biased at graduation, 40% of whom had strong implicit prejudices. The students’ mean implicit score at graduation was 0.42. (For contrast, Nosek et al.’s, 2007, study of 39,000 people from the general public found a mean DA–IAT score of 0.45; moreover, VanPuymbrouck et al.’s, 2020, study of 25,000 health care providers found a mean DA–IAT score of 0.54.) Our findings suggest that occupational therapy programs may fail to intervene with students’ ableist attitudes and may actually reinforce ableist attitudes. As a result of the prevalence of ableism in society (Friedman, 2019), occupational therapy students likely enter the profession with preconceived attitudes that disability is negative, which is similar to the attitudes of larger society (Daruwalla & Darcy, 2005). These concepts may be strengthened as a result of medical or impairment-based models of intervention being entrenched in practice frameworks, educational standards, and reimbursement mechanisms (Gupta & Taff, 2015). Biased ideas about disability problematically affect clinical decision making and lead to reduced health care access for PWDs (Harrington et al., 2009).

Although many of the students in our study had low levels of explicit prejudice, they were likely still participating in prejudice as a result of their implicit attitudes. Although implicit prejudice often is more subtle, it can be just as harmful as overt forms, resulting in maintenance of unjust social, political, and economic structures as well as restriction of opportunities for PWDs (Dovidio & Gaertner, 2008). Implicit attitudes may also result in biased people trivializing the experiences of PWDs and the discrimination that they face (Keller & Galgay, 2010). The mismatch between occupational therapy students’ explicit and implicit disability attitudes may be particularly challenging, because they are likely to believe they feel positively about PWDs and that they are not prejudiced; yet, they still participate in prejudiced thought and behavior without realizing it.

Limitations

Several limitations should be considered when interpreting our findings. Participants came from three different occupational therapy graduate programs in the Midwest that do not necessarily reflect occupational therapy education as a whole. Although they were compensated for their time, occupational therapy students volunteered to participate in this study; thus, self-selection bias is a possibility. In addition, the slight attrition that occurred over the years may have affected the findings.

Implications for Occupational Therapy Education

Occupational therapy education programs have an important role to play in terms of intervening to minimize prejudicial attitudes and assumptions about disability and, in the process, address students’ ableist thinking. Although occupational therapy education continues to attend to client factors such as body structures and body functions (focus on impairment) as targets for intervention design (AOTA, 2020b), recognition of the interactional role of environments in disability is growing. Additionally, there is growing discourse that the unique value that occupational therapy practitioners contribute to interdisciplinary rehabilitation teams is a holistic approach to achieving meaningful engagement in client-identified occupations (Cohn, 2019). In fact, there have been criticisms, including from within the profession, that occupational therapy students often enter practice with little understanding of how to develop interventions targeting the social barriers that prohibit PWDs from participating in occupation (Fisher, 2018).

To reduce occupational therapy students’ (future practitioners’) ableism, and to also give them a richer and more accurate understanding of the lived experiences of PWDs, occupational therapy education programs should work to better align with social and occupational justice (Aldrich et al., 2017). In particular, disability studies concepts that reframe traditional occupational therapy understandings of disability and impairment—particularly in relation to social–political environmental barriers, interdependence, and lived experience—have been increasingly incorporated into occupational therapy literature, research, and education (Magasi, 2008; McCormack & Collins, 2010). Thus, our findings have the following implications for occupational therapy education:

Conclusion

Research indicates that a lack of practitioner knowledge about working with PWDs results in disparities in health care access and outcomes for PWDs (Peacock et al., 2015). When we examined the explicit and implicit disability attitudes of occupational therapy students throughout their education, we found that whereas their explicit attitudes decreased (i.e., became more favorable), their implicit attitudes did not; in fact, the majority of students were implicitly ableist at graduation. These findings have problematic implications for practice and clinical decision making; they show that more emphasis is needed on developing educational standards (ACOTE, 2018) to produce clinicians who are empathetic and nonbiased, because the majority of occupational therapy clients are PWDs.

Supplemental Material