Annals of International Occupational Therapy

Position Paper 

Occupational Therapy in Mainland China: Status, Challenges, and Future Directions

Debbie Lavine, OTD, OTR/L, CIMI; Bobbi Greiner, OTD, OTR/L, BCP

Abstract

Objective:

Occupational therapy has been slow to develop and is a largely unrecognized profession in mainland China. Understanding the challenges affecting the growth of the field in China is critical for encouraging sustainability of the profession and supporting current occupational therapy providers. The goals of this study were to increase understanding of occupational therapy in mainland China and to identify challenges to advancement of the profession.

Methods:

A literature review was conducted to connect Chinese cultural views of health and disability with past practices in rehabilitation and the first author's personal experiences providing occupational therapy services in a large urban area in China.

Results:

Occupational therapy is a developing profession in mainland China. The potential for growth and sustainability is present, yet many challenges also exist.

Conclusion:

Cultural views, educational standards, and best practices will need to be considered as the profession of occupational therapy continues to move forward. [Annals of International Occupational Therapy. 2020; 3(1):38–44.]

Abstract

Objective:

Occupational therapy has been slow to develop and is a largely unrecognized profession in mainland China. Understanding the challenges affecting the growth of the field in China is critical for encouraging sustainability of the profession and supporting current occupational therapy providers. The goals of this study were to increase understanding of occupational therapy in mainland China and to identify challenges to advancement of the profession.

Methods:

A literature review was conducted to connect Chinese cultural views of health and disability with past practices in rehabilitation and the first author's personal experiences providing occupational therapy services in a large urban area in China.

Results:

Occupational therapy is a developing profession in mainland China. The potential for growth and sustainability is present, yet many challenges also exist.

Conclusion:

Cultural views, educational standards, and best practices will need to be considered as the profession of occupational therapy continues to move forward. [Annals of International Occupational Therapy. 2020; 3(1):38–44.]

The World Federation of Occupational Therapists (WFOT) defines occupation as things that individuals do in daily life that are meaningful and purposeful (WFOT, 2016a). Occupational therapy, which addresses an individual's ability to perform daily occupations, is a profession that continues to grow and develop worldwide. In mainland China, many people do not understand the benefits of occupational therapy and therefore do not use the services (Asakawa, Zong, Wang, Xia, & Namba, 2017). Moreover, in China, individuals of lower socioeconomic status and those living in rural areas face more challenges in receiving rehabilitation services because they often do not have health insurance or the ability to access care, which is most often available in urban areas (Hampton, 2001; He et al., 2017). These challenges, along with cultural traditions and views, are among the many reasons why occupational therapy has had limited growth in mainland China. To further understand these barriers, it is necessary to become familiar with the cultural views of illness and disability in China as well as the development of rehabilitation services. Addressing these obstacles through education and support for the promotion of occupational therapy will allow for more growth and sustainability of the profession.

Views of Health and Disability

Culture greatly influences views of health, illness, and disability. The effect of culture and tradition on the development of occupational therapy and other rehabilitative services in mainland China is significant. Traditionally, Chinese culture integrates Confucianism, Taoism, and Buddhism as well as the concepts of yin and yang to describe views of wellness (Hopton & Stoneley, 2006; Yau, 2007). These philosophies encourage harmony with others and with nature as well as respect for traditional patriarchal family values (Hopton & Stoneley, 2006). Yin and yang conceptualize the interdependence and balance between persons or concepts that further affect the ideas of health and wellness (Yau, 2007). Optimum health occurs when there is a balance among qi, or the energy that causes physiological function, with the five elements of earth, metal, water, wood, and fire (Hopton & Stoneley, 2006). Harmony among nature, the self, and others is valued, and importance is placed on an individual's contribution to society. Individuals are interconnected with others, and loyalty to the family is important (Hopton & Stoneley, 2006; Jang, 1995).

Conversely, illness or disability reflects an imbalance between the body and the environment and prevents completion of an individual's roles and responsibilities (Hopton & Stoneley, 2006; Yau, 2007). Chinese individuals may view illness or disability as punishment for past sins or familial sins (Jang, 1995), and as a result, the person who is ill or disabled must be cared for by family members as reparation (Waldman, Wong, & Perlman, 2010). Therefore, the person with an illness or a disability often experiences discrimination and may be considered burdensome and unable to fulfill his or her responsibilities to the family and to society (Hampton & Xiao, 2007). Moreover, Chinese society is more accepting of acquired disability or physical impairment compared with congenital or developmental challenges, which may intensify discrimination against those affected (Hampton & Xiao, 2007; Waldman, Wong, & Perlman, 2010). Additionally, individuals are encouraged to accept the effects of illness or disability rather than to attempt to facilitate change (Jang, 1995). These cultural views have substantially affected the understanding and development of rehabilitative medicine throughout mainland China. Independence with daily occupations seems less of a concern in China than in Western societies, and accepting life situations rather than actively seeking change is commonplace. As a result of these views, the understanding of occupational therapy and its purposes has been limited, affecting the growth of the profession.

Rehabilitation Services

Rehabilitation Medicine

China is the most populous country in the world, with an estimated 85 million people who have disabilities as well as 130 million people who have a chronic illness and could benefit from rehabilitative intervention (Xiao, Zhao, Ma, Li, & Qiu, 2017). Rehabilitation in mainland China was first introduced in the 1980s through cooperation with the Ministry of Health and the World Health Organization (Wong & Li-Tsang, 2010). The establishment of the Chinese Disabled Person's Federation in 1988 helped to increase awareness of people with disabilities and the need for therapeutic interventions (Zheng, Maude, & Brotherson, 2015).

To address the needs of such a large population and provide intervention for individuals with disabilities despite limited economic and human resources, the Chinese government developed various strategies to target the population's needs. Some universities initiated 1-year rehabilitation programs for physicians (Hampton, 2001) as well as 3-year diploma programs for nonspecific rehabilitation, in which graduates are neither physical therapists nor occupational therapists but receive some training in all disciplines (Da Hong, 2006; Wong & Li-Tsang, 2010). A community-based rehabilitation model was implemented, as recommended by the World Health Organization, to provide rehabilitative instruction to individuals with disabilities; however, the clinics providing these services were typically staffed by volunteers from the local community who had minimal training (Hampton, 2001). The high population and the limited number of volunteers available to assist made implementation of community-based rehabilitation difficult (Yu et al., 2009). Community-based stations were also developed to provide social and job training assistance to individuals with mental illnesses and intellectual disabilities to decrease the burden on the family and the community (Chau & Yu, 1998). However, although these sites were called “occupational therapy stations,” the trainers were often individuals with experience in education or health care (Chau & Yu, 1998). In the United States, these services would resemble vocational rehabilitation more closely than occupational therapy because of the focus on employment and the difference in qualifications between trainers and licensed therapists.

Occupational Therapy in the Past

The implementation of rehabilitation services in mainland China starting in the 1980s helped to lay the foundation for more specialized training and services, including occupational therapy. Rehabilitative medicine programs provided some relief for the significant shortage of therapists, yet these programs typically did not differentiate between occupational therapy and physical therapy (Erlandsson, 2011). Traditional 4-year bachelor's degree programs for occupational therapy were first established in mainland China in 2002 (WFOT, 2016b). By 2006, a total of 100 occupational therapists were reported throughout the country. After the Wenchuan earthquake of 2008, the need for rehabilitation services increased greatly as thousands of individuals experienced physical disabilities, posttraumatic stress, and displacement (Lee, 2014). Occupational therapists were particularly valuable during this time because of their skills in edema control, splinting, and scar management (Lee, 2014), and this expertise may have helped to advance the profession. In 2009, there were 2,400 occupational therapists practicing in the country, an estimated one therapist for every 100,000 residents (Shi & Howe, 2016). This was a substantial increase from 2006, although still a significant shortage for such a populous country. Factors including cultural views of acceptance of disability, limited awareness of the benefits of rehabilitation, and the availability of few trained therapists to teach in educational programs have contributed to the slow progression of occupational therapy as a profession from 2002 to the present (Asakawa et al., 2017; Da Hong, 2006).

Occupational Therapy in the Present

Approximately 90% of those currently providing occupational therapy services in mainland China are physicians, nurses, or rehabilitation professionals with 30 to 60 hours of specific training in occupational therapy (Erlandsson, 2011; Fong, 2011; Shi & Howe, 2016; Yan, Sinclair, & Penman, 2012). Those who are trained specifically as occupational therapists often receive little recognition and respect from the community as specialists, have few years of experience, and focus on neurological and pain conditions (Da Hong, 2006; Erlandsson, 2011; Shi & Howe, 2016). Functional independence may not be the goal of intervention because families often assume the caregiving role and those receiving therapy are viewed as dependent, requiring assistance with all mobility and self-care activities (Jang, 1995; Shi & Howe, 2016).

Because so few occupational therapists are available, patients may receive direct care from therapists only for modalities and may perform exercises without therapist supervision (Erlandsson, 2011). The time from the onset of injury or disability to service delivery is often lengthy. For example, Li et al. (2016) reported an average of 75.13 days between stroke onset and admission to rehabilitation. Such wait times are likely to affect rehabilitative outcomes, such as motor recovery, as well as the ability to return to work and participate in society (Li et al., 2016). Moreover, standardized assessments may not be available and documentation guidelines are not strict, so progress notes may not be written (Erlandsson, 2011). Lack of referrals between hospitals and rehabilitation centers, inability to provide care beyond the acute stage, and limitation of services to primarily clinic environments are further challenges (Xiao et al., 2017). Additionally, neither certification nor licensure for occupational therapy is required in China, and there are no guidelines for continuing education (Erlandsson, 2011). Because there is no standardization for education and clinical practices, the provision of services may be inconsistent.

Lim, Honey, Du Toit, Chen, and Mackenzie (2016) suggested that occupational therapy was developed according to Western philosophies, which may create a disconnect between the profession and Chinese culture. However, similarities are evident through the use of activity as a modality, the encouragement of life balance, the influence of the environment, and the importance of intrinsic motivation and meaningful existence (Jang, 1995). A client-centered approach is consistent with the Chinese view of health; the blurring of physical therapy and occupational therapy in many rehabilitation programs may be more challenging than conflicts with cultural values because the scope and outcomes of treatment may not be clearly defined.

Although differences in the standardization and provision of occupational therapy in China can be striking compared with Western countries, the first author's personal experiences working as an occupational therapist in the United States for 23 years in a variety of settings compared with exposure to a Chinese rehabilitation department show the benefits of the Chinese method of care. For example, in China, the patient's family is very involved in treatment, often performing transfers and exercises for the patient with guidance from the therapist. Patients also keep their own x-rays and films rather than the practice of the hospital maintaining the records, which allows physicians and therapists more timely access. This is quite different from Western countries such as the United States, where records must be requested and privacy is strictly guarded (Erlandsson, 2011). The clinical environment in China appears collaborative and relaxed, with therapists frequently sharing thoughts about patient care and asking each other for suggestions regarding treatment. Further, therapists seem open to learning new techniques and enhancing their skills, particularly when a more experienced therapist is available to teach them. This collective and collaborative culture provides many opportunities for enhancing both current occupational therapy services and the overall growth of the profession.

Education and Future Development

One of the greatest barriers to the expansion of occupational therapy services in mainland China is the shortage of experienced therapists (Da Hong, 2006). Understanding the current status of occupational therapy education and using additional resources and strategies can help to promote the growth and sustainability of the profession.

Occupational Therapy Education in the Present

Currently, there are nine accredited professional degree programs offered in mainland China for occupational therapy, seven at the bachelor's level and two at the master's level (Shi, Howe, Hinojosa, & Wang, 2018). Hong Kong, an administrative region of the People's Republic of China, also offers a doctor of health science degree with an occupational therapy specialization (Hong Kong Polytechnic University, 2018). Hong Kong has been instrumental in improving education in the mainland because occupational therapy is more established in this area and programs are more fully developed (Wong & Fong, 2013). Occupational therapy professionals from Hong Kong and Taiwan support mainland China through collaborative efforts and by encouraging Chinese therapists and students to travel to other countries for educational opportunities (Da Hong, 2006).

Da Hong (2006) suggested that one of the challenges in training occupational therapists is the shortage of professional educators. Because the profession is relatively new and is less developed than in other countries, few experienced therapists are available. It is not uncommon for therapists with fewer than 5 years of practice to be educators, which may limit the complexity of clinical skills taught in the classroom setting. Although novice therapists tend to use procedural reasoning, experienced therapists use all types of clinical reasoning, including procedural, interactive, conditional, narrative, and pragmatic (Knecht-Sabres, 2013). Educators who have minimal clinical experience may not possess advanced clinical reasoning skills or provide examples of intervention strategies that are often used in didactic training. Da Hong (2006) suggested sending occupational therapy educators abroad or to Hong Kong so that they can obtain advanced degrees to improve their knowledge base and enhance classroom experiences.

In a clinical setting, it may be difficult to distinguish between occupational therapy and physical therapy. Many nonspecific degree programs include training in physical, occupational, and speech therapies as well as prosthetics/orthotics, electrotherapy, and traditional Chinese medicine (Erlandsson, 2011). Therefore, striving for separate degree programs and aligning programs with international standards for the development of professional competencies may create benefits for both therapists and patients (Da Hong, 2006; Rodger, Clark, Banks, O'Brien, & Martinez, 2009).

For Chinese occupational therapy students, international classrooms and fieldwork settings can enhance clinical reasoning and practice skills and increase the understanding of different views of disability and expectations for care. Lim et al. (2016) reported that Asian students in an Australian occupational therapy program believed that both the classroom and the clinical environment required students to be more assertive and communicative than is typical in China. They also expressed concern about the application of occupational therapy principles in their home country (Lim et al., 2016). Thus, international programs that accept Chinese students must consider these factors and assist students in developing strategies for cultural relevance on their return to China.

Occupational Therapy for the Future

Promotion of occupational therapy services is a crucial need for the survival and advancement of the profession in China. According to Asakawa et al. (2017), government support through restructuring of the health care system, training of therapists, and general health education is needed to assist those with disabilities in accessing services in the mainland. Occupational therapists in the mainland must establish the importance of educating the family in the process of recovery and the importance of participating in activities in conjunction with Chinese culture (Jang, 1995). Globally, occupational therapists from other countries can promote the growth of the profession in China through education, affiliations, partnerships, and technology.

Education. Occupational therapy is a well-established profession in the United States, Europe, and many developed countries. However, in countries where services are newer, promoting understanding of and respect for the profession can be difficult and may affect the growth of the profession (Peer & Pollard, 2012). Promotion of occupational therapy in China is congruent with the tenets of occupational justice and the use of occupation to enhance wellness. This perspective may provide a catalyst for encouraging internationally trained occupational therapists to share knowledge and expertise with colleagues and students in mainland China.

Shi and Howe (2016) suggested that more advanced education for occupational therapists and occupational therapy educators is needed to encourage professional growth. Methods for sharing may include guest lectureships, continuing education programs, and opportunities to collaborate on program development. For instance, the first author's personal experiences presenting lectures on orthopedic topics to various audiences in China, including medical students, rehabilitation students, and occupational and physical therapists, identified much interest in and appreciation for knowledge sharing. Additionally, using live teleconferencing to present information on pediatric conditions to occupational therapy students from an accredited Chinese university proved to be an efficient and effective means of collaboration. Such experiences can enhance both personal and professional development while facilitating the application of occupational therapy principles in clinical and educative settings. The use of similar strategies would greatly enrich cultural awareness and learning opportunities for therapists and educators as well as students and colleagues. Language barriers may be a challenge for international collaboration, so the use of a personal translator, as in the first author's experience, may be necessary.

Membership affiliation. Occupational therapy as a profession in China took a critical step forward in 2018 by joining the WFOT as a full member organization (WFOT, 2018). This membership affiliation allows for continued networking and collaboration as well as progression toward standardization of occupational therapy education and service provision. Membership allows Chinese occupational therapists the opportunity to learn from other member organizations and provides a global platform for identifying needs and creating solutions to barriers to access and delivery of services. Development of professional occupational therapy organizations nationally is also important for achieving a standard curriculum, ensuring the quality of practice, and improving professional status through education, conferences, and publications (Shi & Howe, 2016; Shi et al., 2018).

Sustainable partnerships. Sustainable partnerships with international universities provide another valuable tool for the advancement of occupational therapy in mainland China. International fieldwork placements for occupational therapy students from other countries who desire to experience China can offer many benefits for the student and the host facility. Immersion experiences help to create cultural competency and sensitivity, improve communication, and enhance clinical reasoning through innovation and leadership skills (Knecht-Sabres, 2013; Mu, Coppard, Bracciano, Doll, & Matthews, 2010). Student-led projects and workshops allow knowledge sharing through clinical training for leaders and therapists at the host facility as well as the provision of therapy in underserved areas (Cameron et al., 2013). Collaboration of the host facility, university, and students through the use of technology before and during fieldwork can ensure that the host facility has professional standards and expectations in place to prepare students for success (Cameron et al., 2013; Shields, Quilty, Dharamsi, & Drynan, 2016). Experiential learning in nontraditional environments, such as home health care or community-based practice, is also encouraged to allow practical application of learned concepts (Knecht-Sabres, 2013). Li-Tsang, Choi, Sinclair, and Wong (2009) found that students who were placed in emerging practice facilities reported that they were more able to engage in self-directed learning, problem solving, and creative thinking compared with students in established settings. Such facilities and nontraditional environments must not be overlooked for clinical placement in international settings, such as mainland China.

Similarly, giving Chinese students the opportunity for international education and fieldwork allows them to learn clinical skills that may not be as advanced in their own country and provides varied perspectives for client-centered practice. Lim et al. (2016) conducted a phenomenological study of Asian students studying occupational therapy in Australia. Although these students faced challenges that included the need to learn occupational therapy theory, different styles of learning, cultural adaptation, and socialization, many reported the importance of acceptance of client independence, client centeredness, role balance, and respect for disabled persons (Lim et al., 2016). Establishing English language proficiency based on the requirements of the host country and providing trained interpreters or access to English classes would help to minimize limitations that result from language barriers among Chinese students participating in international programs (Bennett, 2018).

Accessing resources through technology. Many occupational therapy students and practitioners who are from underdeveloped areas or who have limited access to resources experience difficulty securing reference and resource materials as well as continuing education (Peer & Pollard, 2012). According to the WFOT, one way to promote globalization of education is through free access to occupational therapy publications at the undergraduate level via the Internet as a benefit of membership (Peer & Pollard, 2012). This is a valid possibility because the use of the Internet has greatly opened lines of communication and collaboration for students and professionals. For instance, the Occupational Therapy Weekly Forum is an online community where participants attend virtual lectures and discussions via messaging, with sharing of presentations and documents through attachments (Yan, Sinclair, & Penman, 2012). This type of platform is useful for increasing participants' knowledge and awareness of cultural and local issues that affect occupational therapy practice. Another example of the use of technology is the alliance between Xavier University in Cincinnati, Ohio, and Seth G.S. Medical College in Mumbai, India. Occupational therapy students from these universities met online to discuss the provision of services in their respective countries and to present case studies to each other to allow an exchange of ideas and clinical reasoning (Asher, Estes, & Hill, 2014). This exchange benefited students from both countries by promoting cultural sensitivity and alternative views of treatment planning. These examples of the use of technology for education and promotion of occupational therapy are starting points for further innovative strategies to enhance collaboration.

Limitations and Future Research

Limitations encountered during this study included the first author's short-term experience working in China and the language barriers that existed, even with translator assistance, which may have resulted in misinformation. Additionally, the lack of current statistics regarding the number of occupational therapists working in the mainland and the requirements necessary for occupational therapists to become university educators yields an incomplete picture of current practices in mainland China.

Future research on the number of occupational therapy programs being developed, current programs seeking accreditation, and the long-term effectiveness of existing international partnerships would be beneficial. Understanding barriers to expansion of occupational therapy in mainland China through additional research will give Chinese occupational therapists, occupational therapy students, and persons with disabilities greater opportunities for growth and development.

Conclusion

Global health prioritizes health equity among all persons worldwide (WFOT, 2014). Expansion of rehabilitative services to developing countries showed variance in the provision of occupational therapy services as well as the need for the development and promotion of occupational therapy to ensure equity for individuals with disabilities. Through a literature review and the first author's immersion experience, the cultural aspects of health and disability services in mainland China have been explored, with emphasis on the provision of occupational therapy. The need for occupational therapists in China is clear, and growth of the profession has been limited. Understanding traditional views of disability, the status of occupational therapy services and education, and strategies for promoting the profession may help to create more collaboration between China and countries with more established occupational therapy programs.

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Authors

Dr. Lavine is Occupational Therapist, Early Childhood Services of North Central Texas, Fort Worth, Texas. Dr. Greiner is Assistant Professor, Creighton University, Omaha, Nebraska.

The authors have no relevant financial relationships to disclose.

The authors thank the staff of Hebei Medical University and the Third Hospital of Hebei Medical Center in Shijiazhuang, China, as well as the Central Hospital of Petro China and Jingdong Zhongmei Hospital in Langfang, China, for their generosity and kindness during the primary author's short-term immersion experience.

Address correspondence to Debbie Lavine, OTD, OTR/L, CIMI, Occupational Therapist, Early Childhood Services of North Central Texas, 2401 Priscella Drive, Fort Worth, TX 76131; e-mail: DebbieLavine@creighton.edu.

Received: August 02, 2018
Accepted: June 25, 2019
Posted Online: August 15, 2019

10.3928/24761222-20190813-04

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