Perceptions of unilluminated occupations a survey of Danish occupational therapists

Abstract

Background

In occupational therapy and -science positive aspects of occupation are highlighted. Recently, this discourse has been questioned, as it might leave out occupations – referred to as unilluminated occupations (UO) – that hold value to people, without fitting the positive ideal.

Aim

To translate UO into Danish and to examine how occupational therapists (OTs) view and address UO.

Methods

A survey developed in USA was translated into Danish and distributed to OTs across Denmark. We added questions on the Danish wording of the concepts, including a content validity index (CVI). Data was subjected to a descriptive analysis.

Results

The respondents agreed that OTs must include examining the purpose and meaning of UO, however without having a responsibility to support performing these UO. The applied translation: high risk (risikable), unhealthy (usunde), unethical (uetiske), immoral (umoralske), and unacceptable (uacceptable) were deemed relevant in Danish, established by CVIs on 0.72–0.90.

Conclusions and significance

Although most respondents were positive towards examining and acknowledging clients’ purpose and meaning of UO, no clear consensus when addressing UO in interventions was seen. Further research might shed light on ways to approach UO both in assessment and intervention. The Danish terms appeared relevant to encompass UO.

Keywords:

• Attitudes
• client-centred practice
• dark side of occupation
• professional discourse
• unsanctioned occupations

Background

The World Federation of Occupational Therapy [WFOT] describes the main purpose of occupational therapy (OT) as ‘promoting health and well-being through occupation’ [1]. This is incorporated in the foundation of the Danish OT profession where participation in occupation is viewed as fundamental to ‘a good life’ [2]. Historically, a positive correlation between engaging in occupation and health has been somewhat established within occupational science research [3]. The foundational understanding of occupation as health-promoting is distinctly reflected in occupational science literature discourse. Across 112 papers, Stewart et al. found the overwhelming majority portrayed the relationship between occupation and health as positive [4]. Of course, establishing occupation’s positive influence on health is vital to the endorsement of the OT profession’s existence in the health care system. However, the ideal of ‘a good life’ and ‘health promoting’ puts emphasis on the positive nature of occupations.

Stewart et al. [4] problematize this one-sided view of occupation shown in their review and propose that occupations should be viewed as inherently neutral and how they influence health as heavily context dependent. The emphasized discourse potentially leaves occupations that we might not deem as contributing to health and/or well-being unnoticed in our professional consciousness. In fact, not all occupations are inherently positive or strictly health promoting. A qualitative study of experiences of everyday life among persons at risk for stroke, found at the core, a paradox between people engaging in occupations that, on one hand, are subjectively engaging and meaningful for the person (resulting in perceived well-being) while, on the other hand, contribute to the risk of having a stroke [5]. Similarly, Huglstad et al. found that the sex workers gained different kinds of meaning from engaging in sex work, e.g. they felt sexual satisfaction, personal development, a sense of well-being, and quality of life [6]. So even though these occupations are not accepted by society or pose a health risk they may hold meaning to the individual [6–8].

In recent years, occupational science researchers have become increasingly aware of how the positive ideals exclude many occupations. Dr. Twinley introduced the idea of the dark side of occupation describing the occupations that don’t necessarily fit this positive ideal and therefore are often not explored in practice or research – they are left in the dark/unilluminated [9]. As such, Twinley introduced the term of ‘illuminating’ occupations which incorporates that some occupations are unilluminated for various reasons: they may be unhealthy as described above, but these occupations could also be illegal, potentially harmful or in other ways challenge our belief in occupations leading to health [9,10]. Similarly, Kiepek et al. explicates how we are silent about and ignore what they call non-sanctioned occupations. Their concept of non-sanctioned occupations includes occupations that do not comply with social norms and/or legislation [11].

If occupational therapists (OTs) and occupational scientists focus solely on positive aspects of occupation, we risk minimizing subjective experiences and clients’ full occupational repertoires might remain unaddressed in therapy and research [4]. Furthermore, understanding what drives people to engage in occupations that are viewed to be on the edge of societal acceptance can broaden our understanding of humans as occupational beings.

In her introduction on illuminating the dark side of occupations, Hart argues that if we judge or ignore certain occupations, we might also risk further marginalizing already marginalized individuals engaging in them, thus contributing to their exclusion from society [12]. Furthermore, to enable that we identify and work with occupations that are valued by our clients, client-centered practice (CCP) is a prominent value of OT [2,12]. However, if we are to practice in a client-centered manner and be sincere in our search for what matters to our clients, we must examine (as proposed by Stewart and colleagues [4]) our own values, beliefs, and attitudes, and reflect on the impact that these personal factors might have on the practice process. To truly work in CCP we need to be observant of how our personal beliefs and professional discourse might make us overlook certain types of occupations and their value to our clients. Thus, acknowledging that UO might be of importance to our clients, and considering how these could or should be addressed, is critical.

The concept of unilluminated occupations is novel in the Danish OT profession. In Denmark, the idea was only recently introduced by Dr. Hart in the Danish Occupational Research Magazine [13]. For this reason, we might not have a shared understanding of how to address, name, or include this topic in a Danish context.

Therefore, the aim of this study was to examine how the concepts should be translated into Danish, how Danish OTs view these occupations, and what they consider their role should be in addressing them. This study poses the following research question:

• How do we most appropriately translate terms related to the concept of unilluminated occupations into Danish, and how do Danish OTs consider and address these occupations?

Terminology

In discussing and problematizing the positive view on occupations and shedding light on less-explored occupations, different terminology is used in different countries. Twinley (UK) introduced the term ‘the dark side of occupation’ [9,10], whereas the Canadian occupational scientists such as Kiepek describe ‘non-sanctioned’ occupations [11]. Hart (UK) argues that although these two terms differ, they might be an attempt to conceptualize the same aspect of occupation [13]. Both concepts highlight the pervasive positive discourse on occupation in OT and they both challenge the profession’s moral positioning and value judgements [9].

Naming lesser-explored occupations ‘the dark side’ has been understood as and criticized for denoting negative connotations of occupations themselves being dark, dangerous, or evil in nature. Twinley and peers rather use the terminology to illustrate that occupations are left in the dark because we tend to overlook them [9]. However, because of the negative connotations, we will steer away from this terminology and instead (leaning on the analogy used by Twinley of illuminating these occupations) label them unilluminated occupations (UO) for this study.

Occupations may fit under the unilluminated umbrella for various reasons. Based on the literature on the topic, the adjectives listed below have been used in defining these occupations. Most often these words are examples of how occupations are framed rather than an objective judgement of their inherent character [9–11,13–15].

Table

Unhealthy Harmful   Health-compromising  Damaging   Deviant   Destructive   Illegal

Anti-social + not prosocial   Immoral   Not productive   Abnormal   Undesired   Unacceptable   Inappropriate

A wide range of occupations potentially fall within these labels. Hocking [9] goes through the sparse literature covering UO and mentions occupations such as: Smoking, skateboarding, sustained playing of a musical instrument to the point of overuse injury, drug use, addiction, binge drinking, begging, tagging (a form of graffiti), growing olives in Palestine and everyday occupations in the setting of a displacement camp. Other papers include cooking with an eating disorder [16], sex work [6,8], running marathons (mentioned in [11]), and playing computer games [5] as UO. The diversity of these examples clearly demonstrates how the notion of acceptable and unacceptable or healthy and unhealthy is highly culturally dependent.

Methods

To fulfil our aim, the study was conducted as a cross-sectional study with a survey to obtain data from a wide variety of Danish OTs in two parts. As no previous research on the topic has been conducted in Denmark, the first part of our study was to translate the terminology into Danish, dealing with cultural adaptation in the process. In the second part we examined the OTs perception of UO based on a survey originally developed by Dr. Mahaffey and students at Midwestern University, Chicago, USA. In this survey, the definition of UO was developed with consultations from experts Gail Whiteford, Ph.D., Clare Hocking, Ph.D., Clement Nhunzvi, Ph.D., and Rebecca Twinley, Ph.D. [17]. The translation of terminology was conducted on this material.

The survey consisted of 23 quantitative questions, adding three open-ended questions as a small, secondary qualitative component in the end. However, only five comments were drawn from the qualitative data and used verbatim to illustrate the quantitative results. The remaining results from the open-ended questions will be presented in a separate paper.

Part one: translating the survey

The survey (see Appendix A, Supplementary Material) was composed with an introduction including definitions of five terms selected to cover the scope of UO. Then followed quantitative questions divided into four sections: (1) ‘awareness and exploration’, (2) ‘OT and specific UO’, (3) ‘UO as part of an inclusive profession’ and (4) ‘including UO in professional discourse’. The survey also included three open-ended questions and gathered background information on respondents.

Due to the lack of a Danish terminology in this area of occupational science, we wanted to ensure a conceptually sound translation process in which we aimed to appropriately translate and culturally adapt the content of the questionnaire related to the terminology of UO into to a Danish context. Therefore, the translation was conducted partially following the guidelines for translation and cultural adaptation of patient-reported outcomes measures presented by ISPOR in 1999 [18]. The guideline presents a translation process in ten steps. Since our aim was to translate the concepts into Danish to (a) establish a Danish vocabulary, and (b) heighten transferability to enable future comparison with the results obtained with the American survey, we used the ten steps as follows:

First, we conducted steps 1–6 in which we translated the content into Danish, followed by steps 9–10 where we finalized the process and prepared the survey for distribution. Then, as part of the survey, we added steps 7–8 aiming to validate the chosen vocabulary based on the Content Validity Index for Items (CVI) [19]. The process is presented here:

1. Preparation: to examine the topic of unilluminated occupations in Denmark and enable comparison between our countries, we established collaboration and obtained permission from Dr. Mahaffey and students [17] to translate the survey into Danish.

2. Forward translation: the Danish authors individually translated the survey into Danish based on our professional understanding of the concepts described.

3. Reconciliation: the Danish authors discussed discrepancies for each item on the survey sentence by sentence and reached a consensus on the translations.

4. Back translation: This Danish version of the survey was back translated literally into English by a bilingual expert.

5. Back translation review: The English translation was evaluated by Dr. Mahaffey assessing whether the conceptual, cultural contents was equivalent to the original.

6. Harmonization: Feedback from Dr. Mahaffey was taken into consideration and needed adjustments were made in the Danish translation.

After deciding on translation of the Danish terms we included the cognitive debriefing (step 7–8) in the end of the Danish survey. Based on the CVI the respondents were asked to evaluate the five terms from the introduction in terms of their relevance in a Danish context on a scale of 1–4 [19].

1. Proofreading. As part of the finalization of the survey, three pilot tests were conducted. These confirmed that the questions were understandable and that the survey could be completed in 15 minutes. Minor errors in grammar and spelling were corrected, and the survey was finalized in SurveyXact [20].

2. Final report. As recommended, to enable future considerations and derivative translating, the first author ensured keeping track on the translation and cultural adaptation decisions through the process (see Appendix B, Supplementary Material).

Part two: conducting the survey

Data collection

The data was collected using a survey set up in SurveyXact [20]. As we wanted to gain replies from a broad sample of OTs working in Denmark, only two inclusion criteria were applied: (1) holding an OT degree and (2) having worked as an occupational therapist in a Danish practice setting for a minimum of two years, as reflecting on UO demands a degree of professional reasoning, novices might not master [21]. Furthermore, both criteria were applied in the original survey from the US [17], enabling us to compare results on a later instance. All OTs meeting these criteria were welcomed, whether their job title was exclusively OT or not. Based on numbers from the union for OTs, there are about 8100 OTs working in Denmark [22]. To obtain generalizable results and reduce the margin of error as much as possible, we aimed at getting at least 367 respondents [23].

Knowing that the response rates from digital surveys normally are low increasing the risk of bias [24–26], the survey was distributed through several channels. To ensure reaching OTs from all five regions in Denmark, the survey was sent via e-mail to all fieldwork coordinators connected to the seven university colleges offering OT programs, asking them to distribute the survey to their colleagues in the field. The Danish authors shared the survey on their social media profiles. Furthermore, a post was uploaded in a Facebook forum for OTs in Denmark, with 7200 OTs and student members, and a reminder was given after one week requesting members to complete the survey.

We acknowledge that a survey like the present might require gaining ethical approval in different parts of the world. However, this is not the case in Denmark. Adhering to the Declaration of Helsinki principles, participation in the study was based on informed consent, assuring anonymity and confidentiality for each participant [27]. Additionally, we followed EU’s General Data Protection Regulation (GDPR), ensuring that data is kept on a secure database and all data is handled in ways so that the individuals cannot be recognized [28]. Respondents were informed that by participating in the survey they gave consent to our use of the data for publishing purposes and were explicitly informed that we followed GDPR rules by ensuring full anonymity.

Data analysis

Most items in the survey were constructed on a 5-point Likert scale with respondents marking their agreement on a scale from 1 to 5. Background information was measured on a nominal scale. A descriptive analysis was conducted using tools in SurveyXact, to represent frequencies of the responses to the 23 quantitative questions, demographic background information, as well as the CVI. Results from CVI were analyzed by adding together the number of positive responses (highly relevant and relevant) and dividing by total number of respondents [29].

Results

The first section provides an overview of the final report of the translation of terminology as well as the CVI-results. In the following section results from survey will be presented.

Part one: final results

Here we present the process of translating the five terms introduced in the survey as covering the scope of how UO might be viewed. These five terms were chosen by Dr. Mahaffey and students during the development of the original survey with consultation from experts on the topic of UO. Table 1 shows how we went from the original wording through to the final choice of words in Danish following the steps described in methods section. The final choice of Danish words were ‘risikable’, ‘usunde’, ‘uetiske’, ‘umoralske’ and ‘uacceptable’.

Table 1. Final report.

Original	Forward translation	Recon-ciliation	Back translation	Back translation review	Harmoni-zation, final report
High risk	Høj risiko Risikable	Høj risiko	High risk	Authors discussed ‘høj risiko’ not fitting well grammatically as an adjective in parts of the questionnaire compared to ‘risikable’.	Risikable
Unhealthy	Usunde	Usunde	Unhealthy		Usunde
Unethical	Uetiske	Uetiske	Unethical		Uetiske
Immoral	Umoralske Amoralske	Umoralske	Immoral		Umoralske
Unsanctioned	Ikke tilladte ‘Ulovlige eller dømt ude af samfundet’ Upassende	Ikke tilladte eller upassende	Inadmissible or inappropriate	‘Unacceptable’ rather that ‘inadmissible or inappropriate’ was suggested, as ‘unacceptable’ holds both the meaning of being inadmissible by law or norms as well as being judged by societal views. This was also in line with how Kiepek et al. describe the meaning of sanctioning as a social-political process in which what is acceptable and unacceptable varies by culture, social class etc. and changes over time [11]	Uacceptable

CVI results

Majority of respondents deemed the five chosen terms ‘highly relevant’ or ‘relevant’ in a Danish context. Table 2 shows CVI scores for all five terms. The term ‘risikable’ (high risk) gained CVI-score of 0.90 and the term ‘uacceptable’ (unacceptable/unsanctioned) gained the CVI-score 0.72. Comments generally stressed the importance of context when using these words, as they could potentially be stigmatising taken out of context. This sentiment was especially prevalent for the term ‘uacceptable’ (unacceptable/unsanctioned). One respondent commented: ‘Language can heighten stigmatization, and if we want to speak with our clients about unacceptable, unhealthy, amoral, etc. occupations, they will feel judged from the outset’.

Table 2. CVI-I results.

Item	Highly relevant (n)	Relevant (n)	Irrelevant (n)	Highly irrelevant (n)	CVI-score
Highrisk	67	112	15	4	0.90
Unhealthy	79	91	22	6	0.86
Unethical	78	95	20	5	0.87
Immoral	52	103	27	16	0.78
Unacceptable	53	89	41	15	0.72

Part two: survey results

Demographics of respondents

We received 198 completed surveys. 347 respondents entered the survey, but 149 (42.9%) did not complete all questions. The incomplete surveys were excluded from results. Respondents included a wide range of OTs across the Danish OT practice. The mean age was 42 years (ranging from 25 to 66 years). The average work experience was 12.8 years (range 2–36 years). Respondents had experience from 30 different fields of work, including: rehabilitation (28%), social psychiatry (15%), welfare technology (13%), supportive housing facilities, public authorities/administration, NGOs, education and more. A comprehensive list of demographics can be found in Appendix C (Supplementary Material).

Questionnaire results

Overwhelmingly the respondents agreed (partially agree or totally agree) to the 23 survey questions. On average throughout the questions 78.60% agreed with the statements. However, some outliers within each section had especially many respondents agree or disagree. View all results in Table 3.

Table 3. Survey results.

Item	Totally Disagree	Partially Disagree	Neither agree nor disagree	Agree	Totally Agree
Awareness and exploration
Q1	9.1%	1.0%	0.0%	22.2%	67.7%
Q2	2.0%	4.5%	4.5%	36.9%	52.0%
Q3	1.0%	2.5%	5.6%	32.8%	58.1%
Q4	1.0%	1.5%	4.5%	30.8%	62.1%
Q5	4.5%	26.8%	11.1%	49.0%	8.6%
Q6	0.5%	3.5%	2.0%	30.3%	63.6%
OT and specific UO
Q7	2.5%	9.1%	7.6%	37.4%	43.4%
Q8	1.5%	2.5%	29.8%	31.3%	34.8%
Q9	3.0%	2.0%	11.1%	31.3%	52.5%
Q10	0.5%	1.0%	4.5%	27.3%	66.7%
Q11	7.1%	15.2%	30.8%	28.3%	18.7%
Q12	3.0%	6.1%	32.3%	28.8%	29.8%
Q13	4.5%	5.1%	18.2%	32.8%	39.4%
UO as part of inclusive profession
Q14	2.0%	6.1%	9.6%	33.3%	49.0%
Q15	2.0%	4.5%	21.7%	29.8%	41.9%
Q16	2.0%	2.0%	7.6%	22.2%	66.2%
Q17	0.0%	0.5%	10.1%	29.8%	59.6%
Q18	1.5%	10.6%	27.3%	26.8%	33.8%
Q19	2.0%	4.0%	15.2%	35.4%	43.4%
Including UO in OT discourse
Q20	1.0%	1.5%	2.0%	26.8%	68.7%
Q21	0.5%	5.6%	15.2%	33.3%	45.5%
Q22	0.5%	8.1%	18.2%	28.3%	44.9%
Q23	2.0%	7.6%	18.2%	35.4%	36.9%

The first section ‘awareness and exploration’ pertains to how the respondents viewed the concept of UO overall. In all questions but one, about 90% of respondents agreed. 89% agreed that OTs should consider the purpose and significance of occupations that are in contention with dominating cultural norms, values, and practices. This sentiment is represented in a comment about a client with drug use and criminal occupations: ‘Examining the reason or meaning of the occupation for the person was important for me to be able to ‘guide’ the person as open-mindedly as possible’. 94% of respondents agreed on item 6 that there could be an ethical dilemma between encouraging safe, health promoting occupational engagement and a client-centered approach, if a client’s preferred occupations were considered risky, unhealthy, immoral, unethical, or unacceptable. 93% agreed that cultural norms and values affect occupational engagement in meaningful occupations considered risky, unhealthy, immoral, unethical, or unacceptable. However, the question most disagreed upon of all was item 5: ‘Client-centred practice implies therapeutic responsibility for supporting the preferred occupations of the client, whether or not they are considered risky, unhealthy, immoral, unethical, or unacceptable’. 32% of respondents disagreed (‘partially disagree’ or ‘totally disagree’) with this statement. In line with this a respondent wrote: ‘But we should not actively support illegal behaviour’. Another respondent wrote ‘I cannot, however, support occupations which harm others directly’. Comments did have several examples of OTs supporting occupations within the scope of UO such as drinking alcohol, smoking marijuana, gaming, tattooing, and buying pornography. Other comments described balancing supporting occupations in order to be client-centered with ethical concerns by offering alternatives. An example is working towards a goal of opening a can of beer using a can of soda in sessions with OT. Another example is suggesting a piece of liquorice root to a client who had the habit of chewing on dirt.

Section 2 dealt with how OTs viewed specific UO in relation to OT. Overall, most respondents agreed with OT acknowledging and exploring the meaning of the specific occupations mentioned. Specifically, 94% agreed that the profession could play a far greater part in addressing occupational deprivation consequent to immigration and being confined in asylum centres. However, on several items a third of respondents neither agreed nor disagreed. For instance, 31% neither agreed nor disagreed that ‘Future education of OTs must address the impact of occupations on pollution, and how climate change affects occupational participation’ (item 11) and a substantial portion (22%) disagreed with this.

Section 3 related to developing a more inclusive OT practice. Respondents predominantly agreed to the questions in this section. This included that occupational science would benefit from including people whose primary occupations are unilluminated in research (item 19), and that we should develop a method of assessment that recognizes UO and creates a safe space for exploring these (item 14). Relevantly to the latter, a respondent commented: ‘[The value of talking more about UO in education and practice] could be development of assessment tools to explore the value of UO. Tools that are more directive/instructive for a non-judgmental exploration of what increases well-being’. 27% neither agreed nor disagreed and 13% disagreed that research should take a more critical look at occupations that are accepted but might carry a risky or unsanctioned aspect to them (item 18).

Section 4 pertained to including UO in professional discourse, in research and education. Like in the other sections, the majority of respondents agreed to the questions in this section. 10% disagreed that including UO in our education of OTs would reduce prejudice towards marginalized and oppressed groups and 72% agreed. Most noticeably in this section, 96% of the respondents agreed that the OT profession must include discussions about UO in order to be truly inclusive. A respondent commented ‘If it [UO] was mentioned more in the education and in practice, one could hope it would result in a more open-minded approach […] and with that a deeper understanding that not every person fits into the box of what we view as a “normal citizen”’.

Discussion

The aim of this study was to examine how the concepts of UO are best translated into Danish and how Danish OTs view the occupations and their role in addressing them. Results from CVI on the chosen terminology showed that the majority of OTs deemed the terms relevant in a Danish setting, however, giving context to the words was important to avoid stigmatizing individuals who engage in UO. Language can indeed impact stigmatization. A study done by Goddu et al. [30] showed that using certain words in medical records of patients affected practitioners’ attitudes towards patient and even medicine prescribing behaviour. Ashford et al. [31] similarly found that the language used to describe substance use and substance use disorders affected explicit negative or positive bias. Although Goddu et al. and Ashford et al. [30,31] studied language use referring directly to patients, the impact of language use on stigmatization of clients might be true of the language used around occupations as well. In line with Stewart at al. [4], we find it appropriate to view occupations as inherently neutral and to be wary of labelling clients’ occupations ‘unhealthy’, ‘unacceptable’, ‘immoral’ etc. in practice. On this basis, the five terms appear to be relevant in Danish to describe UO specifically in terms of how they are viewed by wider society.

Overall, the OTs showed positive attitudes towards including UO more in professional discourse and research as well as exploring and acknowledging the value of UO to clients. The OTs believed the profession would benefit from developing an assessment that recognizes UO and creates a safe space for exploring these. However, they saw a potential ethical dilemma between a client-centered approach and a client preferring to engage in UO. A third of respondents disagreed that a CCP implies OTs have a responsibility to support UO if a client prefers these. For instance, some respondents drew the line at occupations that are harmful to others or illegal, others offered alternative occupations. In this way, clients’ wishes about UO could pose an ethical dilemma for OTs since on the one hand, based on our codes of conducts, we are ethically obliged to assist clients in pursuing their occupational goals [2,32]. On the other hand, as health professionals we are obliged to provide health services defined by health institutions to meet the needs and demands of our clients [33]. Lastly, as citizens, we are obliged to comply with the laws.

All the same, the respondents overwhelmingly agreed that the OT profession needs to include discussions about UO to be inclusive. This view is aligned with previously mentioned Stewart et al. [4], who argued that excluding UO from professional and academic discourse leaves clients’ full occupational repertoires unacknowledged or ignored. Similarly, avoiding difficult discussions like for instance on deliberately dying or how to address eating disorders, may add to the feeling of being left alone or stigmatized [16,34]. Respondents agreeing that the profession needs an assessment method which recognizes UO might indicate a willingness to further address clients’ full occupational repertoires.

Examining the purpose of and acknowledging the meaning of UO was also agreed with by most respondents. This perspective is supported in research by Huglstad et al. [6] and Asaba et al. [5] whose studies showed that occupations that are deemed unacceptable or unhealthy can indeed hold positive meaning to their partakers. However, as a review on sex workers found that criminalization of sex work increased risk of poorer social and health outcomes in sex workers [8], it seems as though legalization might decrease the risks of some UO [8]. As agued by Hart [13], this calls for OTs to advocate for their clients’ rights in choice of occupations, so that we do not risk further marginalizing already marginalized individuals, thus contributing to their exclusion from society. Although including in discourse, examining, and acknowledging the value was widely supported, which is unsurprising, since a previous survey of Danish OTs’ attitude towards CCP showed almost 100% support for CCP [35], the notion most disagreed with was that OTs have a responsibility to support the occupations as part of CCP. Greber [in 9] argues that client-centeredness does not entail adhering to every choice a client wants to make for an intervention without ‘at least drawing the client into conversations about their choices’ [9,p.100]. He, as Stover [33], proposes that OTs works together with their client in search for the meaning and purpose that the occupations provide, and that together they might be able to find alternative ways of meeting these needs without the legal, moral, or health-related consequences. Approaching the occupations by offering alternatives is also represented in the results of this study. Respondents similarly agreed that a CCP could pose an ethical dilemma when a client prefers to engage in UO. According to Greber, OTs must balance ethical and pragmatic concerns: what is right and what is possible [in 9]. As defined in the Guiding Principles for Ethical Occupational Therapy published by the WFOT, OTs must be accountable to society for the use of their expertise in the service of others, acknowledging that conflict may occur for example, when respecting autonomy of an individual while ensuring no harm. In responding to such dilemmas, the WFOT suggests an appropriately rigorous ethical deliberation process should be used [32]. In the current study, some OTs leaned on pragmatic factors such as legislation and would not support illegal occupations, nor support occupations that are harmful to others from an ethical standpoint. However, it has been shown that occupations themselves are not dichotomously good or bad in nature [4], which means ‘what is right’ is not always clear. Correspondingly, whether or not OTs had a responsibility to support the occupations was the question most disagreed with, thus it was also the question with most difference in opinions between respondents. This might reflect a lack of consensus on how to address UO in practice and that it is up to each practitioner to judge when to support an occupation and when not to. This calls for OTs to be able to reflect on their own practice as critical thinkers (as purposed by Hammel [36] and WFOT [32]) and apply professional reasoning [21].

Methodological considerations/limitations

347 respondents begun the survey and 198 completed it. The target sample size was 367. With 198 respondents included in results, the margin of error is 6,88% rather than the 5% aimed for [23]. Ideally the survey would have been distributed to every person in the target population, however contact information on every OT was not available. Instead, as recommended, we aimed to increase response rates by placing the survey on all the Danish authors’ social-media accounts, as well as repeating the invite [24,26]. This made the survey distribution rely on recipients forwarding the survey to colleagues and network as well as members of the Facebook group and on social media like Linked-In noticing the post. For this reason, we do not know the amount of people who received the survey, nor the characteristics of non-respondents, hence the potential nonresponse bias is unknown [24,37].

A large portion of respondents did not complete the survey. It is possible that some responders got overwhelmed by the novelty of the topic making them discouraged from completing the survey, although the initial description or topic sparked interest. By pilot testing the survey we sought to ensure that questions were accessible, and our pilot-testers said that the survey took no longer than 15 min to complete. However, it seems that to some the expanded time needed to consider and reflect on the questions was longer than anticipated, making them stop. This was unfortunate as it reduced the amount of responders completing the survey, and might have added to potential selection bias [26,37].

As the survey is not a standardized measure, all responses could have been included in the results, in which case the numbers of respondents would have been nearly representative for results from the first questions. Authors chose to exclude noncompleted surveys to ensure that the same group of respondents had replied to all questions. By doing this, we were able to compare results from each question without considering potential differences in those who answered the last questions vs. those who only answered the first and then stopped. However, since the respondents included were demographically similar to OTs in Denmark in general in regard to gender, area of work and age [22], this heightens the representativeness of our sample.

Results showed that a third of respondents neither agreed nor disagreed on a few items. Choosing to include a neutral point on a Likert-scale allows respondents to use this option when they truly feel neutral about the question. However, it may also be used when respondents do not know or do not want to answer the question [38]. It is possible that the novelty of the topic made some respondents unsure or that the specific questions were particularly inaccessible in terms of content or phrasing. However, in including the neutral option we potentially avoided gathering false positive or negative results and might have kept some respondents from withdrawing from the survey.

To fulfil our aim, we used an existing survey albeit not standardized. The original survey was developed, as recommended [26], with consultation from experts on the topic of UO and thoroughly pilot tested before distribution. As such, we found the development of the content robust, adding to the credibility of our findings. However, given the known cultural aspects of UO, as well as ensuring that the questions were formulated in a clear, straight-forward way, e.g. avoiding double-barrelled or ambiguous questions for the Danish OTs [26], we undertook a lengthy translation process, re-formulating the questions in manners appropriate for use in Denmark, while securing through the involvement of the developer that the content was the same as the original survey [18]. Doing so we ended having a survey that enables us to compare the results from the USA and Denmark. Including the CVI [19,29] to validate the translation of specific terms used to encompass UO in the end of the survey rather than executing it with a panel of experts resulted in a much broader insight into how the five terms were viewed by OTs.

One known disadvantage of the survey method is that the data produced tends to be superficial and lack depth [24–26]. To compensate for this, we added open-ended questions on which we had many replies (printed it was 35 pages). As it would extend the length of the present paper without being thoroughly examined, we therefore have included these qualitative replies in an in-depth qualitative study, we presently undertake and intend to publish later.

Implications and future research

Results imply that the translations of the pre-chosen terms were relevant in Danish. In future research, consulting Danish occupational scientists on their expert perspectives on how to linguistically address the concept of UO in Danish in general could enrich the field in a Danish context.

Our findings suggest that there is no clear consensus when it comes to addressing UO in interventions. Results also suggest a need for an assessment method that recognizes UO and creates a safe space for exploring these. With a potential lack of consensus or clear guidelines on how to address UO in assessment and intervention, OT professionals might have to rely on personal views when approaching UO in practice. Further research might shed light on ways to approach UO both in assessment and intervention to develop guidelines and assessment tools that include UO specifically.

Conclusion

Overwhelmingly, OTs in this study agreed that the OT profession must include discussions about UO to be inclusive. Overall, they showed positive attitudes towards examining and acknowledging the purpose and significance of UO to their clients. However, our findings also suggest a lack of consensus when it comes to addressing UO in interventions: OTs disagreed on whether they have a responsibility to support UO or not and saw a potential ethical dilemma between encouraging safe, health-promoting occupational engagement and a client-centered approach, if a client’s preferred occupations were UO. Similarly, OTs saw a need for an assessment method that recognizes UO and creates a safe space for exploring these. Thus, guidelines and assessment tools that explicitly include UO should be developed.

The Danish terms ‘risikable’, ‘usunde’, ‘uetiske’, ‘umoralske’, and ‘uacceptable’ appeared appropriate to encompass UO specifically in terms of how they are viewed by wider society.

Disclosure statement

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