Scandinavian Journal of Occupational Therapy.

2010; 17: 5763

INVITED ARTICLE

*
Occupational Justice Bridging theory and practice

INGEBORG NILSSON1 & ELIZABETH TOWNSEND2

1
Department of Community Medicine and Rehabilitation, Occupational Therapy, and Center for Population studies/Ageing
and Living Condition Programme, Umeå University, Sweden, and 2School of Occupational Therapy, Dalhousie University,
Halifax, Canada

Abstract
The evolving theory of occupational justice links the concept to social justice and to concerns for a justice of difference: a
justice that recognizes occupational rights to inclusive participation in everyday occupations for all persons in society,
regardless of age, ability, gender, social class, or other differences. The purpose of this descriptive paper is to inspire and
empower health professionals to build a theoretical bridge to practice with an occupational justice lens. Using illustrations
from a study of leisure and the use of everyday technology in the lives of very old people in Northern Sweden, the authors
argue that an occupational justice lens may inspire and empower health professionals to engage in critical dialogue on
occupational justice; use global thinking about occupation, health, justice, and the environment; and combine population
and individualized approaches. The authors propose that taking these initiatives to bridge theory and practice will energize
health professionals to enable inclusive participation in everyday occupations in diverse contexts.

Key words: Ageing, diversity, everyday technology, leisure, person-centred practice, population health, social determinants
of health, social inclusion

Introduction social exclusion, such as disabled people, especially

The concept of occupational justice emerged
through a dialogue that began with Wilcock’s vision
of an occupationally-just world supported by public
health and societal initiatives, and Townsend’s vision
of engaging in professional practice with an ethical,
moral, and civic commitment to enable the empow-
erment and social inclusion of persons, individually
and collectively, in the everyday occupations of
societies (1,2). Bridging the gap between the con-
cept and practice of occupational justice will require
health professionals to change practice (3,4), in
particular to mobilize around a health advocacy
agenda based on global thinking (5).
The purpose of this descriptive paper is to inspire
and empower health professionals to build a theore-
tical bridge to practice with an occupational justice
lens. An occupational justice lens may be used to
advance toward the vision of an occupationally-just
world by enabling the empowerment and social
inclusion of populations who routinely experience
disabled women who experience domestic violence
(6,7). We argue that an occupational justice lens may
inspire and empower health professionals to engage in
critical dialogue on occupational justice; use global
thinking about occupation, health, justice, and the
environment; and combine population and individua-
lized approaches. The argument is made with illustra-
tions from a study of leisure and the use of everyday
technology in the lives of very old people in Northern
Sweden, and with attention to the challenges for
health professions of bridging theory and practice
(8). Because occupational therapy was founded on a
social vision of justice (6,7,912), we use this as an
example of a health profession that intends to bridge
theory and practice with a justice lens.
Overview of occupational justice theory
Although the concept and definitions are evolving,
and like any concept will vary in different socio-

Correspondence: Ingeborg Nilsson, PhD, Reg OT, Center of Population studies/Ageing and Living Condition Programme, Umeå University, Sweden.
Tel: 4690 786 6133. Fax: 4690 786 6958. Email: ingeborg.nilsson@umu.se

(Received 2 March 2009; accepted 25 August 2009)

ISSN 1103-8128 print/ISSN 1651-2014 online # 2010 Informa UK Ltd. (Informa Healthcare, Taylor & Francis AS)
DOI: 10.3109/11038120903287182
58 I. Nilsson & E. Townsend
cultural contexts (13), occupational justice has been
described from a Western perspective as a justice of
difference: a justice to recognize occupational rights
regardless of age, ability, gender, social class, or
other differences (1,2,14). The central point is that
occupational injustice is an outcome of social
policies and other forms of governance that structure
how power is exerted to restrict participation in the
everyday occupations of populations and individuals
(9). The governance of societies is typically struc-
tured so that some people experience social inclu-
sion, privilege, and entitlement to choose what they
do, while others experience social exclusion and
restrictions, such as deprivation of full participation
in everyday occupations (15). Implementing occu-
pational justice will be challenging for health profes-
sionals for many reasons: multidisciplinary and
multi-agency teams include members with different
values, beliefs, and practice methods (4); and, some
team members may view justice as outside their
scope of practice.
The concept of occupational rights (1,6,7,14) is
complementary to the concept that humans are
occupational beings who need and want to engage
in doing, being, becoming, and belonging (16). The
reasoning is that the human species needs and wants
to engage in occupations for survival, to connect
with others, and to build communities. If occupa-
tion, like air, food, and water, is necessary for
humans (16) it follows that humans and societies
would advance toward an occupationally-just world
by defining human rights to include participation in
occupations (1,6,7,14).
Key social structures that govern participation in
occupations in all societies are the division of labour
and the classification of occupations (17,18). The
division of labour refers to the cultural organization
of particular activities or occupations to socially
include or exclude particular groups, such as the
typical allocation of housework and parenting to
women and manual labour to men (17). Whether
intended or not, participation restrictions produced
by stereotypical divisions of labour lock some
populations out of occupational opportunities. An
example is that health professionals may lack the
mandate and funding to exert labour in organizing
leisure occupations that would be meaningful to
older people, whereas the mandate and funding may
be available for them to target leisure for children,
adolescents, and adults. Similarly, when occupations
are classified as suitable for men or women, or duties
and responsibilities are attributed as unsuitable for
those of a particular age, the classifications result in
economic and social privileges for some and restric-
tions for others. For instance, occupations, such as
leisure, that are organized without arrangements to
include older persons marginalize this population.
Occupational rights or restrictions are implied in the
division of labour and occupational classifications
because rights are embedded in the sociocultural
beliefs and values, health and other practices,
policies, laws, and economic or economic conditions
that prompt a society to define who will do what,
where, when, how, and with which resources. The
division of labour, occupational classifications, and
other structural forms of governance are part of what
is called the environment in occupational therapy
models, such as the Canadian Model of Occupa-
tional Performance and Engagement (10), environ-
mental forces in the International Classification of
Function, Disability and Health [ICF] (19) and the
social determinants of health in health and social policy
(20).
An occupational justice framework published by
Stadnyk et al. (14) displays how structural and
contextual factors contribute to occupational justice
or injustice. Beyond defining health practice out-
comes in terms of what people do (occupational
performance) or how, where, when, and why they
engage in their occupations (occupational engage-
ment), occupational outcomes are connected to
occupational rights that encompass inclusive parti-
cipation in everyday occupations.
The Stadnyk et al. (14) framework displays
occupational injustice when some populations more
than others are restricted from experiencing occupa-
tional rights, responsibilities, and liberties, either
deliberately or through taken-for-granted social
exclusion from participation, at any point across
the lifespan, in the occupations typical of their
community. From a Western cultural perspective,
Stadnyk et al. (14) propose four overlapping com-
pounding forms of social exclusion and related
occupational rights that are part of the current
dialogue on occupational justice.
1. Occupational alienation: social exclusion by
restricting a population from experiencing
meaningful and enriching occupations (6,7).
2. Occupational deprivation: social exclusion by
restricting a population in diverse contexts,
such as prisons, refugee camps, care facilities,
or other isolating situations, from participating
in occupations that would promote their health
and well-being (15).
3. Occupational marginalization: social exclusion
by restricting a population from experiencing
autonomy through lack of choice in occupa-
tions (7,14).
4. Occupational imbalance: social exclusion by
restricting a population so that some people
have too little to do every day while others

have too much to do, instead of all persons
experiencing participation in a range of the
occupations that would promote their health
and well-being (21).
Study methods and results: occupations of
older people
Health professionals regularly observe occupational
injustice although they may not be aware of doing so.
Practitioners who have worked in or visited nursing
homes will recognize the scene of an older, male
resident sitting and sleeping in his wheelchair in
front of a music-show on the television. One could
imagine that he did not choose this occupation
himself, and that he fell asleep because he was put
in front of a programme in which he had no interest.
He was not able to change the programme on his
own and he was not able to move to another place.
Perhaps there were other reasons. Nevertheless,
many people in nursing homes lack the ability and
opportunities for choosing and engaging in a
balanced array of meaningful occupations each day
as a means of promoting health and well-being (22).
Awareness that some very old people are not very
engaged in daily occupations prompted a collabora-
tive, population-based occupational therapy study of
people who were aged 85 years or older (very old) in
northern Sweden (23,24). People who scored 19 or
lower on the Mini-Mental-State-Examination
(MMSE) were not included. The study (23,25),
continuing since 2001, includes more than 250
persons living in ordinary housing as well as nursing
homes; persons with many or a few medical diag-
noses; and persons living in extreme rural areas as
well as in a mid-sized city. Home visits were used to
administer a battery of self-rating questionnaires on
leisure amongst other things.
Occupational arenas of leisure and using everyday
technology
Before data collection, questions were raised by
some research colleagues and community members
who assumed that research on leisure for very old
people would be meaningless. These assumptions
may reflect widespread yet subtle ageism attitudes in
health professions and society (26). The questions
also illustrate how social attitudes may contribute to
occupational injustice by excluding very old people
from research that would examine and potentially
support their participation in leisure occupations.
None of the very old people in the study questioned
what was meant by leisure; instead they said that
leisure was something no one had asked them about
before. It seems that very old people have a diverse
Occupational justice*bridging theory and practice 59
repertoire (27) of leisure occupations that require
social, cultural, and physical participation (as with
younger people). Yet, typical rehabilitation pro-
grammes for very old people do not address leisure,
but focus instead on mobility, dressing, grooming,
and other basic self-care occupations, as if this is all
there is to their lives (28).
Almost all of the very old persons in the study
reported that they watch a great amount of television
(27). One might view this leisure occupation as
passive and contrary to a vision of active, healthy
ageing. The interviews, however, suggest that tele-
vision is no passive occupation for very old people
but rather is a way to stay updated on what is going
on around the world. They want to keep updated not
only because they are curious, but also because they
want to talk about television shows, news, and
weather forecasts with their families, neighbours,
and friends.
An unexpected finding coincided with the change
in Sweden from analogue to digital television trans-
mission, as this required many people to acquire a
new technology. Those who wanted to watch with-
out buying a new television needed to install a box
with a remote control. Many of the very old people
did not have any experience or skills in using a
remote control. Instead of being able to see their
television programmes freely as they wanted or
needed to, many had to develop a fixed television-
watching schedule or rely on family members to help
them to switch the set on and off and change
programmes. The very old people also spoke at
great length about their technology challenges in
using the Internet as a leisure occupation. They
talked about feeling that without access to the
Internet they were not true members of the state
because so many things that they found interesting
‘‘slipped through their fingers’’. One man was angry
during his interview saying:
‘‘You know when you are looking at the news and
there is an interview that seems very interesting then
they just cut the story and say that you can see the
whole interview on the web*of course I cannot*
I do not even have a computer.’’
Discussion
Excerpts from the study of very old people open
avenues to engage in critical dialogue on occupa-
tional justice; use global thinking about occupation,
health, justice, and the environment; and combine
population and individualized approaches. Two
questions are posed to spark dialogue on the
occupational rights of very old people, global think-
ing about the occupational arenas of leisure and
everyday technology for very old people, and the
60 I. Nilsson & E. Townsend
potential for health professionals to work with and
for very old people by combining population and
individualized approaches.
Do very old people have an occupational right to
engage in leisure activities of their choice?
The Swedish study found no evidence that very old
people only want a life of washing their face, eating,
and putting on their sweater. Conversely, there is
growing evidence that occupational engagement by
very old people can promote their health (25). Yet
within health services, rehabilitation programmes
typically focus on what is described as Personal
Activities of Daily Living (PADL) or Instrumental
Activities of Daily Living (IADL) that largely
evaluate individuals’ abilities in self-care and home-
making occupations (29). Moreover, while instru-
ments that measure PADL or IADL are typically
validated for use with individual, older people (30),
only a few measure occupational engagement in
leisure by very old people as individuals or as a
population in any context (23).
Well-meaning healthcare professionals, including
occupational therapists, may actually be restricting
social inclusion when services overlook leisure for
very old people as a population and instead focus on
individual self-care occupations as defined by prac-
tice protocols. Whether or not these are meaningful
categories to very old people, and whether they really
want to engage in them, is not considered (31). Very
old people may be an occupationally alienated
population when support workers, health profes-
sionals, and family members repeatedly and in many
contexts set individuals in front of a television
without knowing whether this is meaningful to
them. Health professionals may inadvertently under-
mine occupational justice for older, especially very
old people, when there is limited awareness that
occupations continue to be as necessary as air, food,
and water even in very old age (1,2,6,7,16).
Health professionals could take responsibility to
challenge this status quo and combat stigma by
planning both population and individualized strate-
gies for working with very old people. Since health
professionals support the rights of people with
mental illness (32), health professionals could also
give voice to the ethical, moral, and civic entitlement
to leisure of very old people. The alienation of very
old people may be compounded by the silence of
health professionals who overlook participation in
leisure for very old people, in the same way that
people are alienated by silence around sexuality and
disability (33). To date, the leisure occupations of
very old people, such as television watching or
meeting with friends, are absent from the typical
division of labour and occupational classifications
that are oriented to the occupations of employed
adults (17,18). The idea of classifying leisure occu-
pations for very old people may seem outlandish, yet
research shows that lack of leisure may undermine
the health and well-being of very old people
(14,15,25) and that health services that focus mainly
on self-care may not be relevant to what very old
people really need and want to do (31). One
question to discuss is whether the social and
economic costs of health professionals not addressing
leisure as an occupational right are higher than
enabling very old people individually and as a
population to stay healthy and active in their
communities.
Does lack of access to everyday technology infringe
on the occupational rights of very old people?
Everyday technologies such as television, remote
controls, and the Internet have made life easier in
many ways, but until they learn how to handle them
very old people may be excluded as a population
from participation in their desired occupations.
People of all ages rely increasingly on digital com-
munication where information, knowledge, and
services are available, and sometimes only available
through the television, Internet, and cell phones.
Television and other remote control systems and
computer use are widespread: in fact, Sweden is
amongst the countries with the highest level of
access to the Internet in the world (34). Very old
people may not use the Internet like younger groups
because they do not understand how to use and gain
from it: as a result they tend to be ignored as
computer and Internet users. Despite the amount of
information and services available on television and
the Internet, in Western countries especially, older
people seem to be an excluded group (35).
The Internet may enable some people to engage in
their occupations, but the Internet can also restrict or
even prevent very old people from fully participating
in society (36). Very old people may be occupation-
ally marginalized without the right to autonomy in
their occupational experiences when inexperience
with television remote controls and the Internet
exclude them from family and community participa-
tion. Marginalization may be compounded because
they may also be occupationally deprived when they
are isolated from real or virtual community inclusion
by the lack of access to or inability to use television
remote controls, the Internet, and other everyday
technologies. Occupational imbalance may exist as,
without access to everyday technologies, very old
people cannot exercise the occupational privilege of
participating in a range of occupations. For those very

old people who live alone with nothing to do except
self-care, or who have heavy responsibilities for care-
giving or home management, using the television and
Internet enables them to keep up to date and gain
social support from watching television as a diversion
or for information on care-giving. Western societies
typically focus on adult occupations, and not those of
very old people. Very old people seem to be rendered
obsolete by technologies because they are not
designed for their use. One question to discuss is
whether health professionals might develop policies
and practice protocols for local and national partner-
ships with the telecommunications industry to enable
older citizens to participate in leisure and community
occupations as a health-promotion strategy.
Implications for health professionals:
building a theoretical bridge to practise with
an occupational justice lens
While narrow, skill-based job descriptions, restrictive
policies, funding limitations, and diverse multidisci-
plinary team expectations present challenges for
health professionals (3,4,9), the implications for
health professionals to practise with an occupational
justice lens are optimistic. Opportunities exist to
build a theoretical bridge to practice with very old
people and other populations using this lens. Health
professionals could bridge the gap (3) between a
theoretical lens and practice by such actions as:
negotiating how multidisciplinary teams might com-
bine individualized practice with population and
community development initiatives; building coali-
tions for advocacy in professional, consumer,
community, and industry partnerships; and organiz-
ing non-partisan, strategic, political action (37),
with awareness of the political nature of health
professional practices (38).
Implications illustrated in occupational therapy
An example of the potential for greater health
professional leadership to combine population and
individualized approaches is offered by an outcome
of the study reported here. Leisure occupations have
been included in the occupational therapy rehabili-
tation programme for older, especially very old
people in the community in Northern Sweden. A
checklist for leisure occupational engagement
has been developed and validated as an individua-
lized outcome measure for older people (39). The
problem with remote controls is widespread and has
been referred to the Swedish Institute for Assistive
Technology.
Given occupational therapists’ increasing atten-
tion to populations as well as individuals (10,40,41),
Occupational justice*bridging theory and practice 61
population approaches were the starting point for a
project to enable older people to participate in
Internet-based occupations. The project explored
the needs of very old people to use the Internet and
their interest in participating in an Internet café as a
meeting-place to bridge the digital gap (36), as well
as to match their needs to available resources in the
community. Results showed that very old users as
well as non-users would come to an Internet café to
meet others and develop or enhance their Internet
skills. In recognizing the use of the Internet as an
occupation with therapeutic and health-promoting
potential, occupational therapists advocated for and
started this programme to enable very old people to
become Internet users. A collaborative project is
ongoing between occupational therapists and com-
puter scientists to develop a web-based portal with
individual profiles to meet both the population and
individual needs and motivation of very old people
(42).
With a commitment to person-centred enable-
ment for individual and social change (historically
called ‘‘client-centred’’ practice) (10), strong occu-
pational therapy leadership could inspire and em-
power this and other professions to coordinate
different approaches for advancing visions of health,
well-being, and justice. Occupational therapy leader-
ship could also inspire and empower this and other
health professions to advance their competence and
critical dialogue on a spectrum of collaborative
enablement skills and the continuum of effective,
minimal, missed, and ineffective enablement, con-
trasted with hierarchical, professional dominance
and negative, co-dependent enablement [10,
pp. 111131]. For instance, occupational therapy
leadership could enable interested members of
health professional teams to develop enablement
skills and the critical reflection needed to educate the
community about occupational injustice, adapt or
re-design programmes to include real-life occupa-
tions as a strategy to engage people in helping
themselves, and advocate with consumer groups
and families for change where participation restric-
tions exist. By encouraging a multidisciplinary health
professional team to build alternative service models
to enable everyday living beyond treating medical
symptoms, occupational therapists could contribute
leadership to the development, coordination, and
management of combined population and indivi-
dualized approaches to health promotion, primary
healthcare and rehabilitation with many populations,
including very old people, across any sector from
employment, housing, industry, transport, and edu-
cation to social services and health.
Wood et al. (12) state that the concept of occupa-
tional justice gives voice to occupational therapists’
62 I. Nilsson & E. Townsend
implicit historical and ethical stance to address
potential or real injustices. White (11) describes
occupational justice as fundamental to occupational
therapy: ‘‘Once a practitioner has embraced the
basic philosophy of the profession (i.e., that occupa-
tional engagement and meaningful occupation are
essential for health and well-being and the environ-
ment either supports or constrains occupational
performance), it is difficult to think about how
occupational therapy would not be used to promote
occupational justice’’ (11). Hammell (6) states
‘‘Occupational therapy could be the profession
committed to attaining occupational rights and to
enabling people to engage in meaningful occupa-
tions that contribute positively to their own well-
being and the well-being of their communities’’
[p.62]. She further states (6), ‘‘An engagement
with occupational rights will bring our practice
[occupational therapy] into line with our espoused
belief in the relationship between occupation and
human well-being, acknowledge the connection
between human well-being and human rights, and
enable us to state, unequivocally, what occupational
therapy contributes to humanity’’ [p. 63]. Based on
this study and follow-up projects with older and very
old people in Sweden, it seems that occupational
therapists have great potential to take up the
challenges and opportunities of building a stronger
theoretical bridge to practice with an occupational
justice lens. In doing this, occupational therapists
could lead multidisciplinary teams to enable more
inclusive participation in everyday occupations by
different population groups and individuals in a
variety of contexts.
Conclusion
In this paper, we have argued that an occupational
justice lens may inspire and empower health profes-
sionals to build a theoretical bridge to practice with
an occupational justice lens. An occupational justice
lens may be used to advance towards the vision of an
occupationally-just world with an ethical, moral, and
civic commitment to enable the empowerment and
social inclusion of populations who routinely experi-
ence exclusion. By engaging in critical dialogue on
occupational justice, using global thinking about
occupation, health, and justice, and combining
population and individualized approaches, health
professionals may be energized to focus practice on
the social policies and other forms of governance,
also described as environmental forces (10,19) or
social determinants of health (20), that structure
what people do every day and their inclusion in
society. Illustrations from the literature and research
on very old people’s leisure and use of everyday
technology in Northern Sweden illustrated how
very old people face occupational injustice when
they cannot exercise occupational rights. They face
occupational alienation and imbalance without ac-
cess to a range of desired leisure occupations beyond
self-care, and occupational deprivation and margin-
alization because they are deprived and marginalized
from participation in leisure, especially by the
complexity of everyday technologies, such as televi-
sion remote controls and the Internet.
Acknowledgements
The paper is based on a keynote presentation held by
the authors at the International Assessment of
Motor and Process Skills (AMPS) symposium in
Halifax, Nova Scotia, Canada in July 2008. They
would like to thank the scientific committee at the
symposium and their colleagues for encouraging the
further development of this paper.
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