Abstract
In this State of the Science column, we examine evidence that aligns common applications of diversity, equity, and inclusion (DEI) and occupational therapy research and suggest areas of focus to advance a culturally affirming and antiracist science of occupation. More specifically, we describe why DEI is important to the study of occupation, identify DEI gaps in the occupational therapy knowledge base, suggest DEI priorities for occupational therapy research and their implications for practice, and recommend practical strategies for occupational therapy scholars to apply in more immediate efforts to address DEI in their research endeavors.
This State of the Science column examines evidence that aligns common applications of diversity, equity, and inclusion and occupational therapy research and suggests areas of focus to advance a culturally affirming and antiracist science of occupation.
As professional organizations and academic programs continue to reckon with the net impacts of structural inequalities and determinants of health, the occupational therapy profession has been called to commit to transformative practices that center on diversity, equity, and inclusion (DEI). DEI scholars espouse the idea that effective responses to these enduring challenges require diversity of thought, experiential knowledge, and intentional action, as well as a careful evaluation of risks and impacts through the lens of equity and justice (Johnson et al., 2022; Lucas & Washington, 2020; Salvant et al., 2021); accordingly, the American Journal of Occupational Therapy (AJOT) upholds the importance of DEI and endorses the application of its principles toward more transformative occupational therapy research, education, and practice (see https://research.aota.org/collection/3171/DEI-Collection). In this State of the Science column, we describe why DEI is important to the science of occupation and identify DEI gaps in the occupational therapy knowledge base, suggest DEI and antiracist priorities for occupational therapy research and their implications for practice, and provide recommendations for practical strategies in the interim. Although State of the Science columns have historically taken stock of specific evidence in occupational therapy, there is yet no consensus on DEI approaches; therefore, what the aforementioned points of discussion offer is a snapshot of evidence that aligns common DEI applications and occupational therapy research.
The Authors’ Positionality and Intersectionality
Our various attentions to DEI in occupational therapy are the net result of the personal and professional experiences through which our social positions have been derived. We are a body of female-identifying scholar practitioners from racially and ethnically minoritized groups: Three authors identify as Black, one identifies as Hispanic and Puerto Rican, one identifies as Arab and Middle Eastern, and one identifies as Jewish. We hold terminal degrees (i.e., Doctor of Philosophy, Doctor of Education, and Doctor of Occupational Therapy) and are employed full time in research and teaching positions at colleges and universities in the continental United States and Puerto Rico. We also identify as advocates, activists, and organizers who work with marginalized communities in urban and peri-urban sociopolitical contexts. None of us identify as disabled; therefore, this perspective/lived experience is absent. Although we represent an array of experiences, viewpoints, and areas of expertise, our identities of difference (Collins & Bilge, 2016) have undoubtedly informed our interests as well as the adoption and application of DEI in our work as occupational scientists and occupational therapy practitioners.
Naming and Framing DEI in Occupational Therapy
We define diversity as differences among people that include, but are not limited to, demographics (e.g., racial, ethnic, linguistic, cultural), socioeconomics, geography or region, religious and other belief systems, lifestyle, interests, and perspectives on research (American Occupational Therapy Association [AOTA], 2020a; Brown et al., 2021). We define equity as a means of ensuring that individuals and groups have legitimate access to all possible opportunities and resources of their choosing without facing discrimination or bias (AOTA, 2020a; Taff & Blash, 2017), and we define inclusion as the intentional, sustained, and specific effort to create environments in which individuals and groups who occupy identities of difference feel welcomed, valued, heard, and respected (AOTA, 2020a; Taff & Blash, 2017). DEI and its associated strategies complement the occupational therapy profession’s core values and align with the principles that guide our decision making. Salvant et al. (2021) recalled that the profession has dedicated efforts “to address issues related to diversity, equity, and inclusion” (p. 2), including curating resources and toolkits as well as AOTA’s (2020a) “Guide to Addressing the Impact of Discrimination, Stigma, and Implicit Bias on Provision of Services”; however, it is important to note that the ways in which DEI has been applied in occupational therapy research are not well defined or understood. This may also be attributed to the net impacts of deficiencies in workforce diversity (Jesus et al., 2023), in particular in programs of research. As scholars from diverse backgrounds, we may vary in the types of questions we ask, populations we include, and the frameworks and theories in which we ground our research. Moreover, the profession has not fully interrogated the legacy of white supremacy and its influences on our research traditions and approaches as well as the racialized politics of citation and publishing.
DEI is not exclusive to occupational therapy and is often treated as an afterthought (Engram & Mayer, 2023), resulting in an additive approach to research design, products of scholarship, and practice (Johnson et al., 2022). Scholars frequently focus on diversity by directing attention to accounting for differences among people without careful consideration of the intersections of these differences, the impacts of white supremacy ideologies, and how they relate to equity and inclusion. Equity is habitually conflated with equality, which problematizes the utility of this notion; consequently, the misuse of these concepts blurs viewpoints and ultimately perpetuates the need for additional constructs, such as justice and accessibility (Johnson et al., 2022). As Engram and Mayer (2023) noted, these performative approaches seek to appeal and appease whiteness, which is the antithesis of real DEI work. This passive approach to directly addressing white supremacy and the system of whiteness always places the onus of diplomacy on the oppressed. . . . Successful DEI methods must not be passive, and they must directly address the roots of inequity.
Therefore, occupational therapy scholars must also attend to tendencies toward white logic, which standardizes techniques and processes of reasoning rooted in white supremacy (Engram & Mayer, 2023; Grenier, 2020). Race, gender, and class are structural factors that direct scientific inquiry, which is shaped by dominant worldviews (Zuberi & Bonilla-Silva, 2008). It is important to recognize these structural factors when committing to DEI work.
Appropriately using a standard application of DEI principles inherently promotes justice and accessibility for all. Scholars must examine current approaches by engaging with literature that critically examines notions of race, gender, and disability (and other identities of difference) to bridge the gaps in knowledge and understanding. We also argue that the centering of DEI in research moves the profession beyond obligatory, performative, and surface-level practices toward a DEI praxis.
State of the Science of DEI: A Snapshot
AJOT maintains a collection of DEI scholarship items that currently includes 14 articles (6 in Volume 75, 4 in Volume 76, and 4 in Volume 77). These articles broadly highlight health promotion and disability awareness (e.g., VanPuymbrouck et al., 2021), accessibility (e.g., Gately et al., 2023), gender diversity (e.g., Leite & Lopes, 2022), mental health (e.g., Gallagher et al., 2023), antiracist instructional strategies (e.g., Johnson et al., 2022), practice/workplace context (e.g., Bolding et al., 2021), and ethical aspects specific to the profession (e.g., McArthur & Gill, 2021). Methodological approaches in this collection range from mixed-methods and cross-sectional online surveys to systematic reviews and qualitative methods. More specifically, 6 articles have a more reflective or analytic approach, with 5 of those being “The Issue Is . . .” columns (e.g., Johnson et al., 2022; Salvant et al., 2021) and 1 being a Health Policy Perspectives column (Pfirman et al., 2023). Remaining articles in the collection report on quantitative, qualitative, and mixed-methods research. The quantitative design most frequently used was survey research (Bolding et al., 2021, 2022); qualitative approaches included grounded theory (VanPuymbrouck et al., 2021), interpretive description (McArdle et al., 2023), and action research (Gallagher et al., 2023), among others. Systematic and scoping reviews of literature are also included in the collection (e.g., Gately et al., 2023; Leite & Lopes, 2022).
This collection provides a snapshot of conceptual applications of DEI and its implications for occupational therapy practice, but notable gaps remain. Given that recent protests of sociopolitical practices and processes have elicited an increase in DEI initiatives, it is unsurprising that many of the published articles in AJOT have a reflective, descriptive, or exploratory approach. Still, there is a need to engage in research designs that allow for a more nuanced understanding of the experiences and meanings that situations of inequities, disparities, and exclusion pose to those affected. We challenge occupational therapy scholars to use a DEI lens to critically appraise and refute scientific claims evidenced solely through dominant ways of knowing as superior and to legitimize antiracist and intersectional research methods that give voice to the lived experience of marginalized communities. We advocate for the inclusion of mixed and multiple methods of inquiry guided by principles of participatory, emancipatory, and decolonizing methodologies to reify a new paradigm of occupational therapy research to inform and strengthen best practice.
Priorities for Occupational Therapy Research
To better situate and advance the uptake of DEI approaches in occupational therapy research and scholarship, we recommend concerted and intentional prioritization of the following: ▪ Develop research processes that disentangle race and other identities of difference, including disability, as risk factors versus risk markers of occupational outcomes. ▪ Address ableism in research processes and reporting by establishing new, and expanding existing, frameworks that center disability. ▪ Establish DEI as a novel approach to occupational therapy service provision. ▪ Advance the legitimacy of DEI and its impact on workforce diversity, practice ethics, and situating the profession in the larger sociopolitical landscape through advocacy research. ▪ Prepare emerging occupational scientists and occupational therapy scholar practitioners to take up and apply antiracist and intersectional approaches in their work.
Guideposts for Reframing DEI in Occupational Therapy
To improve the implementation of relevant and effective interventions, future research must consider feasibility, accessibility, acceptability, adoption, and sustainability from the onset of research question development. Theories, models, and frameworks that consider equity and inclusion should be applied to ensure best practice and support the generation of more equitable interventions and outcomes. In the field of occupational therapy, there are a number of practice theories (e.g., Person–Environment–Occupation, the Model of Human Occupation), frameworks (e.g., the AOTA Occupational Therapy Practice Framework: Domain and Process), and models (e.g., Kawa Model) that have guided scholars in occupational therapy education, practice, and research (AOTA, 2020b; Iwama et al., 2009; Kielhofner & Forsyth, 1997; Law et al., 1996). However, for scholars seeking to name and frame antiracist, intersectional, and justice-based concepts, as well as occupations that are often overlooked, there are additional models and frameworks that can facilitate a purposeful structure. The following models and frameworks allow for the identification of structural mediators at multiple levels of analysis and can make visible the underlying pathways that link contextual (i.e., sociopolitical, cultural, and physical environments), behavioral, and biological factors that result in disparate outcomes across life domains. Occupational therapy scholars can thus broaden their scope to include targeted and culturally relevant approaches, aiding in our efforts to ameliorate disparities.
The Antiracist Research Framework (Goings et al., 2023) uses 10 guiding principles to center the social construction of race and impacts of racism on the well-being of minoritized populations. In addition, this framework is complementary to Critical Race Theory (CRT) as a schema for understanding and addressing racism while elevating the voice and experiences of minoritized individuals (Goings et al., 2023).
The Public Health Critical Race Praxis Model (PHCRP) combines CRT and public health principles to address racial health disparities and social injustice (Ford & Airhihenbuwa, 2010). Its primary focus is on the dismantling of systems that limit health equity. More specifically, the PHCRP model highlights the following critical components: social determinants of health, intersectionality, power structures, community empowerment, culturally responsive interventions, antiracist practice, and praxis to create sustainable change.
The Gelberg and Andersen Behavioral Model for Vulnerable Populations (Gelberg et al., 2000) is a framework designed to address the health needs of vulnerable populations. A primary focus of this framework is to identify barriers to and facilitators of health care access and use, in particular for those with less socioeconomic wealth. The key components include predisposing factors, enabling factors, need factors, and health care utilization. This framework highlights the intersection of these factors and the fact that multiple challenges and barriers may exist that affect health behaviors.
The Health Equity Framework (Peterson et al., 2021) is a conceptual framework that seeks to address health disparities and move toward equitable health outcomes. It focuses on the intersection of relationships and networks, systems of power, physiological pathways, and individual factors and how this intersection contributes to health and education outcomes. Through these primary domains, this framework can support scholars in incorporating social determinants of health, considering structural and systemic inequities, intersectionality, community and culture, advocacy, and partnership.
Disability Critical Race Theory (DisCrit) is a theoretical framework that combines aspects of CRT and disability studies to establish a way to analyze the intersections of race and ability. The social constructs of race and ability are intertwined and codependent in intangible ways that have a great impact on people of color. DisCrit questions the coconstruction and reinforcement of ability as property to be possessed and owned by whiteness (Annamma et al., 2018).
Quantitative Critical Theory (QuantCrit; Garcia et al., 2018) emerged from CRT’s use of qualitative strategies to develop methods to inform the use of quantitative data in a way that is consistent with CRT. The QuantCrit framework is used to critically examine quantitative data in research to avoid perpetuating racist ideologies. QuantCrit offers an approach to data synthesis that considers the following tenets: oppression, the fact that data and methods are not neutral, the idea that data cannot speak for themselves, the notion that groups are neither natural nor inherent, the taking of an intersectional perspective, and the valuing of narrative and counternarrative.
Practical Strategies in the Interim
Change is ever present, and the current sociopolitical landscape has forced researchers to be creative when identifying appropriate funding sources, using pedagogical frameworks that have not traditionally been taken up in occupational therapy, and reframing what it means to provide equitable and inclusive services. Although mitigating structural challenges requires intentional, persistent, and strategic methods, we offer the following strategies as resources to propel occupational therapy scholarship forward through the application of DEI principles.
Research Funding Strategies
Securing research funding for DEI-related projects is not without its challenges. The National Institutes of Health (NIH) is the largest single funder of biomedical and behavioral research in the world and the primary source of funds for generating scientific evidence for the future of health care in the United States (NIH, 2023). Although the NIH acknowledges the importance of diversity and representation in research, and requires that women and minoritized populations be included in studies (NIH, Diversity in Extramural Programs, n.d.), there is considerable variability in funded projects that engage diverse groups (Pearson et al., 2015). Examples of funders who support DEI research that is congruent with areas of focus and populations with whom occupational therapy scholars work include, but are not limited to, the Robert Wood Johnson Foundation; the William T. Grant Foundation; the Ford Foundation; the American Occupational Therapy Foundation; the National Institute on Minority Health and Health Disparities; and the National Institute on Disability, Independent Living, and Rehabilitation Research. These organizations have expansive funding infrastructures with specific allocations that address the occupational concerns of people from minoritized backgrounds based on race, ethnicity, gender, (dis)ability, and immigration status. Funded projects have focused on health care access and utilization, prevention and promotion, leadership, program evaluation, antiracism, intervention development, and implementation to reduce inequities experienced by minoritized populations. In addition, funders such as the Russell Sage Foundation offer social science research grants and fellowships (e.g., visiting scholars, visiting journalists, and visiting researchers) with a focus on social, economic, and political impacts of disparities.
Beyond determining funding eligibility criteria, project scope and aims, budget, and timeline expectations and requirements, there are other practical strategies scholars can consider: ▪ Evaluate the suitability of potential funders by their mission and vision as evidenced by their funding portfolio and the alignment of your research with their priorities. ▪ Consult with your university office of sponsored programs (or equivalent) to determine whether there are internal funding mechanisms available to support or pilot your work. In addition, leverage the services they provide in helping you to identify funding sources. ▪ Review the acknowledgment sections of relevant products of research applicable to occupational therapy, such as journal articles, conference proceedings, media coverage, art installations, and podcast episodes. ▪ Subscribe to the American Occupational Therapy Foundation newsletter (https://www.aotf.org/Research-Resources/Research-Resources-Newsletter) and those of other professional societies relevant to your work. Newsletters often contain information about funding opportunities. ▪ Seek advice from collaborators, colleagues, and mentors on how their work has been supported.
Partnering with organizations with a DEI mission becomes important when funding is limited. Only a few organizations in occupational therapy provide formal educational support related to antiracism and anti-oppression (e.g., the Coalition of Occupational Therapy Advocates for Diversity), antibias and equity in pedagogical practices (e.g., AOTA’s Academic Education Special Interest Section [https://www.aota.org/community/special-interest-sections/academic-education], the Multicultural Diversity & Inclusion Network [https://ojotc.org/mdi/], the Arab American Occupational Therapists Group [https://drrazanhamed.com/arab-american-ot-group]), and culturally relevant and responsive student experience (e.g., Diverse-OT [https://www.facebook.com/DiverseOTNational/]).
Research Design and Process Strategies
People from groups that have been historically, and are currently, excluded from the health care system (e.g., people of color, people with disabilities, people experiencing homelessness, immigrants) are often not included in the development of research questions and methodology, in research as participants, or in the interpretation or dissemination of research. The exclusion of communities also occurs in occupational therapy research (Morville & Erlandsson, 2016). As has been observed in clinical trials, without adequate representation, a treatment considered efficacious in one cohort may actually be completely ineffective in another (Clark et al., 2019; Corneli et al., 2023). When representation is not adequate in rehabilitation research, we risk testing and implementing interventions that are not equally valid across cultures and populations. Exclusion in occupational therapy research is not limited to clinical populations. Occupational therapy assistants have also routinely been excluded from research, although they are well positioned to support the development and implementation of research activities and utilization of research findings.
Research that endeavors to understand daily life through the lens of identity markers should inherently entail innovative approaches; although the inclusion of populations from racially minoritized and marginalized backgrounds is essential, their inclusion alone is insufficient. These efforts must be accompanied by the intentional centering of those voices and the vision to translate research outcomes into actions that broaden their representativeness and participation. Strategies to achieve these aims may include the following: ▪ Commit to innovative and unconventional/decolonized research conceptualization; that is, select research designs that consider the specific situation and population to which the research will contribute. Investigate which strategies or methods have been used previously and how the approach under consideration centers the experiential knowledge of the population by naming and framing their occupational concerns. ▪ Identify collaborators and choose sampling strategies that increase diversity (e.g., qualitative approach: purposeful maximal variation sampling; quantitative approach: stratified sampling, quota sampling), as well as strategies that guide the careful and accurate collection and description of sociodemographic data (e.g., ethnicity, gender). ▪ Use accessible data collection procedures to increase opportunities for participation in research. For instance, institute procedures that consider people who may not have internet access, people who use alternative and augmentative communication or do not speak English as their primary language. ▪ Use analytic processes that are grounded in or can reconcile tensions between the knowledge and interpretations of the researcher and participants. ▪ Disseminate relevant and accessible products of scholarship that contribute to actionable and sustainable change.
Conclusion
Attention to DEI in occupational therapy has grown exponentially; however, the profession has not achieved unanimity on best practices in DEI research. Calls for intentional and systematic application of DEI principles in occupational therapy research and practice must be accompanied by a critical interrogation of the profession’s epistemological and ontological orientations and their net effect on research conceptualization, implementation, and dissemination. We contend that in order for occupational therapy research to have an impact and relevant translation to diverse communities, DEI priorities are needed; however, approaches must move beyond cursory performative practices toward DEI, antiracist, and emancipatory praxis.
Footnotes
Acknowledgments
We extend our sincerest gratitude to the Diversity, Equity, and Inclusion (DEI) Committee of the American Occupational Therapy Association, for challenging scholars in the field to take stock of DEI scholarship in the American Journal of Occupational Therapy, and to Neil Harvison and Jeremy Furniss for their administrative support.