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ISSN 2526-8910

Reflection Article/Essay

Action on the social determinants of health:

Advancing occupational equity
and occupational rights
Actions in social health determinants: Advancing
occupational equity and occupational rights1
Karen Whalley Hammella ÿ
a Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British
Columbia, Vancouver, Canada.

How to cite: Hammell, K.W. (2020). Action on the social determinants of health: Advancing
occupational equity and occupational rights. Brazilian Occupational Therapy Cadernos. 28(1), 378-400.
https://doi.org/10.4322/2526-8910.ctoARF2052

Abstract
Epidemiologists have sought to focus global attention on the “social
determinants of health” - the conditions in which people are born, grow, live,
work and age - and on the impact of the inequitable distribution of these
determinants on people's opportunities to be healthy. Evidence demonstrates,
unequivocally, that occupation is a determinant of human health and well-being.
Because inequitable social determinants shape the availability of health-
promoting occupational opportunities, occupational therapists have raised the
importance of addressing occupational injustices. However, theoretical
scholarship pertaining to occupational justice and occupational injustice has
been disproportionately dominated by the culturally-specific perspectives of
Anglophone theorists from the Global North. The purpose of this paper is to
highlight some of the problems and confusions arising from Anglophone
scholarship on occupational injustices; and to highlight the importance of action
on the social determinants of health through occupation.
Confused definitions of various occupational injustices are unhelpful to
practitioners. The occupational therapy profession could actively address the
social determinants of occupation through focusing on occupational equity and
occupational rights, informed by existing scholarship on human capabilities.
Issues of occupational rights, denial of occupational rights (occupational
injustices), and of in/equities of occupational opportunities ought to be
fundamental issues for the occupational therapy profession, whose most
pressing concern should surely be: how can occupational therapists most

1 Text translated by Professor Vagner dos Santos, from Charles Sturt University, Australia, contributing with Cadernos
Brasileiros de Terapia Ocupacional.

Received on Jan. 27, 2020; Accepted on Jan. 27, 2020

This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Cadernos Brasileiros de Terapia Ocupacional, 28(1), 378-400, 2020 | https://doi.org/10.4322/2526-8910.ctoARF2052 378

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Action on the social determinants of health: Advancing occupational equity and occupational rights

effectively address the social determinants of occupation such that all people
have the capabilities to engage in meaningful occupations that contribute
positively to their own well-being and the well-being of their communities, as is
their right.

Keywords: Human Rights, Wellbeing, Social Justice, Knowledge.

Summary

Epidemiologists are seeking to focus global attention on the “social determinants

of health” – the conditions in which people are born, grow, live, work and develop
– and the impact of the unequal distribution of these determinants on the
opportunities of people will be healthy. The evidence demonstrates, unequivocally,
that occupation is a determinant of human health and well-being. Due to the
modeling of the availability of occupational opportunities to promote health
among different social determinants, occupational therapists value the importance
of addressing occupational injustices. However, studies relating to occupational
justice and occupational injustice have been disproportionately dominated by the
culturally specific perspectives of Anglophone theorists of the Northern
Hemisphere. Highlight some serious problems and confusions based on
Anglophone studies on occupational injustices and highlight the importance of
actions taken for the social determinants of health by occupation. Confusing
definitions of various occupational injustices are useless for professionals.
Occupational therapy could actively address the social determinants of occupation
by focusing on occupational equity and occupational issues, informed by existing
theoretical studies on human capabilities. Problems of occupational rights, denial
of occupational rights (occupational injustices) and iniquity/equity of occupational
opportunities must be fundamental for occupational therapy, whose greatest
concern should be: as occupational therapists, indeed, we address the social
determinants of occupation in such a way so that all people have the capacity to
engage in meaningful occupations that contribute positively to their well-being
and the well-being of their community, once it reaches everyone.

Keywords: Human Rights, Bem-Estar, Social Justice, Conhecimento.

1 Introduction
Epidemiological researchers report that the chances of leading a flourishing life are unequally
distributed, such that life expectations are significantly reduced and ill health is markedly increased among
those lower on the socioeconomic hierarchy and among those who experience chronic stresses arising
from discrimination, and exploitative and oppressive societal conditions (Krieger, 2012; Marmot, 2004,
2015; Marmot et al., 2008; Thoits, 2010). Accordingly, they have sought to focus attention on the “social
determinants of health” - the conditions in which people are born, grow, live, work and age (Marmot, 2004,
2015; Marmot et al., 2008, 2012) - and the World Health Organization (2018) has declared that “[…] the
social determinants of

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“health are mostly responsible for health inequities – the unfair and avoidable differences in
health status seen within and between countries.”
Occupational therapists recognize that inequitable social circumstances shape the availability
of the occupational opportunities that determine what people are able to do, can choose to do,
believe they should do, or can envision doing (eg Bailliard, 2013; Gallagher et al., 2015; Galvaan,
2015; Hammell, 2019; Ingvarsson et al., 2016; Yet although dominant theoretical models, such
as the Canadian Model of Occupational Performance and Engagement (CMOP-E, Townsend &
Polatajko, 2007), recognize the influence of social and institutional environments on occupational
engagement, surprisingly little professional attention in the Global North has focused on
addressing the social determinants of occupation, or on engaging meaningfully in the struggle to
achieve a society that respects everyone's occupational rights and that provides equity of
occupational opportunity (Hammell, 2020; Levack & Thornton, 2017). Indeed, although a wealth
of cross-cultural and cross-disciplinary research evidence demonstrates, unequivocally, that
occupation is a determinant of human health and well-being (Hammell, 2020) the occupational
therapy profession in the Global North has neither advanced occupation as a

determinant of health, nor actively promoted the occupational rights of all people to engage in
occupations that contribute positively to their health and well-being.
It is regrettable that dominance of the English language within the international publishing
industry - coupled with active promotion, vigorous marketing and extensive export - has
effectively reinforced the global supremacy and hegemony of occupational therapy assumptions,
theories and modes of practice derived from Western knowledge, and informed by urban
Western perspectives, priorities and concerns (Emery-Whittington & Te Maro, 2018; Hammell,
2009a, 2009b, 2011, 2015a, 2019; Magalhães et al., 2019; Yañez & Zúñiga, 2018; Yang et al.,
2006 ). This constitutes a neo-colonial and neo-imperialistic dominance that excludes diverse
worldviews and that neither enables nor permits equality of the opportunity to contribute
knowledge derived from other perspectives (Grech, 2012; Martín et al., 2015; Santos, 2014).
This inequality is epitomized by occupational therapy's theoretical scholarship pertaining to
occupational justice and occupational injustice, which is disproportionately dominated by the
perspectives of Anglophone theorists from the Global North. I employ the terms “Global North”
or “West” to refer to North America, Northern Europe, Australia and New Zealand. Clearly, these
are inadequate terms, not least because Australia and New Zealand are not, geographically, in
the north! However, these are useful ways to refer to the small (white) minority of the global
population that has traditionally wielded the majority of the world's power, wealth and cultural
influence (Connell, 2007); and acknowledges that “[…] the economic and epistemological
dominance of the global North has outlived colonialism” (Cleaver, 2016, p. ii).

The occupational therapy profession evolved in North America and the United Kingdom in
the early part of the twentieth century and was subsequently exported to nations of the Global
South and East by practitioners from Western countries, consistent with long-established colonial
and imperial practices and with recent processes of globalization (Hammell, 2011, 2015b, 2019).
Many occupational therapy

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students traveled from their home countries in the global South and East to be
educated in the USA or UK and have developed occupational therapy education
programs and services in their home countries encultured by theories and inspired by
practices that arose within contexts very different from their own ( Hammell, 2019;
Lim & Duque, 2011; This has contributed to the global dominance of ideas originating
in North America, Australasia and Britain; ideas which may have limited relevance in
the majority world contexts to which they have been exported (Gretschel & Galvaan,
2017; Hammell, 2019; Iwama, 2006; Yazdani, 2017).

However, since the 1970s, innovative socially-focused, ethical, politically-astute

and rights-based approaches to occupational therapy have been developing in Brazil
(Galheigo, 2018; Malfitano et al., 2014a, 2014b, 2019). Galheigo (2005, 2011a,
2011b, 2014) and colleagues (Barros et al., 2005; Barros et al., 2011) have provided
English speakers with translated glimpses at Brazilian social occupational therapy
practices that derive “from a critical standpoint” (Galheigo , 2005, p. and exemplars
of socially-engaged, critical occupational therapy practices in Chile (Alburquerque &
Chana, 2011) and South Africa (Watson & Swartz, 2004) have provided further
inspiration and guidance for the profession in the Global North.
Despite these, and other Southern innovations, Galheigo (2011a, p. 65) has astutely
observed that, within the occupational therapy profession,

[...] contemporary history has witnessed the North and the West being
positioned or positioning themselves both as the source of inspiration and
provider of guidance or assistance for the South and the East.

This paper, which is offered as a contribution to ongoing Global South-North

dialogue, has three objectives. First, to sketch some of the problems and confusions
that have arisen from the Anglophone definitions of occupational justice and injustice
that currently dominate the occupational therapy literature; second, to highlight the
work of critical epidemiologists who have advocated action on the social determinants
of health; and third, to suggest a possible way forward for the occupational therapy
profession through a clear focus on occupational equity and occupational rights,
informed by existing scholarship on human capabilities.
It is important to preface this paper by declaring my social location as a white,
class-privileged, married, heterosexual, adult Anglophone cis-gendered female, with
neither physical impairments nor mental health challenges, and who holds citizenship
status within two nations in the Global North. I recognize, acknowledge and strive to
understand my ultra-privileged position as a member of a global minority, a settler
and citizen of a colonized territory (Canada) and also a citizen of a nation that
invaded, occupied and influences vast regions of the world as part of its colonial
endeavor (the United Kingdom). Clearly, the perspectives that derive from my position
and that shape my ideas are inevitably and unavoidably blinkered, slanted and
incomplete; not least because I am unable to read anything that is not written in
English. Furthermore, the unearned advantages and benefits that accrue to me
because of my multiple privileged social locations are a manifestation of the unjust
and inequitable occupational opportunities that this paper seeks to address.

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2 Occupational Justice: a Brief History of a Concept

The idea of occupational justice was first articulated within the Anglophone occupational
therapy literature by Wilcock (1998), redefined by Wilcock & Townsend (2000), redefined again
by Nilsson & Townsend (2010), and then again by Wilcock & Hocking (2015). Despite repeated
efforts to achieve an acceptable English definition of occupational justice, Durocher et al. (2014,
p. 427) observed that definitions of occupational justice proposed by occupational therapy
theorists, and repeatedly recited in the work of others, “[…] lack conceptual clarity, have not been
developed with reference to other bodies of scholarly work, and are not supported by empirical
evidence.” Considerable confusion was also noted within theorists' work, such that it was unclear
whether occupational justice constituted action to promote necessary change, or whether it
constituted an outcome - the accomplishment of change - leading to the observation that “[…] a
working definition of occupational justice remains elusive” (Hammell, 2017, p. 48).

A critical review has highlighted additional confusions among definitions of the five variants of
occupational injustice that had been named and then recited frequently within the Anglophone
occupational therapy literature – deprivation, alienation, imbalance, marginalization and apartheid
(see below) – and has identified significant problems with the criteria by occupation whichal
injustices are judged (Hammell & Beagan, 2017). This prompted the review's authors to
recommend that in the absence of scholarly debate and theoretical refinement, the term
“occupational injustice” should be used with extreme caution (Hammell & Beagan, 2017). Indeed,
because Anglophone theorists tend to muddle the concepts of rights and of justice as if they
(erroneously) believe these to be interchangeable terms, it was suggested that occupational
injustices should be understood, clearly and succinctly, as violations of people's occupational
rights (Hammell , 2017). “Occupational rights” have been defined 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”

(Hammell, 2008, p. 62). It could thus be claimed that a violation of occupational rights, due to
unfair and inequitable social conditions, constitutes an occupational injustice.

The World Federation of Occupational Therapists' Revised Position Statement on Occupational

Therapy and Human Rights (World Federation of Occupational Therapists, 2019) has been
amended in line with these criticisms, declaring that “Occupational justice requires occupational
rights for all” and articulating clearly that occupational justice “is the fulfillment of the right for all
people to engage in the occupations they need to survive, define as meaningful, and that
contribute positively to their own well-being and the well-being of their communities.” This is a
significant advance.

3 Occupational Injustices: Conceptualisations and Confusions

The occupational therapy profession in the Global North does not have a robust tradition of
rigorous scholarly critiques of theoretical ideas (Duncan et al., 2007), so it should not be surprising
that definitions of five occupational injustices, proposed by

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theorists more than a decade ago, have been subjected to scant critical analysis, and
recited repeatedly within the profession's literature as if they are believed to be correct
or “true”, or the product of expert consensus (Hammell & Beagan, 2017). This is
regrettable, because the obvious definitional confusions and overlaps among these
five forms of occupational injustice are profoundly bewildering for students, and
inordinately unhelpful for practitioners who are tasked with translating theories into
actions. For example, the concept of occupational deprivation was originally named
and described by Whiteford (2000) but later redefined by Townsend and Wilcock
(2004a, p.81), who asserted that occupational deprivation may arise “[…] when
populations have limited choice in occupations because of their isolated location, their
ability or other circumstances.” This was problematic, due to the inherent implication
that residence in a remote, rural location inevitably results in occupational deprivation,
and the suggestion that limited occupational choices are an inevitable consequence
of limited abilities rather than being produced by environments that are discriminatory
and that unjustly limit the opportunities available to disabled people (Hammell &
Beagan, 2017). When Stadnyk et al. (2010) subsequently redefined occupational
deprivation, they omitted any mention of the important element of occupational choice
and of inequitable constraints on people's abilities to make choices (Hammell &
Beagan, 2017). Moreover Crawford et al. (2016) highlighted the problem in determining
whether occupational deprivation pertains to an action by external forces, or to the
experience of being occupationally deprived.
It is unclear why occupational alienation was defined by Townsend & Wilcock
(2004b) without reference to the substantial and influential body of existing work on
occupational alienation by Marx (1964). This effectively limited the ability of
occupational therapists to communicate clearly with scholars from the social sciences
and philosophy (Hammell & Beagan, 2017). Occupational alienation has since been
redefined in the work of Stadnyk et al. (2010), and also of Nilsson & Townsend (2010)
as being a form of social exclusion consequential to restricting a population from
experiencing meaningful and enriching occupations. As a result, the concept of
occupational alienation is now conceptually indistinguishable from either occupational
deprivation or occupational marginalization (Hammell & Beagan, 2017). When
occupational marginalization was originally named as a form of occupational injustice
by Townsend & Wilcock (2004a), no definition was provided, although Stadnyk et al.
(2010, p. 339) subsequently provided a description, and also claimed that “[…]
occupational marginalization at its worst is a form of occupational apartheid.”
This indicates that some occupational injustices are conceptualized by theorists as
being subsets of other occupational injustices (Hammell & Beagan, 2017). Furthermore,
the conceptual distinction between early depictions of occupational deprivation – in
which people have limited choice in occupations – and occupational marginalization - in
which people are prevented from participating in their choice of occupations - is
unclear (Hammell & Beagan, 2017). The inevitable outcome of these confusing
definitions is apparent in the occupational therapy literature, where, for example,
occupational marginalization is bewilderingly associated with having “[…] too much…
to do” (Du Toit et al., 2019, p. 578) .
Occupational imbalance was identified as an occupational injustice by Townsend
& Wilcock (2004a), based on the assumption that human health and well-being depend

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upon a variation in people's occupational engagement. It is puzzling that occupational

imbalance has not been discussed with reference to the significant body of scholarly
work exploring occupational balance (eg Backman, 2004; Eklund et al., 2017;
Wagman et al., 2012; Wagman et al., 2015), yet in the absence of an agreed
definition of occupational balance it is impossible to determine whether an
occupational imbalance exists (Hammell & Beagan, 2017). Does occupational
balance - and thus occupational imbalance – pertain, for example, to quantities of
time engaged in specific occupations or to qualities of experience while engaged in
occupations; to a balance of engagement among “categories” of occupation
prioritized by Western theorists (self-care, productivity, leisure) or to a balance of
engagement among categories of occupation valued and prioritized by those
engaged in occupation; to a balance among a range of occupations that are
meaningful to the individual, or those that are meaningful to a collective; to a balance
among occupations undertaken to fulfill individual or collective needs, aspirations or
priorities; to a balance between obligatory and chosen occupations, between active
or restful occupations, or between solitary, co-operative or collective occupations; or
to a balance among the locations (eg within the home, in a building, on one's land
or in nature) where occupational engagement occurs (Hammell & Beagan, 2017;
Hammell, 2020)? Does an occupational injustice exist if the apparent “imbalance”
among someone's occupations fits with their own priorities? And for how long does
an occupational imbalance have to exist before it becomes an injustice? A year? A
month? A week? Once again conceptual boundaries are unclear, with occupational
therapy theorists' definition of occupational imbalance (Townsend & Wilcock, 2004a)
substantially replicating Marx's definition of occupational alienation. Furthermore,
because Townsend & Wilcock (2004a, p. 82) described occupational imbalance “[…]
as a form of occupational apartheid”, it is apparent that occupational imbalance - like
occupational marginalization - is a subset of occupational apartheid within a
hierarchical system of injustices. It is regrettable and unhelpful that there has been
no further work to explain the hierarchy of occupational injustices to which these
theorists repeatedly allude (Hammell & Beagan, 2017).
First identified by Simó-Algado et al. (2002) and later defined in more depth by
Kronenberg & Pollard (2005), occupational apartheid is unique among the five
proposed forms of occupational injustice in having both an unambiguous definition
and a clearly-identifiable causation (Hammell & Beagan, 2017). Occupational
apartheid is defined as “[…] systematic segregation of occupation opportunity”
(Kronenberg & Pollard, 2005, p. 59) that occurs

[…] through the restriction or denial of access to dignified and meaningful

participation in occupations of daily life on the basis of race, colour,
disability, national origin, age, gender, sexual preference, religion,
political beliefs, status in society, or other characteristics (Kronenberg &
Pollard, 2005, p. 67).

Furthermore, a clear statement outlines both the causes and consequences of

occupational apartheid:

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[…] occasioned by political forces, its systematic and pervasive social,

cultural, and economic consequences jeopardize health and well-being
as experienced by individuals, communities, and societies (Kronenberg
& Pollard, 2005, p. 67).

Obviously, it is therefore inappropriate to misapply the term “occupational

apartheid” to situations that do not match this precise definition and its specific,
political, causality; and it is bewildering how occupational imbalance and occupational
marginalization can be constructed to be subsets, or instances, of occupational
apartheid as Stadnyk et al. (2010) and Townsend & Wilcock (2004a) have insisted.
Furthermore, existing literature implies that the five forms of injustice that have been
named, described and promoted by Western occupational therapy theorists are the
only possible manifestations of occupational injustice, but no evidence supports this
premise and it is surely naïve and unwise to place theoretical blinkers on the capability
to perceive potential instances of occupational injustice2 . Brazilian occupational
therapists have drawn attention to the imperative for the profession to use
unambiguous language that may be transmitted clearly to clients and others, and
that embodies the clarity necessary for international transferability (Magalhães &
Galheigo, 2010). It is apparent that clarity of English terminology concerning
occupational injustices has not yet been achieved.
This very brief critique has attempted to highlight a few of the fundamental
conceptual difficulties with existing variants of occupational injustice, and in so doing,
to suggest that these perplexing categories are inadequate to inform research,
advocacy or action. The following section provides a brief overview of the social
determinants of health as a prologue to considering why and how occupational
therapists might frame their endeavors to address inequities in terms of occupational rights.

4 The Social Determinants of Health

Anglophone occupational therapy theorists in privileged corners of the Global
North have claimed that all humans participate in occupations as autonomous agents
(Stadnyk et al., 2010; Townsend, 2012), and have a long tradition of asserting that
people - all people - choose, shape and orchestrate their everyday occupations (eg
Clark & Jackson, 1989; Kielhofner, 2008; Yerxa, 2000). Assumptions of unrestrained
autonomy and free and unfettered choice fit comfortably with North America's
dominant neoliberal ideology, which promotes individualism, independence, self-reliance
and the notion of personal responsibility for one's circumstances, blames people's
misfortunes on their own “poor choices” and underpins occupational therapy's
fondness for individualistic interventions (Hammell, 2020). However, this toxic
ideology has been vigorously challenged by critical epidemiologists and public health
researchers, who insist that health behaviors and actions are not the products of free
choice and autonomous action, but result, instead from inequitable social factors that
determine people's abilities and opportunities to engage in health-enhancing

2
For a more thorough review of some of the confusions and problems inherent to existing Anglophone concepts of
occupational injustice, see Hammell & Beagan (2017).

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behaviors (Baum & Fisher, 2014; Frier et al., 2017; Frohlich & Abel, 2014; Marmot, 2015;
Marmot & Bell, 2011). The Lancet-University of Oslo Commission on Global Governance for
Health (Ottersen et al., 2014, p. 635) concluded that “[…] the context in which all human activity
takes place presents preconditions that limit the range of choice and constrain action ”.
Recognition of profound inequalities in people's opportunities to be healthy has prompted
critical epidemiologists to focus on the “social determinants of health”, and on human rights-
based approaches to health improvement and promotion (Marmot, 2004, 2015; Marmot et al.,
2008 , 2012;

According to the World Health Organization (WHO), the social determinants of health are

[…] the conditions in which people are born, grow, live, work and age.
These circumstances are shaped by the distribution of money, power and
resources at global, national and local levels. The social determinants of
health are mostly responsible for health inequities - the unfair and avoidable
differences in health status seen within and between countries (World
Health Organization, 2018, w/p).

Researchers assert that people's abilities to be healthy and to live lives have reason to value

[…] are significantly socially produced (ie nurtured, protected, restored,

neglected or thwarted) by a range of political, economic, legal, cultural and
religious institutions and processes operating locally, nationally and globally
(Venkatapuram, 2011, p. 3) .

People who are economically and socially disadvantaged are born, grow, live, work and
age in inequitable environments, in which they experience disempowerment, confront material
and social hazards, and endure unfair and disproportionate exposure to violence, toxins,
hazards and ecosystem degradation (Gamieldien & Van Niekerk, 2017; factors which lead to
poor health and that significantly reduce life expectancies (Marmot, 2004, 2015).

Marmot et al. (2008, p. 1661) are unequivocal in asserting that

[…] the unequal distribution of health-damaging experiences is not in any

sense a natural phenomenon but is the result of a combination of poor
social policies and programs, unfair economic arrangements, and bad politics.

Thus, “[…] the right to health entails rights to equity in the social determinants of
health” (Marmot et al., 2012, p. 1014).
Income inequality, which is increasing exponentially within and between countries
(Braveman, 2012; Oxfam, 2016) exerts a negative impact on population health and
wellbeing (Pickett & Wilkinson, 2015). In societies where income inequalities are

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profound, physical health is worse, violence is higher, levels of illegal drug use are
significantly higher (Pickett & Wilkinson, 2010) and rates of mental illness are five
times higher than in more equal societies (Wilkinson & Pickett, 2010). Social
oppression, resulting, for example, from class, caste and gender inequities,
colonialism, racism, disablism, homophobia or transphobia, is a well-documented
and measureable social determinant of health; and structural inequalities such as
economic exploitation, inequitable transportation options and limited access to
education and employment opportunities diminish the well-being of specific groups of
people, thereby contributing to inequitable distributions of injury, illness and
impairment over the life course and across generations (Balsam et al ., 2011; Marmot,
2004, 2015; Importantly, racism, heterosexism, stigma and other forms of
discrimination are found to be effective, not solely in reducing the opportunities,
health, wellbeing and longevity of some, but in expanding
the opportunities and enhancing the health, wellbeing and longevity of those within
the dominant group (Lukachko et al., 2014). Inequitable (limited) opportunities and
disadvantages for some people inevitably lead to inequitable (expanded) opportunities,
privileges and advantages for others: as they are intended and designed to do by
those in positions of privilege (Wildman & Davis, 1995).
Because unequal social circumstances shape the available choices and determine
what a person can or cannot choose to do, or envision doing (Smith & Seward, 2009),
insights derived from research into the social determinants of health are of fundamental
relevance to occupational therapists. Thus, in South Africa, occupational therapists
have documented how structural inequities and chronic poverty violate people's “[…]
right to be occupied in activities that enhance self-sustaining human development”
(Watson & Duncan, 2010, p. 31); and in Australia, occupational therapists have
identified structural disadvantages and socioeconomic injustices that inequitably
impact the wellbeing and occupational rights of Indigenous people (Nelson, 2009).

Epidemiologists recognize that because inequalities in opportunities for full social

engagement and participation produce a social gradient of health - in which the health
and longevity of people closely match their economic and educational statuses -
efforts at health promotion require a focus, not solely on biology and behavior , but
on the circumstances in which people live and work, on equality of opportunity, and
on people's real abilities to choose among an equitable range of available
opportunities: their capabilities (Marmot, 2004).

5 Action on the Social Determinants: Opportunities and Capabilities

Amartya Sen (1985, 1999, 2005) outlined the “capabilities” approach as a way to
address human well-being, poverty and inequality from a human rights perspective.
The capabilities approach demands consideration of whether a person is able to do
the things they would value doing (their abilities), and also whether their circumstances
actually allow them to use their abilities to do what they would like to do (their
opportunities). The capabilities approach requires recognition

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[…] that a person's capabilities are significantly shaped (and perhaps at

least partly constituted) by their environmental and social circumstances –
both past and present (Entwistle & Watt, 2013, p. 33).

This approach focuses attention, not solely on the things that people actually do,
but on the range of choices that they can envision themselves doing and that are
realistically available to them (Robeyns, 2005; Sen, 1999; Trani et al., 2009) , and
recognizes that the ability to make and to enact choices is dependent upon both the
availability of real choices and of “meaningful opportunity” (Ryff & Singer, 1998, p. 3;
Connell et al., 2014).
Since Sen first articulated the capabilities approach, researchers and theorists
have demonstrated its merit as a means to establish disability as a human rights issue
and to focus attention on equality of opportunities, empowerment and participation (eg
Dubois & Trani, 2009; Graham et al., 2013; Stewart, 2005; Trani et al., 2009, 2011a,
2011b). Congruent with the understanding of disability long held and advanced by
critical disability theorists (eg Barnes, 1991; Neufeldt, 1999; Oliver, 1990), the
capabilities perspective recognizes that impairments do not inevitably lead to disability.
Rather, society creates and sustains disability through processes of ableism, stigma,
prejudice and discrimination that erect barriers to the full and equal participation of
vulnerable people who have disabilities (Trani et al., 2018). Thus, for example, an
impairment and female gender (both personal traits) may interact with poverty (a lack
of available resources) combined with a lack of support from the environment, to
create disability (Mitra, 2014). A man in a position of racial, class and economic
privilege with the same impairment (and thus the same degree of ability) may not
experience disability. Disability derives, therefore, from reduced opportunities and from
deprivation of basic capabilities.
People with mental distress experience disproportionate levels of poverty and are
more likely than most people to be victims of violence, to be homeless or to live in
disadvantaged areas, to be unemployed and under-employed and to experience
stigma and discrimination: factors that both produce and perpetuate mental illness and
that contribute to reduced life expectations (Brunner, 2017). Accordingly, Sen's
capabilities approach is being used by researchers concerned with mental health
recovery as a tool to highlight the lack of community supports and financial resources
that limit the substantive freedom for people with mental health problems to achieve
recovery through making meaningful choices from a range of real opportunities (eg
Onken et al., 2007).
Bailliard (2016, p. 4) has urged “[…] scholars and those advancing an occupational
perspective of health to consider adopting the capabilities approach as a philosophical
foundation for occupational justice”, a recommendation supported by Hammell (2015a,
2017) and Pereira (2017). Furthermore, occupational therapists have been encouraged
to frame the right to engage in occupations that contribute to people's survival, health,
and well-being as an issue of basic human rights (eg Bailliard, 2013; Galheigo, 2018;
Hammell & Iwama, 2012; Hasselkus, 2004;Witson & Duncan, 2014; Taff et al. (2014,
p. 324) contend that a human

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rights perspective is required both to inform the practices of occupational therapy

and to provide a basis for redefining the essence of the profession, and have
advanced the capabilities human rights framework as “[…] a foundation for
expansion of practice and research to meet global occupational needs and well-
being of individuals, communities and populations”.

6 Occupational Injustices and Occupational Inequities =

Occupational Rights Denied
So far, this paper has outlined some of the problems inherent to existing
Anglophone categories of occupational injustice. But it has also emphasized the
fundamental importance of a human rights approach to advancing human health
and well-being through attention to the social determinants of health, and has
advanced the utility of a capabilities approach in so doing.
Because all people have equal human rights, and because health is a human
right (Kallen, 2004), the right to engage in occupations that contribute positively to
health and well-being ought to be enjoyed equally by all people, regardless of
gender identity, sexual orientation , geographic location, race, ethnicity, age,
religious/non-religious affiliation, citizenship status, class/caste, dis/ability or any
other dimension of difference. Denial of occupational rights constitutes an occupational injustice.
I contend, therefore, that all occupational injustices and inequities could be
understood, clearly and succinctly, as violations of people's occupational rights
(Hammell, 2017).
I see no useful purpose in delineating five specific occupational injustices (an
endeavor that risks overlooking and obscuring all other instances of occupational
injustice), or in striving to establish parameters that might demark one form of
occupational injustice from all others (an endeavor that has proven futile over the
course of two decades). I believe it is fundamentally more important to attend to the
impacts of occupational injustices on people's lives than to determine what variety
of occupational injustice they are experiencing. If displaced people in refugee
camps, for example, are enduring profound disruptions to their habitual and valued
occupations and, as a consequence, severe suffering and disabling effects that
threaten their health and survival and that undermine the well-being of their families
and communities, it is surely both more useful and more effective to be able to
declare – unequivocally – that their occupational rights are being violated by their
circumstances of occupational inequities and occupational injustices, than to expend
energies arguing over whether occupational marginalization is leading to
occupational imbalance, or whether people are, instead, experiencing occupational
deprivation or occupational alienation, or both. More importantly, if occupational
therapists are to play any meaningful role in advancing action on the social
determinants of health through a focus on occupation, we shall need to be able to
use language that is unambiguous and devoid of discipline -specific jargon or
“academic- speak.” This is possible. It has been accomplished by the World
Federation of Occupational Therapists (2014, p. 1), for example, when it was declared, unequivocally, that

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Action on the social determinants of health: Advancing occupational equity and occupational rights

[…] all persons…by virtue of being human, have the right to occupational
opportunities necessary to meet human needs, access human rights, and
maintain health. This right is not conditional.

Numerous scholars have criticized the occupational therapy profession's abiding

concern with individuals' problems and simultaneous heedlessness to the structural and
systemic issues that impact the health and well-being, not just of individuals, but of
collectives (eg Gerlach et al., 2018; Gupta, 2016 ; Hammell, 2019, 2020; Hocking, 2012;
Rudman, 2013), and they have drawn attention to the fit between practices focused on
modifying individuals and the neoliberal political and economic agenda that dominates
the Global North (Hammell, 2020). Poverty, class, caste and gender inequities, sexism,
colonialism, racism, disablism, homophobia and transphobia, that are well-documented
determinants of health, are also determinants of occupational opportunity and engagement
(eg Beagan & Etowa, 2009; Bergan-Gander & Von Kürthey, 2006; ); Indeed, “[…]
occupational injustices that are experienced at the individual level frequently point to
larger structural issues of injustice” (Kinsella & Durocher, 2016, p. 163).

I support the containment

[…] that occupational therapists need to continue to advance the

development and application of collective approaches to occupational
justice to enable broader participation of people in their lives (Malfitano et
al., 2016, p. 177)

and believe this would contribute to increasing the social relevance and impact of the
occupational therapy profession.
I also believe that occupational therapists need to adopt a relational approach to the
idea of choice and autonomy, recognizing that capabilities are developed and exercised
within deeply interconnected and interdependent relationships with others (Entwistle &
Watt, 2013; MacDonald, 2002). Furthermore, I contend that a broad focus on occupational
injustice and its manifestations (eg social exclusion, discriminatory and inequitable access
to resources and opportunities) would enable a focus on the larger structural issues of
social injustices and their impact both on individuals and collectives, and that this would
be more fruitful than seeking to identify which of five labels best encapsulates the nature
of each injustice.
Poverty is one of the most important and consequential social determinants of health
(Canadian Medical Association, 2013; Marmot et al., 2008). The problems inherent to
poverty are not just about having inadequate financial resources, but about confronting
multiple forms of social exclusion, such as limited access to education, employment,
housing and transportation (Sakellariou & Pollard, 2009). Researchers have therefore
characterized poverty as a restriction of opportunities that diminishes people's “capabilities”:
their abilities to act and to do (Frohlich & Abel, 2014).
And this is why occupational therapists ought to be engaged in addressing inequities of

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Action on the social determinants of health: Advancing occupational equity and occupational rights

occupational opportunities for all those people whose abilities to act and to do are
constrained by poverty (Hammell, 2015c).
Surely one of the most impressive innovations undertaken by occupational
therapists to address the wellbeing, through occupation, of people living in poverty
has been the Grandmothers Against Poverty and Aids (GAPA) project, which
originated in South Africa. Initiated by an occupational therapist with a clear
commitment to human rights, the project reflects a conscious effort to enable women
living in poverty, and raising grandchildren orphaned by AIDS, to engage in new
occupations within supportive social networks from which they gained financial
benefits and which contributed significantly to their own well-being and the well-
being of their grandchildren and their communities (Broderick, 2004). And in
England, occupational therapists established community craft groups within an
economically-deprived, inner city housing estate. These low cost, local interventions
contributed positively to individuals' social, emotional and physical well-being through
the development of social capital and community cohesion within safe spaces in
which participants reportedly experienced a sense of belonging through the
opportunity to participate in meaningful occupations (Diamond & Gordon, 2017).
Importantly, enlarging people's capabilities - their real opportunities to use their
abilities - requires action to ensure equity. In the English language, the word “equity”
refers to fairness; it does not mean equality or sameness. It has been stated that
“[…] there is nothing more unequal, than the equal treatment of unequal people”
(cited in MacLachlan et al., 2016, p. 152); people differ both in their abilities to
access resources, and in their need for resources, due to personal factors such as
impairments or advanced age, social factors such as religious or cultural traditions,
discrimination and stigma, and environmental, structural factors such as social
policies or architectural barriers (Bailliard, 2016; Robeyns, 2005). A human rights
perspective thus acknowledges that disparities (inequities) in the opportunities
available, for example, to disabled people to live an ordinary life with the same rights
as others lead to their entitlement to additional resources (Harnacke, 2013; Sen,
1999, 2010 ; Wilkinson-Meyers et al., 2015). Furthermore, a capabilities and human
rights perspective recognizes that occupational therapists' efforts to enhance the
capabilities of children who are racially-marginalized or refugees, or who live in
impoverished communities, for example, are no less important than enhancing the
capabilities of disabled children ( Hammell, 2020).
Equality of occupational opportunity cannot be achieved by treating everyone
the same; thus employing a capabilities approach “[…] elucidates the importance of
discussing unequal chances in terms of inequity, rather than inequality, in order to
underscore the moral nature of inequalities” (Frohlich & Abel, 2014, p. 199). This
foregrounds the importance of striving towards occupational equity: conditions
wherein the substantive freedom fully and fairly to access occupational opportunities
necessary to fulfill occupational needs and rights for health and well-being is
available to all people, fairly, regardless of their differences.

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7 Concluding Comments
The work of epidemiologists and other social and health researchers demonstrates -
unequivocally - the inseparability of human health, and social conditions. Action on the
social determinants of health through attending to occupational injustices has been
hampered by occupational therapy's dominant theoretical models – which portray social,
economic and political forces as peripheral and divisible from individuals – and by
Western modes of practice, which strive to enable individual clients to increase their
abilities without addressing their unjust and unfair access to opportunities or the
inequitable circumstances of their lives and of the collectives of which they are a part.
Issues of occupational rights, of the denial of occupational rights (ie occupational
injustices), and of in/equities of occupational opportunities ought to be fundamental
issues for the international occupational therapy profession, whose most pressing
concern must surely be: how can occupational therapists most effectively address the
social determinants of occupation such that all people have the capabilities to engage
in meaningful occupations that contribute positively to their own well-being and the well-
being of their communities, as is their right. Such a rights-based approach to practice
requires the profession to consider how occupational therapists can better serve those
most in need: those who have the least access to occupational opportunities, those
whose well-being is undermined as a consequence of occupational injustices, and
those whose need for occupational therapy services, resources and supports is greatest,
but whose access is often the least. Answering these challenges requires those in the
Global North and South to draw from each other's knowledge and build on each other's
experiences.

Acknowledgments
It is an honor for me to contribute to the Brazilian Journal of Occupational Therapy,
and I am sincerely grateful to Dr Vagner dos Santos, who encouraged me to write this
paper and who undertook the daunting task of translating my words into Portuguese.

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Corresponding author
Karen Whalley Hammell
e-mail: [email protected]

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