Scandinavian Journal of Occupational Therapy. 2015; 22: 82–94

ORIGINAL ARTICLE

Occupational therapy culture seen through the multifocal lensof fieldwork in diverse rural areas

INMACULADA ZANGO MARTÍN1,2, JUAN ANTONIO FLORES MARTOS3,PEDRO MORUNO MILLARES4 & ANITA BJÖRKLUND5

1Social Health PhD Programme, University of Castilla-La Mancha, 2Department of Occupational Therapy, UniversityCatholic San Antonio-Murcia, Guadalupe, Spain, 3Department of Philosophy, University of Castilla-La Mancha,Talavera de la Reina, Spain, 4Department of Occupational Therapy, University of Castilla-La Mancha, Talavera de laReina, Spain, and 5School of Health Sciences, Jönköping University, Sweden

AbstractBackground: Existing occupational therapy culture has not yet fully articulated diverse worldviews on occupation, health, andwell-being and the link between them. Taking into consideration the diversity of the global world, incorporating differentworldviews would be a valuable contribution to expanding the relevance of occupational therapy. Aim:The aim of this researchwas to analyse worldviews regarding human occupation and the link between occupation, health, and well-being among peoplefrom rural Honduras, Morocco, Burkina Faso, Tanzania, and Ecuador. Methods: This ethnographic research used threemethods, i.e. semi-structured interviews, participant observations, and in-depth interviews, to collect data from 27 participantsin five countries. The material was analysed using a Grounded Theory approach. Results: One core category, “Occupations aresocial practices”, was identified and it included three subcategories: “Occupation, health and well-being as a personal andcommunity experience”; “Co-occupations, collective occupations and collaborative occupations are the most importantoccupations”; and “Occupation, health and well-being mutually influence each other”. Conclusion and significance. The overallfindings showed that taking different worldviews into account is needed for developing an occupational therapy culture that isuseful globally and hosts diverse meanings and occupation-focused practices.

Key words: assumption, culture, ethnography, global world, intercultural

Introduction

Everyone is embedded in a culture, that is, a particularmanner of thinking and doing things that they havebeen taught in a specific social context. Additionally,culture has an impact on the understanding of healthand it determines a particular behaviour in relation topractices in the health care system (1). Occupationaltherapy, like other professions, embraces a particularculture (2) that comprises specific knowledge relatedto the use of occupation as therapy (3).In this sense, the specific professional culture of

occupational therapy identifies and distinguishes itsmembers from other professionals (4).

According to Hammell (3), occupational therapyculture is underpinned by shared assumptions. Someof these assumptions are related to the beliefs andvalues of occupations that give meaning and purposeto life and to the understanding of which occupationsorganize human behaviour as important determinantsof health and well-being (5-8) . Other assumptionssupport the idea that occupation, health, andwell-being are linked and closely related to adapta-tion, competence, independence, and occupationalbalance (9-11).In recent years, there has been an increase in critical

thinking regarding occupational therapy culture,linked to an interest in researching and analysing

Correspondence: Inmaculada Zango Martín, Department of Occupational Therapy, University Catholic San Antonio-Murcia, Campus de los Jerónimos,s/n, Guadalupe, 30107, Murcia, Spain. Tel: +34 636567405. E-mail: inmayla@yahoo.es

(Received 22 October 2013; accepted 9 September 2014)

ISSN 1103-8128 print/ISSN 1651-2014 online � 2014 Informa HealthcareDOI: 10.3109/11038128.2014.965197

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occupational therapy interventions that consider theclients’ perspectives on a global scale (4,12-14). Thismay be regarded as a reconfiguration of occupationaltherapy from an intercultural perspective (15-23)that is needed to achieve health efficacy whichrespects worldviews related to health in differentcultures (23,24). Hammell (3) accordingly assertsthat the main assumptions underpinning occupa-tional therapy have been developed in urban areasof the English-speaking nations of the Western world.For this reason, we need to consider that the prob-lematic culture of occupational therapy is seldom thatof the client but rather that of the occupationaltherapist (2,25,26).Moreover, several articles from the past two dec-

ades highlight the ethnocentrism in occupationaltherapy’s main assumptions, concepts, and beliefs(3,4,11,23). These studies explained that the mainassumptions underpinning occupational therapy areculturally specific and were developed without suffi-cient regard for different views around the world(27-35). Furthermore, we need to recognize thatoccupation is not a cross-cultural universal concept(29,34), and neither are health/disease, ability/disabil-ity, or therapeutic care (26).However, a cross-cultural encounter enables occu-

pational therapists to analyse and integrate a broaderperspective on the culture of occupational therapy; itoffers possibilities to learn and consider how differentoccupational experiences impact on daily lives (2). Toaccomplish this, fieldwork, defined as researchprojects undertaken in the field in various culturalcontexts, needs to be undertaken by occupationaltherapists. Doing so may facilitate the understandingof assumptions, values, and beliefs from differentperspectives in order to match cultural needs(29,31,32). In this sense, fieldwork might be usedas a bridge for moving theoretical understanding ofculture into practice and vice versa (23,29).Knowledge of cultural diversity may be gained

through critical analysis in multicultural contextswhere occupational therapy and other health inter-ventions are developed. For this reason, in beingaware of the interactions between the client’s perspec-tive and the occupational therapy profession’s culture,it is important to view human occupation and the linkbetween occupation, health, and well-being from aglobal perspective. Developing an intercultural per-spective on occupational therapy culture should takeinto account the concepts, the language, the practicalapproach, and the institutions where interventions aredeveloped and articulated (23). However, the inter-cultural approach of occupational therapy is moreoften focused on occupational therapists (12,13,15)than on understanding the clients’ lived experiences

(25,35,36). Therefore, further knowledge about thelatter is needed.This reflection generates the following questions.

First, what is the understanding of occupation and itsrelation to health and well-being, taking into consid-eration different perspectives from around the world?Second, how do diverse worldviews contribute toexpanding occupational therapy? Although studieson clients’ perspective on occupational therapyservices have been undertaken (17,21,25,37), analy-ses focusing on occupational therapy culture thattake into account the clients’ worldviews are scarce(4,14,38,39). Therefore, the aim of this research wasto analyse worldviews regarding human occupationand the link between occupation, health andwell-being among people from rural Honduras,Morocco, Burkina Faso, Tanzania, and Ecuador.

Material and methods

A methodological design based on ethnography wasused in this research. According to Willis and Trond-man (40), ethnography embraces a group of methodsinvolving direct and sustained social contact withagents to gain access to their particular perspectives,at least partly in their terms. Therefore, ethnographyhelps to understand the irreducibility of humanexperiences.The first author was engaged in occupation-focused

projects from 2004 to 2011 in the following fivecountries: Honduras, Morocco, Burkina Faso, Tan-zania, and Ecuador. Because of misunderstandingsthat arose during the first occupation-focused projectin Honduras, the first author decided to understandthe participants’ perspectives on human occupationand its link to health and well-being before continuingwith the project. These misunderstandings werepivotal and were the seeds of this study. So, theyprompted the first author, before developing theoccupation-focused projects, to perform an initialanalysis of the worldviews and meanings related tooccupation and the link between occupation, health,and well-being among participants in all five countries(Table I). For this reason, both the aim and theprocess of gathering and analysing data were thesame when doing fieldwork in Honduras, Morocco,Burkina Faso, Tanzania, and Ecuador. The researchwas developed in accordance with the ethics inresearch and international cooperation proposed tothe European Commission by the European Groupon Ethics in Science and New Technologies (41).

Participants

The criteria for participation were that the potentialparticipants should be involved in the forthcoming

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occupation-focused project; have no difficulties incommunicating with the first author (because of beliefsystem, social status, or gender); and they shouldagree to participate according to the three proposedresearch methods. In each piece of fieldwork, theparticipants were purposefully chosen to cover thosedemographics considered important for attaining avariety of perspectives, i.e. sex, age, family situation,level of education, having/not having children, andreligious practice.The first author’s network was used to reach poten-

tial participants with different demographics. Demo-graphic data concerning the participants are presentedin Table II. The participants also varied regardingtheir involvement in the occupation-focused project.The participants comprised one occupational thera-pist, one nurse, one social worker, three relatives, onecommunity leader, and 20 potential clients.

Data collection

Semi-structured interviews, participant observation,and in-depth interviews were used to collect the data.Before the data were gathered, the first author met theparticipants and explained the purpose of the researchto them, clarified what methods would be used, andasked each participant about the best date to applyeach method. Also, in this initial meeting, all partici-pants were informed that participation in the researchproject was voluntary and they had the right towithdraw at any time without any consequences.Confidentiality was assured throughout the researchprocess. Informed consent was signed or recorded,in the cases of illiteracy, before the data collectionstarted.Thereafter, certain demographic questions were

asked (related to age, social status, number of

children, level of education, and religion). Data-gathering started with a semi-structured interviewthat included the following open-ended questions:“How would you explain occupation? Health? Well-being?”; “What occupation is the most important toyou, and why?”; and “How do you think what you aredoing influences your health and your well-being?”.The questions were adjusted based on the populationbeing interviewed by using words from the locallanguage to ask about occupation, health, and

Table I. Occupation-focused projects developed in each country after the respective fieldwork.

Date Country Occupation-focused project

May–December 2004 Honduras (Comayagüa, Tela,El Progreso y San Lorenzo)

Educate health workers regarding the occupational approach topeople with disabilities who attend primary health care servicesin rural areas

June–December 2006 Morocco (Nador) Promote occupational equality through the implementation ofan Argan oil cooperative run by women in the rural area ofAlhoceimas

June–December 2007 Burkina Faso (Houndé) Analyse the daily life of women affected by HIV-AIDS inHoundé

January–December 2008September–December 2009October–December 2010

Identify the need for and develop an Occupational TherapyCentre to promote mental health

July–December 2008 Tanzania (Iringa) Promote the meaning of occupational participation of peopleaffected by HIV-AIDS in Iringa

June–November 2011 Ecuador (Guaranda) Identify the relevance of meaningful play in the occupationaldevelopment of children at nurseries in the Bolivar region

Table II. Demographic description of the participants (n = 27).

CharacteristicsWomen(n = 15)

Men(n = 12)

Age Range (years) 22–40 35–72

Mean age (years) 28 36

Family situation Married/cohabiting 13 12

Living with relatives 2 0

Education Compulsory school 13 5

Upper secondaryschool education

1 5

University 1 2

Children Range (children) 2–8 1–9

Mean children 5 6

Religious practice Christian (Catholic) 5 1

Christian (Protestant) 1 2

Muslim 8 5

Animist beliefs 1 4

Country Honduras 3 2

Moroco 3 3

Burkina Faso 4 2

Tanzania 3 3

Ecuador 2 2

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well-being. In some cases, if the participant did notunderstand or know how to explain him/herself,examples were used or asked for.Then, each participant was observed in relation to

the information obtained from the interview for threeto four days. During participant observation, the firstauthor was involved deeply in participating andobserving the participants in their daily life athome, at work, and in the community. This methodallowed an in-depth understanding of their world-views in relation to human occupations and the linkbetween occupation, health, and well-being. All datacollected by participant observation were registered atthe end of each day.Finally, in order to better understand the

participants’ perspectives and to clarify questionsthat arose from the previous methods, in-depth inter-views were conducted. The semi-structured and in-depth interviews were audio-recorded, except in twocases where they were written down. In five cases (twoin Burkina Faso, one in Morocco, and two inEcuador), it was considered necessary to use inter-preters. The interpreters also stayed for participantobservations in Burkina Faso and Morocco, but thiswas not allowed in Ecuador.

Data analysis

In line with Grounded Theory, the data analysis wasconducted by establishing a coding system emanatingfrom open, axial, and selective coding (42). Throughthis process, categories emerged and were linked inconstant comparison with each other (42). Accord-ingly, the data analysis was conducted in two phases.In the first phase, an analysis of the material from thefieldwork in each country was conducted followingthe same procedure. In the second phase, an analysisof the material from all of the fieldwork taken togetherwas done.The first phase started with a verbatim transcrip-

tion of all interviews in the respective countries. Also,the notes from the participant observations wereadded to the register kept for each participant. Thetranscripts were read several times to get some notionof the content before the data analysis of the materialfrom each participant started. Second, when thefirst participant’s material was complete (i.e. therewere results from the semi-structured interview,participant observation, and in-depth interview),relevant parts were grouped under a summarizingheading to identify some preliminary categories.Third, the data were compared with the previousparts, and categories were related to their subcate-gories in terms of their properties and dimensions.During these analyses, it was considered relevant toreturn to earlier data in a constant comparative

process. In addition, memos were written describingthe first author’s thoughts regarding the content.Finally, as the analysis progressed, the categoriesand subcategories that had emerged were refined.As a result, a core category, which explained thephenomenon being studied, was identified. Severalcategories emerged during the early data analysis.However, the later interviews added depth andvariation to the categories established, which ledto the conclusion that the data from the fieldworkin each country were considered sufficiently satu-rated to fulfil the aim of the study. The same proce-dure was conducted with all the data from eachparticipant.After the analysis of the material from the fieldwork

in each country, the second phase, analysing thematerial from all the fieldwork taken together, wascompleted. To do this, an analysis of the materialfrom all the fieldwork was considered by constantlycomparing the properties and the relationships amongcategories, subcategories, and the core categories. Inthis second phase, the data collected during partici-pant observations in each piece of fieldwork wereconsidered and used to clarify some aspects relatedto categories and subcategories, and the core categoryemerged. In the progress of this analysis, it becomeclearer that the properties and relationships amongthe categories emerged in all the pieces of fieldwork.The analysis process was continuously revised and thecategories, the subcategories, and the core categorywere renamed, using the most relevant names for theircontent, considering the phenomenon being studied.Memos were constantly written describing the firstauthor’s thoughts and observations regarding thecontent. Moreover, the comparison of categoriesthat had emerged from the fieldwork facilitated theunderstanding of how the participants in diversecontexts perceived occupation and its link to healthand well-being.In order to increase the trustworthiness of the

analysis, a separate document was created for eachparticipant and memos from the analysis were alsowritten. Data-gathering from five countries, indifferent years and with distinct participants,contributed to the data triangulation. The method-ological triangulation was ensured by the use ofsemi-structured interviews, participant observations,and in-depth interviews for gathering data. The firstauthor conducted the main part of the data analysis,but did so in collaboration with the second and thirdauthors, who offered comments and reflections onthis process. The fourth author supported the doc-umentation of the research findings. The authors’diverse knowledge with regard to an interculturalapproach in occupational therapy enriched thediscussions.

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Results

A total of one core category, three categories, and sixsubcategories emerged from the analysis. The corecategory, “Occupations are social practices”,comprised three categories: “Occupation, health,and well-being as a personal and community experi-ence”; “Co-occupations, collective occupations, andcollaborative occupations are the most importantoccupations”; and “Occupation, health, and well-being mutually influence each other”. Six subcate-gories capture what was said with respect to the threeidentified categories. Together they represent theparticipants’ perspectives regarding human occupa-tion and the link between occupation, health, andwell-being (Figure 1). The results, supported by illus-trative quotations, are presented in relation to eachcategory and its subcategories. The quotations arecoded with the first letter of the name of the country

and a number identifying the participant (e.g. H1

means participant one from Honduras).

Occupations are social practices

This core category describes the participants’ viewsregarding their understanding of how occupations aredirectly influenced by the interaction between prac-tice and context in social situations. In this sense,some participants expressed that no occupation canbe understood as an entity separate from other aspectsthat influence their life (e.g. the economy, socialstructure, political aspects, and belief systems):

Well . . . when you ask me about my occupation Idon’t know if I can explain it to you . . . because . . . Idon’t understand you exactly . . . because . . . eh . . .my occupation is me, lives with me but at the sametime it is also in relation to others and where I live

Occupations are socialpractices

Occupation, health and well-being as a personal andcommunity experience

• Occupation, health and well-being aspersonally interpreted concepts

• Occupations that allow connectionwith the community

Co-occupations, collectiveoccupations and collaborativeoccupations are the mostimportant occupations

• The community determines the modein which the occupations are carriedout

• The aim of the most importantoccupations is interdependence

Occupation, health and well-being mutually influenceeach other

• Belonging is related to health andwell-being

• Accepting available occupationscontributes positively to health andwell-being

Figure 1. Participants’ perspectives on the nature of human occupation and the link between occupation, health, and well-being.

86 I. Zango Martín et al.

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. . . they are so linked that I can’t separate them andspeak of them as different components of my life. . ..(H3)Considering that occupations are connected in

continuous processes, the participants argued thatoccupations cannot be categorised into separateoccupational areas. If occupations are regarded asbelonging to different occupational areas, the mostmeaningful occupations cannot be taken into account:

I don’t know if being outside watching people ornature is regarded as being occupied, but I reallyenjoy it . . . and I usually meet someone and we talk. . . this has meaning for me, but what kind ofoccupation is that? (BF2)

In fact, social practice determines the possiblestructure of each occupation:

. . .if you go to visit your in-laws, you need to knowwhat you need to say, who you need speak with andalso what types of clothes and actions are accepted.(BF1)Moreover, the rules concerning occupations are

determined by the context in which they aredeveloped:

We know if we can do it or if it’s forbidden . . . yoursociety establishes that . . . everyone knows. . .. (T3)

Therefore, context determines the relevance andmeaning of certain occupations; as one participantput it:

. . . in my village, everybody likes me and respectsme because my main activity is ensuring that thetraditions are properly applied. I know all abouthow the traditions must be carried out at funerals,weddings and in other situations . . .my grandfatherexplained a lot about that to me . . . in my daily life,traditions have a strong influence. (H2)However, other participants described how occu-

pations are valid social practices in a specific societyand, for this reason, it is not possible to consider themvalid in other societies:

I have been to Europe once and there are a lot ofthings that we usually do . . . but if you go to Europethese occupations have nomeaning because in Eng-land they havemachines to do a lot of things. . .. (T1)

Related to this, some participants explained howoccupations, developed in specific contexts, areinfluenced by the contextual understanding of healthand well-being:

I take care of my sister’s children and I deal withpaying the school fees because she can’t . . . that

shows I’m healthy to work and all my familyappreciate it. (H1)

The need to understand the occupational experi-ence in the person’s real life was stressed by oneparticipant:

. . . real life is different to theoretical life . . . occu-pation in real life is to live . . . and in life there are alot of aspects which are interconnected . . . you needto take this into account. (E3)

Occupation, health, and well-being as a personal andcommunity experience

The connection between the person and his/her com-munity formed the most prominent aspects of thiscategory. Two interconnected subcategories relatedto this category were identified based on theparticipants’ worldviews: “Occupation, health andwell-being as personally interpreted concepts” and“Occupations that allow connection with thecommunity”.

Occupation, health and well-being as personally inter-preted concepts. According to the participants, theseconcepts are personally interpreted and to understandthem one must consider and know the context inwhich they are developed. For this reason, theseconcepts are difficult to explain because they arerelated to each other and are abstract and concreteat the same time:

I’m occupied and I can say that I’m in good healthand thus that I enjoy well-being, but I don’t knowhow to explain that to you . . . they’re difficultconcepts . . . because all of them are at the sametime abstract and concrete. . .. (E1)

Occupation, health and well-being are consideredconcepts which may have different meanings. In rela-tion to the conceptualization of occupation, one par-ticipant argued:

Occupation is a word with a lot of meanings . . .what aspect do you mean? . . . to me it is whenyou’re completely involved in something . . . but thisis difficult to explain . . . so complicated. . .. (H5)

Other participants defined the link between occu-pation, health and well-being as the result of a con-sistent relationship between their actions and beliefs:

When you’re in line with your beliefs and yourbehaviour in this situation, you can enjoy beingoccupied because you have good health and youcan feel well-being. . .. (BF6).

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Furthermore, the participants reported thatbecause the researcher is not a member of the culturalcontext, she cannot deeply understand certain aspectsrelated to what people do every day. They alsoexplained that belonging to another culture hinderedthe researcher from understanding how following therules and the beliefs established in their communitieshelps them to maintain their health and well-being.

If I try to explain why I’m healthy or why I becameill . . . eh . . . I need to explain to you somethingabout ancestors and perhaps you won’t understand. . . to me it’s important to make sacrifices, sharingthem with my community because it’s a way tomaintain my health but . . . I’m sorry, I can’t explainit to you . . . your eyes need to learn how to see mylife. (BF3)

Related to this, some participants highlighted theirfear of rejection or being the object of judgmentalremarks if they explained to the researcher theirunderstanding of health and well-being:

It’s difficult to share with you my perceptions ofhealth andwell-being because you don’t understandmy life vision. . .. I don’t want you to thinkI’m crazy . . . there are a lot of things that are linked.(H4)

Occupations that allow connection with the community.The participants emphasized the importance of par-ticipating in occupations related to belonging andbeing connected with their communities in order tomaintain their health and well-being.

All the things I’m involved in [the community]allow me to find meaning in life, yes, it’s truebecause occupation, health and well-being andother things have meaning because they allow meto follow this meaning. . .. (E4)

In this way, occupation is related to being con-nected to someone and if this is not the case, they donot consider it as an occupation:

If you do something alone, only for yourself, it hasno meaning and it is not a real occupation. (BF4)

Furthermore, the participants described beingconnected as the main goal when engaging in anoccupation.In addition the participants were of the opinion that

the goals of an individual must be closely linked withthe goals of the community:

If I know that doing something isn’t consideredgood [by my family], for instance, dressing in acertain way at a sacred rite, I will choose somethingto wear that I like but at the same time will beaccepted. . .. (E4)

In this sense, religious practice was also describedas a relevant occupation that promoted their connect-ness with the community:

I go to the mosque five times a day and I organizemy life depending on that, because my religiouscommunity is also my family. (M1)

Beingdisconnected fromone’s community, becauseof marginalisation or stigmatization, was consideredsocial death, as reported by one participant:

When I got it [referring to being infected with HIV]my family didn’t allow me to take care of my baby,because the neighbours in my community thoughtmy baby could also get infected . . . eh . . . this ismorepainful than being infected by the disease. (M3)

For this reason, some participants believed thatbeing engaged in an occupation is a bridge to stayingin contact with the community.

Now, I feel better and I can go to the countrysidewith my sisters and brothers and for this reason, I’msure, the others don’t consider me as crazy, as arisk. (T6)

Co-occupations, collective occupations, and collaborativeoccupations are the most important occupations

The occupations that participants considered mostimportant were co-occupations, collective occupa-tions, and collaborative occupations. Co-occupationsrefer to occupations conducted by two or more peoplein an interconnected manner whereby each personhas an individual responsibility to achieve the com-mon goal. Collective occupations were conceptualizedas daily occupations in which the main aim is relatedto social interaction. Finally, collaborative occupationswere described as those in which a group of peopleare involved in all parts of the occupational processwith a common goal. There are two subcategories inthis category: “The community determines themode in which the occupations are carried out”and “The aim of the most important occupations isinterdependence”.

The community determines the mode in which the occupa-tions are carried out. The community does not specifyall actions that are performed within an occupation,but it does determine the structure for possibleactions. One participant explained how the wholecommunity knows the actions needed to cook; evenif the type of meal is different, there are some actionsthat will always be done:

To cook you will need at least the following activ-ities: finding wood, going to the local market to buy

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the food, drawing water from the well and lighting afire. . .. (T5)

Another participant emphasized the influence ofrural and urban contexts for the types of possibleactions involved in a particular occupation. Theparticipant also drew attention to the differencebetween the actions carried out in a rural or an urbancontext:

When I’m visiting my sister in the city, I do notneed to go for water to the well since there isrunning water at home. (M5)

Moreover, the community has a strong influence onhow some occupations develop. Consequently,certain occupations are articulated in such a waythat no one questions whether something could bedone in a different way:

I involved my family members in my business and Ishare the benefits of it with them, because I’m theeldest and responsible for their support. (T4).

The aim of the most important occupations is interdepen-dence. According to one participant, reaching a com-mon goal in a co-occupation influences how thepeople engage in the occupation:

In the argan oil cooperative, each women is respon-sible for particular actions and she masters her area. . . but the goal is the same for everyone, to makebetter argan oil and to support the family. (M4)

However, when occupations are collective occupa-tions, as in a wedding or going to a club to drink somelocal beer, the main goal is social interaction:

Every day I go there (the club) to drink dolo andmeet the neighbours and I know the latest news andif something important is going to happen in thenext few days in Houndé. (T2)

In collaborative occupations, the goal is commonand everyone is engaged in the whole process:

The whole family is involved in the activities ofcultivating the field when it is rainy season. . . theobjective is common for everyone, to have food allyear round. (BF6)

Occupation, health, and well-being mutually influenceeach other

According to the participants, occupation, health, andwell-being mutually and constantly influence eachother. For this reason, a positive or negative changein one of these aspects influences others directly. Thetwo subcategories identified were: “Belonging isrelated to health and well-being” and “Accepting

available occupations contributes positively to healthand well-being”.

Belonging is related to health and well-being. Belongingto a community, through engagement in occupations,was considered by some participants as a means tomaintaining health and well-being. One participantexplained:

When I was diagnosed I had no money and thecommunity paid all the costs of hospitalizationand medications. . .. I was a good teacher beforebecoming ill and my behaviour was always correct. . . for this reason all the community gaveme a hand.(BF5)

In this sense, other participants stated that what ismost important is that your occupations are in linewith your community rules. So, if people are involvedwith and accepted by the community, the communitywill be responsible for them when they are in need:I know this has value [referring to going to the

mosque every day] and if I need money, someone willlend it to me because they know that not being honestis punishable in my religion. (M2)One participant argued that if you do something of

great social value in your community, for examplestart a new business or sacrifice a lamb on the occa-sion of a celebration, but you do not follow thecommunity rules or behave appropriately, the out-comes of your actions will not be positive. Conse-quently, according to this participant, the mostimportant thing is to share your achievements withthe community and to respect the established rules.Thus, when in difficulty, the community will sup-

port you in return. In line with this, one participantreported that health and well-being are linked tobelonging to a community:

. . . well . . . health and well-being are when you’reaccepted by your community . . . you know yourrole and what others expect of you . . . that bringswell-being and maintains your health. (M5)

Accepting available occupations contributes positively tohealth and well-being

The participants explained the relevance of acceptingavailable occupations so as to have health and well-being:

. . . yes, if you’re always wanting to do somethingdifferent . . . you’ll become ill . . . this is clear . . . theold people know a lot about that. . .. (T2)

On the other hand, one participant proposed thatfeeling grateful to life also has an impact on health andwell-being:

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I know that my life could be better but I love my life,my family and my work, and these feelings helpmaintain my health . . . emotions have an influenceon your health . . . if you’re happy it’s not possible tobecome ill. (E3)

Acceptance of available occupations is not regardedin a passive way, but as a conscious process wherebythe person is active in analysing and understandinghis/her life as a continuous process:

You need to think about yourself, about yourthoughts and your actions, to understand whyand how you will continue living, for that youneed time and to think of life as a spiral. (M2)

The results revealed that the key is to fully trust theprocess of life as supported by spiritual beliefs andreligious practice.

Discussion

In the present study, the overall results showed thatthe participants, from diverse cultural contexts, devel-oped their own understandings of human occupationand how it is related to health and well-being. More-over, taking into account these results, the communityhas a strong influence on their worldviews. In fact, theparticular views formed by the participants revealedmany fundamental questions about whether the mainassumptions underpinning the culture of occupa-tional therapy are globally relevant (3,4).For example, in the category “Occupation, health

and well-being as a personal and community experi-ence” the participants explained how occupation,health, and well-being simultaneously concern theindividual while always being articulated togetherwith the particular characteristics of the community.Because of this, occupation cannot be understood as apart separate from its context (43), and health andwell-being need to be considered as culturally con-structed experiences (13). In line with these findings,it is not possible to approach occupation, health, andwell-being without considering the social value con-nected with the context. Therefore, our results revealthe understanding of occupation as a social practiceand as an expression of historically produced socialrelations, which takes into consideration the interac-tion between the occupation and the context (43).In addition, occupation, health, and well-being are

understood by the participants as personally inter-preted concepts but closely linked with their commu-nity. For this reason, they explained how difficult it isto share their understanding if the researcher is not amember of the community. Consequently, this factmay cause the researcher to misunderstand and judgewhat people do to maintain their health and promote

well-being. This shows the importance of being cul-turally sensitive (14) in occupational therapy inter-ventions and promoting cultural competence (12,15)in the educational area of occupational therapists so asto meet the challenge of relevance in a multiculturalsociety.Findings from the present study also reveal how

occupation, health, and well-being were defined bythe participants in relation to being involved in thecommunity and acting in line with their beliefs. Thesefindings are consistent with the study by Pooremamaliet al. (21), where it was found that being engaged inthe community and spiritual practice are consideredthe most relevant aspects of the occupation in relationto health and well-being. In this sense, and in linewith previous studies, occupation cannot be consid-ered a cross-cultural universal concept (29), nor canhealth and well-being (26). Furthermore, it is impor-tant to recognize the influence of Western society’sconstruction of a healthy daily life on the conceptu-alization of occupation (44,45). For this reason,incorporating diverse worldviews about occupation,health, and well-being is needed to expand the rele-vance of occupational therapy.Another interesting result, which has implications

for occupational therapists, is the considerationof occupation, health, and well-being as personallyinterpreted concepts that are directly linked with thecommunity perspective. This implies that the goals ofan individual should correspond to the objectives ofthe community. In addition, the research findingssupport the view of occupation as extending beyondthe limits of the individual (46-48), considering thatbeing part of a community is more importantthan engaging in an individual occupation (32). Inthis way, the research findings generate some inter-esting questions concerning the purpose of occupa-tion and its impact on occupational therapy theoryand practice.However, in line with Hammell (3), only a minority

of people around the world might have the opportu-nity to engage in personally meaningful occupations.Conversely, the majority of people around the worldmight choose their occupations based on the meaningattributed by the community, which in some casesmight not be in line with what is considered as ameaningful occupation by the person concerned(20,35). Consequently, the conceptualization ofhuman occupation and the link between occupation,health, and well-being need to be critically analysed(3,14,34). Moreover, the concepts of occupation,health, and well-being need to incorporate othermeaningful perspectives from around the world(46,47).With regard to the category “Co-occupations, col-

lective occupations, and collaborative occupations are

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considered the most important occupations”, thefindings indicate that the community determinesthe way to carry out occupations and that interde-pendence is the most important goal. These findingsare supported by a study by Zango and Ulla (19),which analysed the activities of the daily lives ofwomen affected by HIV/AIDS in Burkina Faso. Theirresults show how the community determined thewomen’s engagement or not in meaningful occupa-tions. Moreover, the community also established apossible structure of actions that determined howoccupations must be done to be accepted andrelevant. Therefore, being aware of this in an occu-pational therapy approach would be important foroffering culturally significant interventions and atherapeutically effective approach (23,38,47).The participants in this study argued that the

most important occupations were related to socialrelationships, interdependence, reciprocity, mutualobligations, and belonging. Consequently, theseoccupations have cultural value and are directlyrelated to health and well-being. This is in agreementwith Kantartzis (45), who explained how occupationsare rarely individual. Furthermore, the findings con-firm previous studies where the most deeply engagingoccupations are related to the interdependence(3,38). Thus, considering these findings may be influ-ential if occupational therapists are to be aware ofoccupations as pathways to meaning and connectionto other people. However, if this are not considered,occupational therapists may denigrate those peopledeemed to be dependent or unproductive, andactively reinforce the economic and social statusquo that is present in the minority world, but notrepresentative of the global world (49). For this rea-son, the results of this research invite occupationaltherapists around the world to be aware of and analysepeople’s reciprocal obligations and relationships andhow these impact on their health and well-being. Inaddition, it is relevant to know that in some contexts“being dependent” should not be undervalued orregarded as in need of a therapeutic intervention(3,14,23).These results may also have implications for

occupational therapy theory and practice if theinfluence of co-occupations, collective occupations,and collaborative occupations on health and well-being is reported and deeply understood. However,we need to consider that in some cases the needs ofthe group may seem to be in conflict with the needs ofthe individual (20). Our findings are also supportedby Guajardo (43) and Ramugondo and Kronenberg(44), who argue that the well-being of the communityand the teleological approach of occupationaltherapy highlight the facilitating of collective occupa-tions. Consequently, co-occupations, collective

occupations, and collaborative occupations enablethe understanding of how the interconnectednessbetween the individual and the collective has thepotential to lay the foundation for social practice.In the category “Occupation, health and well-being

mutually influence each other”, the results supportthe idea that belonging is directly linked to health andwell-being. Related to this, most of the participantsargued that they need support to be and feel healthy.This confirms the work of other authors who arguethat, in different cultural contexts, occupations asso-ciated with interdependence and belonging to thecommunity are the most relevant for maintaininghealth and well-being (13,17,18,25,37,38). Oneparticipant reported that belonging to a religiouscommunity determines a person’s behaviour andalso establishes how to perform or not performsome occupations when the person needs supportfrom the community. In this sense, belonging maybe a sufficient cause for doing something and for thisreason, in order to have human interaction, a humanbeing must do that something (44). Hence, theseresults support that belonging is more importantthan being, doing, and becoming. These results con-tradict and challenge Wilcock’s thoughts (9), wheredoing, being, becoming, and belonging are equallyimportant for maintaining health and well-being.Furthermore, in line with the mutal influence

among occupation, health, and well-being, the rele-vance of accepting available occupations has beendiscussed. The participants explained how being con-scious when engaging in occupations promotes healthand well-being. These findings are consistent withPooremamali et al. (21), whose results indicated theacceptance of life as a relevant aspect for maintaininghealth and well-being. Therefore, spirituality andreligious practice should be considered as centralaspects in occupational therapy intercultural interven-tions. Additionally, how these occupations areconnected with health and well-being should beanalysed.The similarities between our results and the

arguments and theories reported by other authors(13,14,30,34) raise the question of reviewing theculture of occupational therapy that reflects a partic-ular perspective on human occupation and the linkbetween occupation, health, and well-being. Hence,our results support that each person brings a uniquepattern of personal traits linked with a unique set ofcontextual conditions, and occupational therapistsneed to consider this in their the approach.Further research is required to understand and

identify how social practice influences occupationsand determines health and well-being. However,this research and research from diverse contextsmay contribute to proposing an intercultural

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perspective of occupational therapy that takes intoaccount the perspectives of people around the worldrelated to human occupation and the link betweenoccupation, health, and well-being.

Conclusions

The overall findings showed a tentative theoreticalstructure that incorporates a core category withrelated categories and subcategories, based on thethe understanding of occupation as social practice.Accordingly, the understanding of human occupationand the link between occupation, health, andwell-being among people from Honduras, Morocco,Burkina Faso, Tanzania, and Ecuador invites occu-pational therapists around the world to consider howother cultural perspectives are needed in occupationaltherapy in order to be more culturally relevant.One of the most important findings in this study

was that occupation was considered as social practice.Because of this, the context determines the practice insocial interaction, the rules, and the meanings ofoccupations. Thus, this understanding of occupationand its influence on health and well-being invitesoccupational therapists not only to be aware ofthe main aspects related to particular contexts, butto promote critical thinking regarding the cultureof occupational therapy and to incorporate otherapproaches.Moreover, a complementary view of occupation,

health, and well-being, integrating individual andcollective views, could enhance and expand the rel-evance of occupational therapy around the world.Furthermore, occupational therapists are urged toface the intercultural perspective in theory andpractice, incorporating and recognizing diverseworldviews from around the world.

Limitations

Several limitations can be discussed in relation to thepresent study. First, it should be recognized that otherways of analysing the understanding of human occu-pation and the link between occupation, health, andwell-being among people in diverse rural areas exist. Itshould also be considered that other results mighthave emerged with other methodological approachesor with other researchers.Another possible limitation is the small number of

participants from each location. However, the parti-cipants were purposively recruited by the first authorwhile considering the variety of backgrounds of theparticipants from each piece of fieldwork. We couldalso have searched for differences between the parti-cipants from the different locations but this was notour purpose. During the data analysis, nothing

became evident to make us think that there wereany major differences with regard to this issue. Inthis sense, we recognize that our interpretation is onlyone of many possible interpretations (42). It should berecognized that recruiting other participants mightperhaps have contributed with other perspectiveson occupation, health, and well-being and the linkbetween them.An additional limitation is the lack of occupational

therapists as participants in the studies fromHonduras, Morocco, Burkina Faso, and Ecuador,which resulted in perspectives from other healthand social professionals alone. Only one occupationaltherapist from Tanzania participated in this research.This might have had an impact on the feedback thatwas given to the researcher during the data analysisregarding the cultural relevance of the categories andsubcategories that emerged. On the other hand, ifbeing familiar with the context and the participants isconsidered a possible limitation, in this case it wascrucial for developing participant observation in theparticipants’ daily contexts and clarifying someaspects in collaboration with each participant.Another question is whether it was appropriate to

do this analysis of the studies conducted in differentpieces of fieldwork on different occasions. Neverthe-less, the fact that it was the same researcher (firstauthor) who collected all the data, using three meth-ods in the five places during different periods of time,allows for a deeper understanding of human occupa-tion and the link to health and well-being taking intoaccount a more global worldview.Finally, data collection was realized during differ-

ent periods of time and this allowed for criticalreflection on the conceptualization of human occu-pation and the link between occupation, health, andwell-being. In this sense, the first author’s develop-ment of critical thinking regarding the relevance ofoccupational therapy culture might have influencedthe participants’ answers. If so, the answers from theinterviews would have been different from the datacollected through participant observation. This isone reason for collecting data using three differentmethods and collaborating with the other authors inthe data analysis.

Acknowledgements

The authors would like to thank all the participantsfrom the different locations for sharing their world-views and experiences and for inviting occupationaltherapists to evolve personally and professionally.Their sincere thanks go to Petra Wagman for thehelpful discussions and comments during the prepa-ration of this paper.

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Declaration of interest: The authors report noconflicts of interest. The authors alone are responsiblefor the content and writing of the paper.

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