rehabinkmag Issue 16, Knowledge Summary

Challenges Faced by Occupational Therapists: Lessons from India

Knowledge Summary

By Catherine George, ElizabethMary Thomas, Grace Elizabeth Muppidi, & Reema Samuel

Occupational therapy (OT) is a growing profession in India, with an increasing number of graduates each year (1).

Initially developed in North America, the field of OT was introduced throughout India by Kamala V. Nimkar, an occupational therapist trained in the United States (1). Consequently, much of OT knowledge and practice are rooted in concepts, approaches, interventions, and evaluations conceptualized and practiced in Western countries (2). This Western influence has led to Occupational Therapists (OTs) in India using these same conceptual frameworks and outcome measures. While these frameworks may be effective for an affluent minority, they do not apply to most Indians. India is a diverse country in which several factors contribute to the occupational choices available to individuals. These factors can include casteism, classism, and sexism, combining or overlapping significantly to discriminate against marginalized individuals or groups. This complex and cumulative manner in which an individual experiences multiple layers of intersecting barriers is termed intersectionality (adapted from Merriam-Webster).

Based on our experiences practicing as OTs in India, insights from clinical supervisors, and current literature on OT, we have outlined several challenges that OTs in India face and the ingenious solutions employed by OTs in India to resolve them in this paper. These challenges are not unique to India but are also faced by occupational therapists working with multicultural (3), indigenous (4,5), immigrant (6,7), or refugee (8) populations in other countries such as the UK (3), North America (8), and Australia (4-6). Other colonized, low and middle-income countries may face these challenges worldwide (9,10). The challenges listed below are not comprehensive, and we hope to encourage discussion and further research in this area.

Luana Azevedo (Unsplash)

Challenges

A common challenge OT’s face is the conceptual misalignment between context-informed core OT principles (occupation focus and value for independence) and OT assessments and interventions in the Indian context (which is collectivist and values interdependence). For instance, for a client with spinal cord injury, OT principles recommend that the client focus on developing independence in activities of daily living (ADLs). Within the Indian context, independence in self-care is essential. However, while independence is helpful for discharge planning, it may not fit in with the varying roles, timings, and preference for interdependence within the family structure. Consider Mr. Arun, a 55-year-old man with quadriplegia (incomplete ASIA C). At discharge, he could independently perform his daily activities with supervision. However, upon follow-up assessment, his family members were seen feeding him as this was more feasible than supervising him while maintaining their other roles (ex. running the household). Mr. Arun, in turn, was able to contribute to household tasks, which the family prioritized over his independence in his ADLs. When assessed for functional ability, Mr. Arun received a lower score due to being dependent because most outcome measures are geared to assess the client’s level of independence. These outcome measures do not account for a client’s level of functioning as an interdependent family member (9). Due to the intersecting layers of discriminating factors like disability, socioeconomic status, societal stigma, and the loss of autonomy faced by Mr. Arun, his occupational choice is at risk (11). Thus, OTs need to modify or develop frameworks and outcome measures which conceptualize occupational functioning as interactional (i.e., person in the context of his suprasystem, not just as a stand-alone system as seen in many existing frameworks) (1).

Treatment plans in therapeutic settings have low utility in real-life scenarios. Clients in rural areas often face several barriers to access to treatment, such as inaccessible infrastructure, limited transportation options, uneven terrain, unfavourable weather, personal and socioeconomic limitations, and a lack of qualified rehabilitation professionals in these settings (1). For example, Navya is a 15-year-old girl with spastic quadriplegic cerebral palsy from rural India. She required an adaptive seating device to help position her trunk, reduce contracture, and prevent deformities. Due to the abovementioned barriers, the OT could not schedule a timely home visit for Navya. Thus, Navya received OT services at the clinic only once every three months. Within these constraints, the OT designed a seating device based on recommendations from the literature and a verbal description of the home provided by Navya and her parents. However, this was insufficient information for designing a seating device, as there are architectural, familial, and contextual barriers to the design that the OT can only discover on a home assessment. Months later, upon the scheduled home visit, the team found that Navya was not adhering to the home program or using the seating device. After integrating feedback from the caregivers and Navya and a thorough in-person exploration of the home environment, the therapist designed a more effective, accessible, practical, and affordable design. Navya’s feedback after using the seating device at home was necessary to overcome her loss of bodily autonomy (11). Getting feedback from clients in their home context is imperative to develop a treatment plan with high utility in real-life scenarios. 

The lack of liaisons in the community limits continuity of care. There is a shortage of OTs in India, resulting in unequal distribution across states. Patients often travel to other states to receive OT services, and the therapists wouldhave to travel large distances (often to another state or province) to conduct an in-person home assessment.They also may not have other OTs to refer to in the client’s home city, which limits the continuity of care. In Navya’s case, the OT handed over her care to the local community-based rehabilitation (CBR) worker with expertise in implementing the home program. These CBR workers also identify and refer individuals to hospitals for rehabilitation services (12). 

Apart from the challenges mentioned earlier, there is widespread acceptance of the biomedical model of illness in India, which influences OT practice. The biomedical model of care focuses on the physiological factors contributing to health. In contrast, the biopsychosocial model of care is more holistic and emphasizes cultural, social, and contextual factors related to health (13). India has made commendable progress in healthcare policies and educational awareness programs, with a focus on communicable diseases and maternal/child mortality rates. However, it is important to recognize that non-pharmacological management for chronic disabling conditions has not received the same level of attention. To improve overall health outcomes, we need to encourage a more comprehensive approach that considers psychosocial factors. By raising awareness and promoting a holistic approach to healthcare, we can ensure that individuals receive the best possible care. 

Ksenia Chernaya (Pexels)

Moreover, there is a misconception among the general population and medical professionals that OT is synonymous with Physical Therapy. This misconception leads to a higher preference for physical treatment modalities versus OT treatment plans, which include a holistic approach, including aspects like leisure and self-care. For example, sometimes in a pediatric context, there can be a disconnect between what caregivers believe is beneficial for their children and what occupational therapists (OTs) believe is therapeutic. For instance, some caregivers may prefer that OTs focus on “exercise” rather than play when working with their children. This can create a challenge in which there is a misalignment between the client’s perception of therapy and the therapist’s perception of therapy. The issue stems from a combination of factors, including the healthcare system’s organization and the differing attitudes and mindsets of the clients and therapists.

Lessons Learned

Despite these challenges, OTs in India have been resourceful in developing context-driven solutions that meet the needs of their diverse clientele. We describe some of these solutions below and recommendations to spark further discussion. For instance, OTs in India are beginning to use a decolonial lens to critically reflect on the relevance and source of empirical knowledge to gauge what is appropriate, feasible, and applicable for their clients. There are also efforts to create literature relevant to the client’s immediate (e.g., familial) and larger context (e.g., community). Some examples of context-informed knowledge translation strategies include applying ergonomic principles to occupations specific to India, like dressing in sarees or dhotis among people with low back pain. Home programs and educational interventions address daily tasks such as hand washing dishes, soiled clothes, and cooking using a chulha (a mud stove on the floor/low height). The language and illustrations used in home programs also represent the patient’s cultural background.

Despite systemic challenges such as lack of resources, leadership, and poor communication within different healthcare sectors, OTs in India are taking strides to encourage the implementation of best practices and provide efficient care. Health institutions and professional organizations conduct regular in-service webinars, profession-specific and multidisciplinary workshops, and communities of practice like special interest groups (14). There is a lack of scientific literature curated towards the Indian population. Due to this, OTs often depend upon other forms of knowledge to drive their practice, such as tacit knowledge and clinical expertise (15). We encourage OTs in India to continue engaging with these knowledge forms and create standards of practice to guide routine care. We also advocate for international professional organizations, continuing education certifications, conferences, and journals to have discounted membership, participation, or publication fees to ensure equitable access to these opportunities.  

The OTs in India are responsive and sensitive to the complexities of Indian subcultures. Due to the myriad of subcultures and languages, OTs respond to the nuances of the client’s background. They are validating internationally developed outcome measures for the Indian population (e.g., the Sensory Profile Caregiver Questionnaire (16) and the Peabody Developmental Motor Scales 2nd edition (17)). In addition, new outcome measures relevant to the Indian population are used by OTs in psychiatry (e.g., the Vellore Occupational Therapy Evaluation Scale (18); the Vellore Inventory of Life Skills (19); the Vellore Assessment of Social Performance (20)), neurology (the Indian Stroke Scale (21)) and pediatrics (e.g., Trivandrum Developmental Screening Chart (22). Though these advancements at the local level are encouraging, we need to increase awareness and its uptake in routine care. In agreement with Murthi’s research, we advocate for creating local literature and frameworks in regional dialects to solve some of the dilemmas described earlier (1). Besides these recommendations, the Indian OT curriculum should prioritize and value locally developed frameworks and measures alongside Western equivalents. Indian OTs are making admirable progress in developing cultural humility and responsiveness through their clinical experiences. With the proper support and resources, universities can further enhance this progress by providing culturally appropriate OT education.

Shruti Singh (Unsplash) 

Conclusion

Occupational Therapy is a dynamic profession that can bridge the gap formed by various social, economic, psychological, and cultural divides. We are thankful for seminal frameworks developed in North America, which helped serve as a starting template for OT internationally. However, we critically reflect on how some initial frameworks are not applicable in other countries and OT knowledge should be decolonized and revised to suit the client. As India is home to a culturally, economically, and socially diverse population, OTs in India are trained to be sensitive towards cultural differences and other factors (such as caste, ethnicity, and gender) that may marginalize their clients. We have described the uniqueness of the Indian client’s culture and recommended some ways for OTs internationally to create knowledge and best practices that best suit the culture and background of the client. These strategies may also help OTs within the Global North approach their immigrant citizens and culturally diverse populations from non-Western Educated, Industrialized, Rich, and Democratic (WEIRD) backgrounds through contextually and culturally appropriate lenses.

We hope this article contributes to the existing conversations on decolonizing OT theories and promoting cultural humility. Globally, OTs are making significant strides towards this effort (15). We understand the need for contextually relevant occupational therapy practices in India and other countries and populations outside the Global North. Let’s work together to spark further research in this area to improve the lives of those in need.

**Note: Names of patients are changed

Acknowledgements

We are grateful for clients and their families in India, our fellow OTs, our teachers from whom we learned, and our families who support us. Thank you for sharing your vulnerabilities with us, shaping our clinical outlook, enriching our learning, and laying the foundation for our careers as occupational therapists. 

We are grateful for clients and their families in India, our fellow OTs, our teachers from whom we learned, and our families who support us. Thank you for sharing your vulnerabilities with us, shaping our clinical outlook, enriching our learning, and laying the foundation for our careers as occupational therapists. 

Featured illustration by Catherine George for rehabINK.

To refer to this article, it can be cited as:

George C, Thomas E, Muppidi G, Samuel S. Challenges faced by occupational therapists: Lessons from India. rehabINK. 2024:Issue16. Available from: https://rehabinkmag.com

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