VOLUME 6(4), JULY/AUGUST 2004
Meeting the challenge of diversity: Results from the 2003 survey of occupational therapists in Ontario
Janet M. Lum, A. Paul Williams, Susan Rappolt , Michel D. Landry, Raisa Deber and Molly Verrier
This article, the second in a series of three, outlines initial findings from a three-year study of rehabilitation services in Ontario conducted by a multidisciplinary team of researchers at the University of Toronto and Ryerson University.
Occupational therapists, like other health professionals in Canada, face the challenge of providing linguistically and culturally appropriate care to an increasingly diverse client population. Recent research has reemphasized the importance of clear communication between practitioners and clients particularly in fields like occupational therapy where problems may be the result of multiple factors, where therapeutic approaches may not be well-known to the public and where the course and direction of treatment may rely heavily on ongoing communication not only with the client but with the client’s family and broader social support network.
If providers and clients do not speak the same language, neither the issues requiring intervention nor the course of treatment may be clearly understood, thus undermining care. Furthermore, if providers are unaware of the cultural context of the client, they may misinterpret the client’s failure to follow through on a plan of action, not realizing that some clients are constrained by their cultural norms. For example, patients who do not attend hand therapy appointments may be responding to a cultural prohibition against touching between men and women. While public concern has focused on stemming the erosion to Canadian Medicare and its guarantee of universal access to medically necessary care without financial barriers, there is a growing awareness that other barriers, including those related to language and culture, need also be considered (Bowen, 2001). The challenge of diversity is particularly acute in Ontario, the favoured destination of immigrants to Canada. In 2001, visible minorities accounted for almost 20% of the population of Ontario, and for 37% of the population of Toronto (Statistics Canada, 2003a).
To what extent is the growing diversity of the population reflected within occupational therapy practice in Ontario? How diverse are the clients of occupational therapists? How do occupational therapists respond to diversity in their practices?
This article, the second in a series of three, reports preliminary results from a large-scale mail survey of Ontario’s occupational therapists conducted during the spring and summer of 2003. As detailed in our earlier article, the sample of occupational therapists consisted of 1,022 practitioners randomly selected from the registrant database of the College of Occupational Therapists of Ontario (Williams et al., 2004). Just over 64% (657) completed and returned questionnaires, ensuring that the results accurately reflect the characteristics and attitudes of Ontario’s occupational therapists as a whole.
Characteristics of individual practitioners
In the survey, we used standard Statistics Canada categories to ask occupational therapists about their ethnoracial backgrounds. While recognizing that such categories are always open to interpretation and debate, these categories have the advantages of relative simplicity and direct comparability with census data. Table 1 reveals that 86.5% of occupational therapists self-identified as white (e.g., British, Portuguese, Italian, Eastern European), while 7.6% categorized themselves as Asians (e.g., Chinese, Filipino, Japanese, Korean), and 4.2% as South Asians (e.g., East Indian, Pakistani). While revealing a significant degree of diversity within the profession, this diversity is less marked than in the general population in Ontario where ethnoracial minorities account for almost 20% (Statistics Canada, 2003a).
When asked, “In which of the following languages do you provide professional services: English, French, other?”, most occupational therapists (99.5%) said they provided services mainly in English, with only a few (0.5%) indicating that they provided services in other languages. Compare this to the general population of Ontario where 24.2% speak neither English nor French as a first language (Statistics Canada, 2003b). These data also show that occupational therapy remains a predominately female profession: only 6% of occupational therapists are male.
Again using the Statistics Canada categories, occupational therapists were asked to identify the three main ethnoracial origins of their clients. Responses were recoded into three summary categories: 1) practices with primarily white clients: 2) practices with a mix of white and ethnoracial clients; and 3) practices with primarily ethnoracial clients. As can be seen in Table 2, over three-quarters of occupational therapists’ practices (78.8%) were mixed; these included both white and ethnoracial clients. A much smaller percentage (17.1%) said that their practices consisted primarily of white clients, and only a few occupational therapists (4.1%) indicated that their clients were primarily Asian or South Asian.
Occupational therapists were also asked to list the languages, other than English, “typically spoken” by their clients. Over 90% reported that their clients typically spoke other languages; only 7.3% said their clients typically spoke English only (Table 3).
Response to diversity
Given this diversity, how did occupational therapists respond when clients required services in languages other than English? Table 4 reveals that the most common response was to “use unpaid family members or volunteers”; half (50.0%) indicated that they did this often or always. The second most common response was “to do what [they] could without an interpreter” (29.8%). About one in five occupational therapists (19.6%) said they used paid interpreters, while just under a fifth (17.4%) provided services in another language themselves. Only a small percentage of survey respondents (4.5%) said that they referred clients elsewhere.
Table 4 also reports responses to a survey question that asked occupational therapists how frequently they felt they could provide “culturally appropriate care.” We note here that no definition of “culturally appropriate care” was provided in the survey; hence, occupational therapists were free to apply the most liberal and subjective meaning of cultural appropriateness. Just over a half (53.7%) said they could offer such care “often” or “always”; conversely, just under a half said that they could provide what they considered to be culturally appropriate care infrequently, “rarely” or “never.”
Discussion: addressing diversity
In the first article in this series, we noted that occupational therapists face important challenges to their practices tied to ongoing changes in the funding and delivery of health care in Canada. In this article, we emphasize that the changing demographic face of Canadian society poses additional challenges. According to Statistics Canada, visible minorities in Ontario grew from 13% of the population in 1991 to 19% in 2001; allophone speakers whose first language was neither English nor French increased from 20% of the population to 24% during the same decade (Statistics Canada, 2003a; 2003b). The significance of these changes, and their relevance to occupational therapy, is suggested by Canadian and international research that has emphasized that effective planning and delivery of health and social services must take into account differences in race, culture and ethnicity (Bowen, 2001; Leavitt, 1999; Pillay, 1999; French, 1992; Dolman, Shackleton, Ziain, Gay, & Yeboah, 1996; Woloshin, Schwartz, Katz, Welch, & Gilbert, 1997; Bigby, 2003; Lassiter, 1995; Office of Minority Health, U.S., 1999).
One line of argument is that to become more “culturally competent,” health-care providers should closely reflect the demographic face of the population. In addition to promoting greater sensitivity to the cultural context in which care takes place, and improving communication between provider and consumer, the logic is that when those who deliver services look and sound more like those who receive them, greater levels of trust and openness will follow, promoting more positive outcomes for clients. As noted earlier, such considerations may be particularly important in occupational therapy, where problems and therapies are often complex, involving not only the client, but also the broader environment in which the client lives and works.
What we don’t know, and what no survey can show, is the extent to which diversity within the profession actually produces better clinical outcomes. What we do know is that visible minorities are currently under-represented within Ontario’s occupational therapists compared to the general population, although our data shows that younger therapists are more likely than their older counterparts to be from diverse cultural and language backgrounds. We also know that almost half of the occupational therapists surveyed reported that they could only “rarely” or “sometimes” provide culturally appropriate care.
Perhaps the most striking finding is the widespread use of family members or untrained volunteers to overcome language barriers. Previous research has shown that this is the most common way used by Canadian health-care professionals as a whole for addressing language barriers (Perkins, 1999). However, there is mounting evidence that this practice poses risks. These include violating confidentiality, the possibility that important pieces of information may be omitted, that words or phrases may be inadvertently substituted for others that have a different meaning, that “editorial” comments may be added by the interpreter, or that full disclosure of a client’s situation may be impeded, potentially exposing providers to liability (Early, 2003; Okasha, Arboleda-Florez, & Sartorius, 2000; Smart & Smart, 1995; Betancourt & Jacobs, 2000). Relying on young children as language brokers may increase risks as children may lack the maturity to conceptualize complex health issues, or sufficient command of language to communicate information correctly. Further, children of all ages may find themselves in the stressful situation of having to convey information that a parent may not want to hear.
Language challenges may be complicated by health system restructuring. As noted in our first article, a heightened emphasis on home care means that more therapists are providing care outside of hospitals, where professional translation services are less likely to be available. Facilities in Canada and the U.S. are currently experimenting with telephone translation services. As yet, however, there are few studies assessing the availability, quality, effectiveness and standards of these services, particularly in home care settings.
The ways in which cultural differences can affect care may be less obvious, but nonetheless crucial. For instance, while client autonomy and agency is often assumed, in some Asian and African cultures, decisions over health may be family-centred (Hawker, 2004). To give another example, while clients may appear to understand and comply with the directions of a health-care professional, they may be nodding out of respect, while totally disagreeing with what has been said (Banja, 1996). Such cultural factors may contribute to a key finding of the recent report of the Canadian Home Care Human Resources Study (The Home Care Sector Study Corporation, 2003). When asked about the difficulties they faced in home care settings, occupational therapists, physical therapists and social workers most frequently cited lack of cooperation from the consumer (66%), followed by lack of cooperation from informal caregivers (55%).
These preliminary results raise important questions for the future. For example, are there variations in the way language and cultural issues are addressed by visible minority practitioners, or across different organizational settings (hospitals versus large for-profit agencies), funding arrangements (public versus insurance versus out of pocket), or diverse client populations? Presently, there seems to be many challenges around language and cultural issues that occupational therapy and other health professions will need to address.
This research was funded by the Social Sciences and Humanities Research Council of Canada. The authors gratefully acknowledge the assistance of the College of Occupational Therapists of Ontario, the Ontario Society of Occupational Therapists, the College of Physiotherapists of Ontario and the Ontario Physiotherapy Association.
About the authors
Janet Lum is in the Department of Politics and School of Public Administration, Ryerson University, Toronto; A. Paul Williams, Raisa Deber and Michel D. Landry are at the Department of Health Policy, Management and Evaluation, University of Toronto; Susan Rappolt is at the Department of Occupational Therapy and Graduate Department of Rehabilitation Sciences, University of Toronto; and Molly Verrier is also at the Graduate Department of Rehabilitation Sciences, University of Toronto.
For further information, please contact: Janet M. Lum, Associate Professor, Department of Politics and School of Public Administration, Ryerson University, 350 Victoria Street, Toronto, ON M5B 2K3. Tel: (416) 979-5000, ext. 7045 or fax: (416) 979-5289 or e-mail: firstname.lastname@example.org.
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