Occupational therapy education provides an early opportunity to extend occupational literacy to include issues of occupational justice (Wilcock 1998) and occupational apartheid (Kronenberg & Pollard 2005a). Introducing students to ‘ethical, moral and civic principles associated with fairness, empowerment, and equitable access to resources, and the sharing of rights and responsibilities’ (Wilcock & Townsend 2000, p. 84) sets the stage for action that addresses issues of disadvantage at an individual, organizational and societal level through hands-on participation. Little has been published about how to implement such a process in overburdened occupational therapy curriculums. The ‘political activities of daily living’ (pADL) framework (Kronenberg & Pollard 2005a) and dialectical triangle (see Ch. 1) offer a developing model and preliminary tool to use in education.

The purpose of this chapter is to describe one strategy used to develop a politically conscious approach to the education of occupational therapy students. It was designed to encourage students to explore personal and professional values that enable them to envision practice in new contexts that promote occupational health and justice while addressing issues of occupational apartheid associated with health disparities as they acquire skills to facilitate political competency. The successes and challenges in using the pADL framework and dialectical triangle to focus the educational process are discussed.

Over the past two decades, empirical studies have presented evidence that medical care contributes relatively little to health when compared with social and societal factors, environmental factors, health behaviours and genetics. Determinants such as socioeconomic status, education, transportation and environmental control have been found to play a more prominent role in health outcomes than medical care alone (McKinlay et al., 1989 and Institute of Medicine, 2003). Unfavourable conditions within this broader environmental context lead to the growing phenomena of health disparity, i.e. differences in the quality of health care or overall rate of disease, disability or death (Carter-Pokras & Baquet 2002) especially for poor, rural and minority populations as compared to the health status of the general population (National Institutes of Health, 1999, Eberhardt et al., 2001, Hartley, 2004 and LaVeist, 2005).

The World Health Organization has defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’, since 1946 (World Health Organization 1946). Many health-related associations are beginning to notice. The American Medical Association, with its traditional aim to alleviate physical disease or pain, now demonstrates a constructive interest in the non-medical components of health services, including a commitment to eliminate disparities in health care (American Medical Association 2008). With the recently published position statement on community-based rehabilitation, the World Federation of Occupational Therapists (2004) recognizes occupational therapists’ engagement in coalitions and strategies with people who experience disabilities to promote equalization of opportunities, social integration and inclusion. In response to the goals outlined in Healthy People 2010 (United States Department of Health and Human Resources 2005) to 1) increase quality and years of healthy life and 2) eliminate health disparities, the American Occupational Therapy Association (AOTA) conducted a study that concluded ‘addressing [health disparities] is no longer an option for AOTA. It is imperative that we do so’ (American Occupational Therapy Association 2005b, p. 2). The AOTA statement on health disparities (American Occupational Therapy Association 2006a), updated strategic plan (American Occupational Therapy Association 2006b) and revised occupational therapy educational standards (Accreditation Council for Occupational Therapy Education 2008) that specify actions within multiple contexts to address social issues and prevailing health and welfare needs reflect the seriousness of this conviction.

Clearly, the evolving values of key actors in the political landscape have begun to support a cooperative approach to address health inequities. Yet there remains a discrepancy between what we say we believe and value and what we actually deliver. The disabled community recognizes this: the very population we claim to help accuses us of promoting health disparities by participating exclusively in a health care system that denies access to health and well-being for all populations (French and Swain, 2001 and Markwalder, 2006). We have much to offer our local and global communities in addressing issues of occupational injustice, yet the conflict between reimbursed medical-based care versus unfunded health promotion endeavours results in minimally established services. Because the talk of change does not yet match current practice, occupational therapy students enter their education with limited knowledge of the roles that occupational therapy can play outside traditional medical model systems (see Ch. 3).

Beyond external evidence and association directives, the need to enact moral and ethical values and beliefs drives some health professionals, including occupational therapists, to address these issues of concern. In a discourse on Ethics in Practice, Slater stresses that ‘it is ultimately a personal and professional responsibility not only to recognize unethical situations, but also to take action to expose and correct them’ (Slater 2005, p. 14). The political will that drives action emerges when our personal aims and motives align with our professional occupational therapy core values and code of ethics (American Occupational Therapy Association, 1993 and American Occupational Therapy Association, 2005a).

At Pacific University School of Occupational Therapy, ‘We envision a world in which our graduates use the skills, knowledge, art, and science of occupational therapy to promote social justice while delivering excellent services to enhance the quality of life of their clients’ (Pacific University School of Occupational Therapy 2005). Our vision statement was not a response to any external mandate; rather it emerged from the expressed and subconscious intersection of the personal and professional aims, motives and interests of faculty members (see Ch. 1). Educating students and collaborating with partnering university programmes and community entities enable us to enact our vision through our everyday engagement with our students and the community.

Participating in the Health Care Disparities in Oregon project is the initial means by which we prepare students to serve marginalized populations who experience injustices within our local community while developing occupational literacy in the classroom and beyond. Funded in part by a grant from Learn and Serve America, the project responds to the growing needs in our state and local community while providing primarily our first-year occupational therapy students with an opportunity to take leadership roles as they enact concepts of occupational justice studied in the classroom. In addition to meeting immediate educational goals for occupational therapy students, the overall outcomes of the project are:

To focus higher education, the project first offered an Interdisciplinary Health Disparities Seminar that brought together over 65 students and faculty from the four schools of the College of Health Professions at Pacific University. This seminar enabled students and faculty to gain a deeper understanding of the prevalence of health disparities in Oregon, the issues that lead to health disparity, and the complexities involved in identifying and implementing viable solutions to reduce health disparity. Following a discussion by a panel of faculty members and public officials, concurrent small-group breakout sessions provided opportunities to explore four topics in greater depth: 1) the patient-provider relationship, 2) the urban-rural divide in health care, 3) chronic disability and health care and 4) advocacy and the role of the health care professional. Students returned to the large group to share health disparity issues uncovered in the small-group breakout sessions and proposed actions that the health professional could take to address these issues.

The seminar laid the foundational knowledge for occupational therapy students to learn more in the classroom and participate as leaders in the community. Integrated coursework activities required students to expand their understanding of the concepts of occupational justice, occupational apartheid, professional and ethical responsibilities as a health care provider, aspects of cultural competency and the workings of the democratic process. Faculty introduced the pADL framework, described in the textbook Occupational Therapy Without Borders (Kronenberg et al 2005), to guide the process for students. The functional application of this framework and its relevance to occupational therapy remained a mystery to most students at this early stage in their education, although students adeptly provided a definition of occupational apartheid and readily recognized how it presents itself in far-off lands through the stories of international contributors in their textbook. They struggled, however, to identify relevant examples within their own lives and communities. Students questioned the usefulness of the pADL framework in guiding daily occupational therapy practice. Clearly, students must gain occupational literacy and political reasoning skills by engaging in a pADL process within their local community to appreciate, recognize and decode conflict and cooperation situations in everyday political situations.

One principle of occupational literacy is that ‘everyone is responsible for everything, it is not enough to merely read’: occupational literacy is expressed through action (see Ch. 3). Knowles (1990) and Knowles et al (2005) argue that graduate students connect new learning to a known life experience or knowledge base. Adults are practical, focusing on the aspects of learning they perceive most relevant and useful to their future work. Although occupational literacy can provide knowledge, learners require personal experience and participation with social networks in order to synthesize, use and integrate that knowledge (see Ch. 3).