Social and environmental determinants of occupation: An intersectional concept focused on occupational justice and participation

ABSTRACT

Although there is a focus in occupational science (OS) and occupational therapy (OT) research on social, policy, and physical issues that limit participation, there needs to be continued emphasis on populations and global worldviews. I propose the identification and use of the concept of social and environmental determinants of occupation (SEDO) to examine the complex issues that influence people’s experience through an intersectional lens and affect their access to participate in culturally meaningful occupations. SEDO are defined as broad (and intersecting) social and environmental factors that increase or limit an individual, community, or population’s participation in culturally meaningful occupations of their choice. Unique to SEDO and supported by OS and OT research and practice is the consideration of intersectionality, or how these global factors intersect in a multiplicative manner to influence participation. The discussion highlights health and non-health related examples of the ways intersecting SEDO identify disparities and occupational injustices that affect access to occupations for populations who experience these injustices. The need for continued research and consideration of proposed SEDO is imperative to further OS research, OT practice, and education supporting occupational justice through program and policy development and advocacy. In addition to the effect on research and practice, these considerations provide a strategy for occupational scientists and occupational therapists to monitor and evaluate the impact of policies and programs developed to address these issues and increase participation in culturally meaningful occupations for marginalized populations.

KEYWORDS:

• Occupational science
• Intersectionality
• Social determinants of health
• Inequity
• Culture

The World Federation of Occupational Therapists (2019) asserts that “people have the right to participate in a range of occupations that support survival, health and well-being, … choose these occupations without pressure, force, coercion or threats.., and freely engage in necessary and chosen occupations” (p. 1). Occupation has been conceptualized as “nested in and emerging through historic power structures, oppression and dynamic community formation” (Lavalley & Bailliard, 2021, p. 31). This conceptualization of occupation implicitly refers not only to the importance of participation in meaningful occupations but justifies the necessity of occupational science and occupational therapy’s (OSOT) research and practice focus on equitable access to and participation in culturally meaningful and purposeful occupations. I would argue that the concept of equitable participation and consideration of the influence of social and physical environments, supported by theoretical models and contemporary occupational science research, is what differentiates occupational scientists and occupational therapists from other professions. However, commentary over the last decade has identified that a a substantial proportion of OSOT research consistently identifies that research and practice strategies continue to focus primarily on the individual (Fransen et al., 2015; Laliberte Rudman, 2013; Lavalley & Bailliard, 2021) and fail to consider the societal and environmental limitations in access to health and participation in occupations inequitably experienced by populations.

As a response to this critique, in this commentary, I explain the development of the concept of intersecting social and environmental determinants of occupation (SEDO) and how it is complementary to the concept of social determinants of health (SDH), but is unique in the use of intersectionality when considering participation in occupations. I present an example of how SEDO can be used as a lens in OSOT research. Limitations of SEDO are discussed relative to its infancy as a concept; however, future contributions to research, practice, and education within and outside of OSOT are presented.

Social and environmental determinants of occupation (SEDO) is proposed to consider the complex factors (e.g., socioeconomic status, food insecurity) that influence equitable participation in occupations using an intersectional lens. Grounded in the Participatory Occupational Justice Framework (Whiteford et al., 2018), SEDO are defined as “broad (and intersecting) social and environmental factors that increase or limit an individual, community, or population’s access to participate in culturally meaningful occupations of their choice.” Consideration of SEDO is meant to complement SDH by specifically identifying social and environmental factors that facilitate or hinder access to participation in occupations whose outcomes may be inclusive of, but are not limited to, health (See Figure 1). Focusing on culturally meaningful participation, the person is considered relative to the communities and populations within which they identify and are situated, consistent with the Participatory Occupational Justice Framework’s focus on promoting occupational justice at the population level (Whiteford et al., 2018). Through its broad perspective of societal and environmental influences, the concept of SEDO incorporates the work of OS researchers focusing on fostering positive social change (Hocking, 2017; Laliberte Rudman, 2014; Laliberte Rudman et al., 2019; van Bruggen et al., 2020) and the recognition of occupation as political, rooted in issues of justice and human rights (Angell, 2014; Bailliard, 2013, 2016; Bailliard et al., 2020; Hammell, 2008; Pollard et al., 2008; Pooley & Beagan, 2021; Thibeault, 2013; Whiteford, 1997).

Figure 1. Relationship of SEDO and SDH

I began to develop the concept of SEDO during preparation of a keynote speech for the American Occupational Therapy Foundation (AOTF) International Breakfast at the 2022 AOTA National Conference. My topic was occupational therapy’s role in addressing climate change and although references mentioned climate change as a possible “social determinant of occupation,” the concept was not defined or developed. In addition, though it was clear that climate change did affect participation in culturally meaningful occupations, it was also clear that the effects of climate change on populations (e.g., food scarcity, migration) were not experienced equitably by all populations and that other, intersecting factors (e.g., racism, socioeconomic inequalities) had to be considered to provide a complete picture of those individuals and societies affected. This was an example of how consideration of SEDO that affect participation moves beyond consideration of SDH, identifying issues that can be addressed not only by occupational scientists and occupational therapists, but also policymakers, social workers, and activists.

I developed the concept of SEDO using SDH as a template. SDH are defined as “conditions in the environment where people are born, live, learn, work, and play that affect a wide range of health, functioning, and quality-of-life outcomes and risks” (US Department of Health and Human Services [DHHS], n.d.). In some situations, these SDH have also been shown to affect participation (Hammell, 2021); however, SDH research often overlooks the specific effect of various SDH on occupational possibilities, defined as how these factors result in some having more opportunities and options than others to participate in culturally meaningful occupations (Laliberte Rudman, 2005). Consideration of the potential limitations of these occupational possibilities contributes to OSOT research and practice beyond consideration of SDH, focusing specifically on how SEDO facilitate or hinder equitable access to and participation in occupations (Figure 1).

Development of the concept of SEDO is an important response to the need identified in OS research to consider a more population and global perspective (Hammell, 2021; Hammell & Iwama, 2012). Unique to SEDO, and absent from both the use of SDH and dominant OSOT perspectives in research and practice, is the consideration of intersectionality or how these global factors intersect to influence participation. Collins (2015) stated that intersectionality “references the critical insight that race, class, gender, sexuality, ethnicity, nation, ability, and age operate, not as unitary, mutually exclusive entities, but rather as reciprocally constructing phenomena” (p. 2). Moreover, an intersectional approach contrasts with the more traditional OT approach of considering each of the SEDO in an additive manner, but instead considers the SEDO in a multiplicative manner. Refocusing OSOT research on SEDO, and identification of how these factors intersect to affect people’s ability to access and participate in culturally meaningful occupations, could provide data to assist in development of a framework to guide assessments and interventions that more specifically identify and address these factors, or the effect that these factors have on participation. Depending on the SEDO factors that intersect, and how they intersect, the occupational justice or injustice effects may facilitate or hinder access to participation on a continuum, ranging from complete access to participation in a chosen occupation to inability to participate. Because these factors are population-based, “interventions” may move beyond occupational therapy’s traditional treatment modes and include activism, and/or program development to address inequities (Bailliard et al., 2020; Hammell & Iwama, 2012).

Research examining the relationship of SDH and intersectionality has emerged outside of OSOT (Holman et al., 2021; López & Gadsden, 2016) but also within OS and OT. For example, Huot and Veronis (2018) used an intersectional lens to examine French-speaking minorities’ access to or exclusion from certain environments and how this inclusion/exclusion affects opportunities for occupational engagement. Ambrosio and Silva (2022) identified the concept of intersectionality as an epistemic and practical research analysis tool in occupational therapy for African diasporic and indigenous populations. Further, Balanta-Cobo et al. (2022) called for a dynamic understanding of how occupation/daily life interacts with multiple situations where human and social rights are compromised, such as those proposed with the SEDO, and how inequalities undermine capacities and opportunities for participation and social inclusion. As a result, these authors proposed five dimensions of a research process represented in an intersectional model of human and social rights and occupational therapy. This exciting emergence of the use of intersectionality in OSOT supported the development of concepts such as SEDO.

Development of the SEDO was guided by Hammell’s (2008) definition of occupational rights as “the right of all people to engage in meaningful occupations that contribute positively to their own well-being and the well-being of their communities” (p. 62). Indeed, OSOT consider equitable participation in culturally meaningful occupations as paramount for all persons (Hammell, 2008, 2013; Hammell & Iwama, 2012). This belief guided the development of SEDO.

Figure 2. The SEDP process

Though still in its infancy stage of development, an example of the use of SEDO in research would begin with the researcher identifying the SEDO that are part of a population’s current life situation that limit their access to participation in a culturally meaningful occupation, for example, cooking. Climate change is identified in OSOT literature (Lieb, 2022; Ung et al., 2020) as a factor that inequitably affects access to sustainable land for farming, resulting in food scarcity. As shown in Figure 2, following identification of research to determine the effect of SEDOs on access to participation, the researcher would need to consider not only the SEDOs that are identified through assessment and research, but also, the weight or multiplicative influence that the combination of SEDOs have on participation. Also identified in the OSOT literature, food insecurity, due to the presence of food deserts, may limit the availability of necessary food (Beagan et al., 2018). The researcher would need to investigate further into the population (perhaps through informants) to determine the level of influence each SEDO may have on the occupation of cooking to identify the intersection and multiplicative effect of the determinants. This strategy is supported by scholars responsible for the development of intersectionality (Collins, 2008, 2015; Crenshaw, 1989) who explained that the concept of intersectionality can help advance equity and social justice (or, in this case, occupational justice) for marginalized populations who have and continue to experience structural inequities. An important consideration of the intersection of the factors is that these circles are dynamic and may shift depending on the ever-changing influences of these SEDO on participation. Identification of intersecting SEDO and the resultant occupational injustices affecting participation, for example inequities in access to health, can inform priorities for advocacy, policy or program development, and intervention.

This focus on the influence of the environment is informed by the transactional perspective to approaching occupation. Described by Dickie et al. (2006) as “what we would typically see as separate from each other are really part of each other” (p. 88); meaning that, since individuals and their environment are co-constitutive of one another, occupations cannot be considered “as a type of self-action or inter-action” (p. 90). Therefore, there is a need to take into account SDH and SEDO for an exhaustive understanding of occupation as the observable aspect of the person-context transactional relationship. Understanding and applying evidence-based interventions that address these SEDO specifically within occupational therapy practice allows practitioners to address the identified occupational injustices.

The concept of SEDO can be used to provide a common repository from which to inform and grow the research developed by existing and future researchers interested in occupational justice. Other professionals, community workers, and policy makers would be able to access important research about SEDO and participation inequities to consider beyond SDH in development of interventions, programs, and policies that could improve access and participation in culturally meaningful occupations of all people.

Relative to education, Bailliard et al. (2020) suggested that OT education programs need to consider issues of occupational justice [and SEDO], necessitating occupational therapy curricula that include content and assignments related to identifying and addressing occupational injustice, such as inequality in health, in traditional and non-traditional practice settings. In addition, these authors suggest that, through continuing education, current practitioners should engage in continuous reflective practices to remain aware of the threat of implicit biases that could result in unintentional occupational injustices in interventions.

There are several limitations in this commentary inherent in the proposed nature of the definition of SEDO and the inclusion of intersectionality. These concepts, borrowed from and complementary to established SDH, and the use of intersectionality are unique as a concept and therefore not tested. However, this proposal is appropriately identified as a starting point for consideration, scrutiny, and revision of these concepts toward a continued and deeper understanding of the global and intersectional issues affecting access to the participation. Another limitation is that by the concepts’ very nature, directed, guiding SEDOs are not prescribed, but instead, will be developed by researchers specific to the populations examined. The approach, as it stands, is meant to be flexible and additions or deletions to these SEDO are not only important, but imperative, depending on people’s current experience at all levels.

This paper proposed the concept of SEDO using an intersectional lens to examine more fully the occupational injustices that affect participation in culturally meaningful occupations. Moving forward there is a need for continued research and consideration of proposed SEDO to further OS research supporting occupational justice. For example, phenomenological research could provide the “lived experience” of SEDOs faced by populations most affected. Quantitative research using publicly available datasets could provide additional information on the relationship between SEDO and specific populations within the dataset. In addition to the effect on research, practice, and education, these considerations provide a strategy for occupational scientists and occupational therapists to monitor and evaluate the impact of policies and programs developed to address these issues and increase participation in culturally meaningful occupations for affected populations.

Further consideration of specifically how the complex and intersecting barriers to participation in occupations address occupational and social justice is important in OSOT research. Therefore, future research could identify how identified SEDO influence the transactive relationship between occupation justice and inequity in participation in culturally meaningful occupations. In addition, this research could examine interventions, policies, and program development that are necessary to address these issues to reduce the identified inequity and increase participation. Occupational science and occupational therapy have an integral role in working toward the resolution of problematic and unjust community relationships (Lavalley & Bailliard, 2021). It is through addressing these issues that occupational scientists and occupational therapists can assist in giving voice to marginalized and oppressed populations.

Disclosure Statement

No potential conflict of interest was reported by the author(s).