key: cord-0746256-o95546dk authors: Lewis, Kathryn E.; Lehman, Michelle J.; Cockburn, Lynn title: Looking Back to Move Forward: Canadian Occupational Therapy In Public Health, 1914–2019 date: 2021-03-10 journal: Can J Occup Ther DOI: 10.1177/0008417421992617 sha: 97d94fca093331b8f346494fe49234c1c2832ef7 doc_id: 746256 cord_uid: o95546dk BACKGROUND. Decades of literature demonstrate that occupational therapy is well-suited to collaborate with public health due to overlapping views of health. However, there has been little collaboration between these professions with few examinations of why they remain distinct. PURPOSE. This study examines historical events that have led to the present-day separation of occupational therapy and public health. METHOD. This narrative review and thematic analysis of the scholarly, archival, and grey literature was conducted to examine the development of both fields. FINDINGS. Fifty texts were analyzed revealing four themes: the influence of structural and social forces; professional, societal, and institutional hindrances; potential for a shared vision; and next steps for integration. These themes highlight historical barriers to collaboration and provide evidence that occupational therapy could benefit public health. IMPLICATIONS. Collaboration between occupational therapy and public health has many potential benefits, however new approaches to bridge the divide are needed to advance collaboration. Rationale O ccupational therapy has many potential contributions to the field of public health. However, its services are largely distinct from Canadian public health initiatives. Histories and narratives have been written on both fields regarding their respective development and overlapping principles. This literature has not examined the causal factors that led to these fields remaining distinct. By using a historical lens to examine occupational therapy contributions to public health in Canada, this study provides a rich account of what has taken place to constrain and expand the profession in the public health sector. Using thematic analysis methodology, the study focuses on the Canadian public health context and its relationship to the profession of occupational therapy, both in traditional (e.g., services for people with disabilities) and emerging (e.g., disease prevention) roles. Understanding the historical rationale behind the lack of collaboration will assist in overcoming barriers to develop a plan of action for improving Canadian public health and expanding occupational therapy. The Canadian public health sector aims to prevent disease, prolong life, and promote physical and mental health through informed decision-making on individual, population, and societal levels (Government of Canada, 2019). Public health includes areas such as "healthy eating and physical activity programs, immunization, and infection control measures" with the goal of helping Canadians manage their health effectively through health-promotion activities (Government of Canada, 2019). These goals align with the field of occupational therapy, which aims to promote well-being through meaningful engagement in occupation (Townsend & Polatajko, 2013) . Areas of similarity between the two fields can be seen in each profession's guiding documents. The Public Health Agency of Canada (2008) groups its 36 competencies into seven categories: public health sciences; assessment and analysis; policy/programming planning, implementation, and evaluation; partnership, collaboration, and advocacy; diversity; communication; and leadership. Many of these categories can be matched to equivalent occupational therapy competencies, such as communicator and change agent (Canadian Association of Occupational Therapists [CAOT] , 2012). Awareness of this overlap in scope and discussions in the literature surrounding the benefits of adopting an occupational perspective in public health have grown in concert with public health trends towards prevention through health promotion (Bass & Baker, 2017) . The value of a collaborative relationship has been explicitly discussed for the last century, with greater emphasis beginning in the 1980s (Burnette, 1921; Jaffe, 1986; Rider & White, 1986; Simpson et al., 1929) . A 1986 article by Evelyn Jaffe demonstrated this discussion, arguing that health care's increasing focus on health promotion provided an ideal opportunity for occupational therapy to become more involved in public health (Jaffe, 1986) . Later works expressed similar entiments, arguing that including occupational perspectives in the scope of public health provided new collaborative opportunities, could reduce inequities, and improve the efficacy of programs (Bass & Baker, 2017; Gewurtz, et al., 2016; Moll et al., 2013; Tucker et al., 2014) . Authors encouraged the use of an occupational perspectives to prevent disease (Jaffe, 1986) , and promote occupation as a key component of health (Gewurtz et al., 2016; Moll et al., 2013) . While occupational therapy primarily uses the concept of occupation to signify the concept of doing, public health uses a range of terms such as actions, behavior, participation, and lifestyle choices to signify similar concepts (Gewurtz et al., 2016; Moll et al., 2013; Murray, 2003) . Many health and well-being factors are encompassed under the umbrella of occupation. Both fields understand that everyday activities and occupations carried out by individuals are shaped by broader contextual forces and can be somewhere on a continuum of protective factors for health and risk factors for poor health (National Collaborating Centre for Determinants of Health, 2018). When viewed in this manner, the line between public health initiatives focused on improving societal health, and occupational therapy initiatives focused on improving an individual's quality of life, becomes blurred. Public health incorporates attention to occupation (as understood by occupational science) in its initiatives, although it is not always named as such. Apparently recognizing this shared understanding of the importance of activity and everyday occupations for the public, the official practice guidelines for the CAOT state that occupational therapists should promote well-being not only at the level of the individual, but also at the level of the public -by working with communities, organizations, and populations (Townsend & Polatajko, 2013) . Despite the incorporation of activity and occupational considerations into public health initiatives, and this official recognition of possible public health contributions, there continues to be minimal representation of occupational therapy within the public health sector (Canadian Institute for Health Information, 2017). A better understanding of the factors contributing to occupational therapy's relative absence from the field of public health is warranted to increase its future representation in the field. Histories of public health and occupational therapy have been undertaken (Andersen & Reed, 2017; Canadian Historical Association, 2003; Friedland, 2011; Reitz, 1992) . These accounts have not critically examined the pathways resulting in occupational therapy remaining largely outside the public health sector. Each of these histories focused on their own profession, with examination of interprofessional influences limited to specific fields, such as medicine and social work. A transdisciplinary approach is therefore needed to understand the relationship between the two fields. In the modern Canadian context, with shifting funding models and ongoing restructuring of health care and public health systems, occupational therapists are continuously considering professional expansion. Simultaneously, issues posed by the COVID-19 pandemic and anti-racism/anti-oppression movements have inspired health professionals to critically examine the systems they work within (Hewitt-McVicker, 2020; Manzi et al., 2020) . The World Federation of Occupational Therapists states that occupational therapists must be "concerned with human rights in pursuing occupational justice for all" (World Federation of Occupational Therapists, 2019, p. 1). Occupational therapists must thus expand their capacity to practice at a population level, including addressing issues of inequality, racism, and social determinants of health: all areas that have been identified as public health concerns (National Collaborating Centre for Determinants of Health, 2018). Understanding the pathways leading to the modern absence of occupational therapy in public health is necessary to ensure that previous barriers can be addressed, and commonalities found to support expansion. Building upon previous historical analyses, this research aimed to identify the primary historical contributions shaping occupational therapy's position in relation to the Canadian public health sector. This study employed a narrative review of historical texts paired with thematic analysis to understand patterns in the literature pertaining to Canadian occupational therapy and public health. Narrative reviews provide a comprehensive, non-systemic overview of the literature published on a specific topic (Green et al., 2006) . Green, Johnson, and Adams argue that many of the potential risks associated with an unsystematic review can be mediated by careful acknowledgement and transparency from the research team (2006) . To manage concerns of bias, we implemented these guidelines. We aimed to be thorough and transparent in our data collection sources, search terms, and selection criteria. Pairing a narrative review with thematic analysis allowed for the results to be systematically analyzed and be summarized to understand the themes and patterns within the literature. Thematic analysis refers to a method of identifying, analyzing, and communicating themes within qualitative data (Braun & Clarke, 2006) . We employed Braun and Clark's (2006) six-stage method for thematic analysis: (a) familiarization of the data, (b), generation of initial codes, (c) identify themes along, (d) review themes, (e) define/name themes, and (f) communicate results. The source material was composed of books, primary and secondary academic articles, archival materials, and grey literature. To be included, materials must (a) have been published after 1914, (b) be available in English as the research team was not fluent in other languages, and (c) principally discuss occupational therapy and public health. Non-narrative articles (e.g., randomized control trials) were excluded, as they were unable to be adequately captured through thematic analysis. Online sources. The research team developed a search strategy to identify potential articles from relevant online databases. Key public health journals were searched for articles referencing occupational therapy, and vice versa for occupational therapy journals, with sources identified by title and abstract. Figure 1 details the search strategy employed. The body of each document was screened to determine if it met inclusion criteria, with researchers meeting monthly to ensure inter-rater reliability. A breakdown of resource selection and a link to all sources analyzed is provided in Figure 2 . Online data was stored using the electronic reference management system Zotero (Roy Rosenzweig Center for History and New Media, 2016). Archival and hard copy sources. Archival and hard copy materials were collected from the University of Toronto Gerstein Science Information Centre, the Library and Archives of Canada, the McMaster Health Sciences Library, and the Nova Scotia Archives. Library material was identified using our search strategy. Archival material was identified with assistance from archivists. Archival sources were used to provide social context to and provide more meaning to our review. Archival material included meeting minutes, newspaper articles, and occupational therapy textbooks. Data analysis followed Braun and Clarke's six-phase approach to thematic analysis (2006) . Phase one, familiarization of data, consisted of reading all articles while maintaining an audit trail and field notes to improve credibility, transferability, dependability, and confirmability of results (Merriam & Tisdell, 2016) . Phase two, generation of initial codes, consisted of the research team independently coding the same article using NVivo software (QRS International Pty Ltd., 2020), and then meeting to discuss preliminary codes. Codes represented groupings of influential events, concepts, and constructs within the data. A codebook of recurrent or important ideas was then developed, and the same article was re-coded using the codebook to assess inter-rater reliability. The use of multiple raters during this process illustrates a form of triangulation, which improved dependability (Merriam & Tisdell, 2016) . This second phase culminated with the research team coding each document, adding to the codebook as new ideas emerged. During this phase, we met bi-weekly to discuss emerging codes, explore beliefs, and identify assumptions. The research team also met informally with experts in the field to gain further insight into the social contexts surrounding the texts and gain new perspectives. Phases 3-5 (search for themes, review themes, and name/ define themes) occurred after coding completion. The researchers met several times to examine codes and discuss the social contexts surrounding the themes. During this process we incorporated consideration of forces that shaped the current situation but did not do further searching for detailed descriptions of them. The codes were then grouped into four overarching themes and named/defined. The results of our analysis produced four primary themes and highlighted key historical events. A summary of key historical dates is provided in Table 1 . The first theme, "influence of structural and social forces" explores the context surrounding the development of each profession. Reasons for collaboration are explored in "improving the lives of Canadians: potential for a shared vision". "Professional, societal, and institutional hindrances to integration" examines barriers occupational therapists have faced when looking to collaborate with public health. The fourth theme, "next steps to facilitate occupational therapy engagement in public health" provides examples of proposed solutions. These themes provide explanations as to why occupational therapy is largely distinct from public health work and provide preliminary evidence of the value of collaboration. Comparison of the historical pathways of each field illuminates how the larger Canadian context led to the present-day absence of occupational therapy in public health initiatives. Larger societal forces served as barriers or enablers towards collaboration between the two fields, and provide insight into the goals, identity, and scope of each profession. We mapped the key time points in each field's history onto a single timeline, which can be consulted for reference 1 . The early 1920s, the Great Depression, the 1950s, and the 1980s are four critical time points that capture how the social and institutional context partially dictated the extent of inclusion of occupational therapy in public health work. After the end of World War I in 1918, the newly created profession of occupational therapy was looking to remain practising as their roles working with veterans dwindled (Driver, 1968) . At that time, Canadian public health work was starting to emphasize individual agency over one's own health (Rutty & Sullivan, 2007) . The first mentions of collaboration between occupational therapy and public health occur in this postwar context, through descriptions of occupational therapists working with public health nurses, travelling into communities to help enable meaningful occupations amongst sick and disabled individuals (Simpson et al., 1929) . Nurses Simpson, Emory, and Hund chronicled the value of occupational therapy involved in their public health nursing service, The Montreal Branch of the Victorian Order of Nurses has been the first organization in Canada to take occupational therapy into the homes of its patients. Such work came into being three years ago as the result of requests on the part of staff nurses . . .. Just as the greatest values in life are intangible, so it is impossible to put into words what occupational therapy can mean to the home-bound and the hopeless. (Simpson et al., 1929, p. 257) Other articles from this time period carried a similar sentiment, highlighting the value and practicality of involving occupational therapy services in public health nursing initiatives (Burnette, 1921; Hamilton, 1930) . The advent of the Great Depression in 1929 brought cuts to health care funding, which negatively impacted both professions (Friedland, 2011; Rutty & Sullivan, 2007) . During this time, the intertwined themes of hierarchies in health systems and larger funding structures had a significant impact on the potential for collaboration, as each field focused on keeping its own profession relevant rather than on collaborative efforts (Andersen & Reed, 2017; Rutty & Sullivan, 2010) . This separation is reflected in the literature, with few identified articles discussing collaboration published between 1930 and 1950 (Davis, 1948; Drew, 1938) . In the years following World War II, the literature suggests that public health and occupational therapy continued their shift apart, with evolving scopes of practice that left fewer areas of overlap (Andersen & Reed, 2017; Rutty & Sullivan, 2010) . Occupational therapy continued following a trend towards remaining within hospitals, and it focused on medically driven rehabilitation, with occupational therapy education joining with physiotherapy in the early 1950s (Cockburn, 2001) . A 1957 article concerning the Victorian Order of Nurses demonstrated the evolution of this distinction through descriptions of the role of public health nurses, stating: The patient also is encouraged to maintain muscle tone and a full range motion through self-help activities such as washing himself, brushing combing the hair, etc . . . . Nurses should always encourage self-help activities to assist in adjusting to any limitations of a long-term illness and thus becoming self-reliant . . . . Example, a man with a gangrenous leg which required amputation. . .. The leg was treated. . .and the patient discharged as cured. . .What was done to assist him to face the many problems that arose upon charge from the hospital? Although cured, he was barely alive. (Crandlemire et al., 1957, p. 62) The absence of consideration of occupational therapy from an organization, which 30 years prior had advocated for involvement of occupational therapy, demonstrates the shift in emphasis of the professions. The literature from this time period highlights, however, that some occupational therapists were uncomfortable with their union with physiotherapy and primary locus within hospitals (Colman, 1992; Friedland, 1998) . In 1974, shortly after occupational and physiotherapy became distinct educational programs, an occupational therapist consulting to the Ministry of Health, wrote, Where do we want to get to?. . .If we are to remain relevant in this rapidly changing world, we must prepare ourselves and educate our students to provide a consultative problem solving approach to the delivery of health care rather than narrow clinical procedures or techniques in relation to specific pathology. We must use our knowledge of disease and disabling conditions within a framework of social systems rather than in the confines of the treatment facility. (Tate, 1974, pp. 8-9) During this time, such calls for expansion beyond the hospital started to combine with calls for increased integration with public health. This trend can be seen in Evelyn Jaffe's (1986) seminal paper on health promotion in which she stated: "occupational therapists must remember the philosophical orientation of the profession and use their many skills to develop techniques and programs that enhance health, prevent disease, and improve the social climate that fosters and promotes a healthy society" (p. 752). This shift in thinking was enabled by occupational therapy's return to community-based considerations, in combination with public health's focus on health promotion through supporting and enabling individual action. We identified the theme of the potentially shared vision of improving the lives of Canadians as one reason why occupational therapy would be a valuable component of public health. Areas of ideological, theoretical, and scope overlap were common arguments put forward to justify collaborative efforts by occupational therapists. The majority of works within this theme discussed how this overlap supports occupational therapy's capacity to learn and contribute to public health, rather than how public health theory and information could improve the field of occupational therapy. Goals of advocacy, enablement, and education are clear areas of overlap and were highlighted as starting points for collaboration by numerous authors (Bass & Baker, 2017; Finlayson & Edwards, 1995; Jaffe, 1986; Madill et al., 1989; Moll et al., 2013; Reitz, 1992) . Referring to public health, Bass and Baker (2017) state, "In particular, the essential services of 'monitor health status'; 'inform, educate, and empower'; 'mobilize community partnerships'; and 'link people to needed services/assure care' overlap with the scope of occupational therapy practice" (p. 175). Authors such as Madill et al. (1989) , Thibeault and Hébert (1997) , and Gewurtz et al. (2016) also discussed how occupational therapy and public health have similar values. These values include empowerment, social justice, autonomy, and the importance of meaningful activity. Tied in with these values were each field's view on the concept of health and well-being. Both fields prioritize concepts such as quality of life and social determinants of health: Community participation, empowerment, autonomy and the individual's worth are recurrent themes weaving a golden thread from beginning to end. This demonstrates the possibility of blending occupational therapy practice with a health promotion model without losing our identity or bending the pillars of health promotion out of shape. (Thibeault & Hébert, 1997 , p. 285) Building upon the overlap in scope and core values, numerous authors proposed ideas for how occupational therapy could improve public health efforts (e.g., Bass & Baker, 2017; Finalyson & Edwards, 1995; Jaffe, 1986; Moll et al., 2012; Rider & White, 1986; Thibeault & Hebert, 1997) . We identified many articles that explicitly discussed how occupational therapy could benefit public health work. Common areas proposed include program evaluation, health education, and preventative medicine/health services. Through participation in such efforts, authors argued that occupational therapy involvement could improve cost-effectiveness, efficacy of services, quality of life, and reach of public health initiatives. In their 1995 article encouraging occupational therapists to expand their work into the community further, Finlayson and Edwards state: "Legitimate and practical roles exist for occupational therapists who integrate health promotion and community concepts into their practice . . . as enablers, mediators and advocates" (p.74). Tucker et al. (2014) provided additional support for this concept through mapping components of the Canadian Model of Occupational Performance and Engagement onto the Ottawa Charter of Health Promotion to explore and demonstrate the nexus between health promotion and occupational therapy. Moll et al. (2012) took this work further with the development of the Do-Live-Well Framework, stating, We believe that occupational therapists have the potential to be leaders in challenging the current health promotion paradigm, by promoting a broader focus on not only physical, but mental, social and spiritual health, and the important role of occupation in promoting the health and wellness of people in all stages of life. (p. 19) Despite this popular sentiment of the theoretical value of occupational therapy in public health by occupational therapy authors, we were unable to identify many texts acknowledging or calling for participation of occupational therapists within existing public health initiatives. As touched upon in the first theme, the structure of the Canadian medical system, including its evolution, and provincial and federal legislative frameworks, played a significant role in dictating the extent of collaborative efforts (Prud'Homme, 2016). Examining this broader context sheds light on many periods of malalignment, differing priorities, and insular focuses. A primary hindrance is the notion that occupational therapy and public health have different scopes of practice and approaches to care. While there is a significant amount of overlap, there has been a historical distinction of occupational therapists working on the level of the individual person, while public health works on the levels of community and population. As early as 1948, there were calls for occupational therapists to include population-and community-level considerations into their work to make the transition into health-promotion initiatives (Davis, 1948) . There have also been tensions between preventative and reactive methods to health care. Occupational therapy has often followed a primarily reactive medical approach, which is largely in opposition with preventative public health approaches. There is an ongoing reality that occupational therapists were not sufficiently prepared or accustomed to practicing in a similar method as public health. The matter of identity played a significant role throughout each field's history in preventing collaborative efforts. Both occupational therapy and public health have undergone significant changes in their identities over the past century (see timeline). Changing identities created two barriers: (a) the two fields did not consistently align and (b) each profession was focused on establishing their identity. In the pursuit of this establishment, less focus was put upon branching out to collaborate and more was put upon staying within each domain to establish the legitimacy, purpose, and value of the field. For example, from the 1940s onwards, there was a trend towards public health nurses engaging in what could be considered occupational therapy roles, which is in stark contrast to calls for collaboration from the 1920s and the 1930s (Hoadley, 1940) . Leaders in public health in the 1940s and the 1950s described the scope of public health nursing in ways that fell exactly within the realm of occupational therapy expertise, unlike the earlier calls from nurses to include occupational therapists (Crandlemire et al., 1957) . This transition highlights the transition to a more insular focus of public health as professionals were focused on maximizing public health work instead of looking to collaborate. Closely tied to identity is the concept of gender, and how gender plays a role in social and professional hierarchies present in Canadian health care. Women have largely dominated the practice of occupational therapy since its inception, while much of the early leadership were male physicians (Driver, 1968; Friedland, 2011) . A similar trend can be seen in the history of public health nursing (Prud'Homme, 2016). How gender influenced the development of occupational therapy and public health was an area not fully examined with the present study but that would be a valuable area for further research. Women's rights and work patterns evolved significantly over the course of the twentieth century, and it would be worthwhile to examine if and how gendered hierarchies influenced the development of occupational therapy and public health. The last theme identified suggests potential next steps. Occupational therapists have written articles mentioning next steps to facilitate the integration of occupational therapy into public health; many are focused on how occupational therapists can adjust their approach to be better integrated (Jaffe, 1986; Moll et al., 2013; Morris & Jenkins, 2018) . However, there have been few considerations put forward as to what the health care system and public health could do to facilitate collaboration and integration of occupational therapy. Generally, it was suggested that if the system prioritized preventative, community medicine rather than the traditional, reactive medical model, there would be more avenues for occupational therapists to expand their scope to work within the field of public health. As early as 1948, authors were suggesting that occupational therapy education include public health as a primary subject area in preparation for work in this field. Articles dating back to 1948 state that occupational therapists need improved knowledge and education on public health (Davis, 1948) . Authors, most of whom have been occupational therapists, provided models and outlined educational topics for improving occupational therapist's knowledge on public health (Hyett, Kenny, & Dickson-Swift, 2019; Jaffe, 1986; Madill et al., 1989) . Calls for increased education remain a priority today; however, today's calls appear to be stronger, advocating for a paradigm shift towards a more preventative, population-based approach within the field of occupational therapy as necessary for collaboration to occur (Lewis & Lehman, 2020 ). The present historical analysis demonstrates that the potential value of occupational therapy in public health initiatives has been seen since the early twentieth century. Incorporation of health promotion and population-level considerations have been discussed as potential tools to improve the reach of occupational therapy practice for over four decades. While the value of an occupational perspective in public health has been a consistent message in the occupational therapy literature, population-based perspectives have been less evident. The focus on population perspectives appears to be part of the larger trend in health care systems towards preventative rather than reactive health methods. There appears to be a disconnect between what has been written in the occupational therapy literature instructing occupational therapists to include health promotion and public health considerations into daily practice, and the reports from occupational therapists stating that they do not have a sufficient knowledge base and opportunities to comfortably work in public health (Tucker et al., 2014) . There is also an apparent underestimation of what is required to have a significant impact within public health. Since the publication of the Ottawa Charter for Health Promotion in 1986, occupational therapy in Canada has increasingly incorporated health promotion and comparable public health theory into educational programs and expectations of practice (Townsend & Polatajko, 2013 ). Yet occupational therapists have yet to move or be welcomed into the sphere of public health. Our work echoes Tucker and colleagues' calls for more training and education; yet, based on the evidence, the previous calls for increased education, and changes in occupational therapy curricula, do not appear to have resulted in significant change or opportunities as calls for collaboration have remained constant throughout the century. Perhaps more specific curricular development and advocacy efforts are needed to integrate occupational perspectives into public health policy and practice. There are also larger systemic barriers limiting inclusion of occupational therapy in public health. Funding models have limited the capacity of both fields and have subsequently hindered avenues for collaboration. We write this article during the COVID-19 pandemic, a global situation that has highlighted the invaluable nature of public health and has begun to open avenues for other professions to contribute to the efficacy of public health initiatives. Including occupational therapists as the experts in enabling occupation has the capacity to improve the efficacy of public health initiatives, subsequently improving the health of Canadians and reducing the burden on primary, secondary, and tertiary health care (Hammell, 2020; Hewitt-McVicker, 2020) . This study has demonstrated that there have been over 40 years of writing and research putting forth variations of similar arguments: that occupational therapy is well-suited to be integrated into public health initiatives and that occupational therapists should learn more about health promotion to make a meaningful transition into public health settings. Experts in knowledge translation have stated that, on average, it takes 17 years for research evidence to enter practice (Balas & Bohen, 2000) . The consistency of this message affirms the potential value of occupational therapy in public health but brings into question why this argument, well past the 17-year mark, has yet to be adopted into practice. A new approach is therefore warranted for increased consideration of occupational science and occupational therapy in public health programming. As most of the literature published on occupational therapy involvement with public health is published in occupational therapy journals, a first step to re-evaluating the approach is to consider how to reach a public health audience and decision makers. Our third theme, "Professional, Societal, and Institutional Hindrances," demonstrated how occupational therapy's scope and identity have proven to be a barrier to collaboration. To bridge the divide with public health, occupational therapists must be funded to work with public health professionals to develop a clear vision of the roles occupational therapists could create and/or fill in public health. This knowledge can build upon the established alignment of the two field's philosophies, to provide a base for collaborative efforts. Current health-promotion frameworks and initiatives consider social determinants of health as well as participation in daily activities. Including occupational science and occupational therapists into public health will expand the understanding of participation and engagement. As Moll et al (2015) outline in their Do-Live-Well framework, broadening the definition of participation in daily activities to include factors beyond diet, exercise, and lifestyle is necessary and empirically supported to improve health and well-being. Inclusion of occupational therapists layering considerations of meaning, control, and "dimensions of experience" into health-promotion programming will increase the efficacy of public health work, and therefore the health of Canadians (Moll et al., 2015) . To overcome the hinderances to collaboration identified in our historical review, as well as implement some of the proposed solutions, changes must also be made to occupational therapy and public health education programs. As it is now well understood in the scientific literature that health promotion is valuable and impactful, it is an appropriate time to re-evaluate education on health promotion in occupational therapy. A shift from pieces of health promotion and population-based perspectives spliced throughout occupational therapy curriculum to concrete and explicit discussion has the potential to better prepare occupational therapists to work in public health settings. In public health, increased interprofessional educational opportunities can illuminate the role of occupational therapy and provide the basis for building interprofessional networks (Thompson et al., 2016 ). The current study had several limitations that should be considered when interpreting these results. Due to the expertise of the researchers, only articles published in English were coded, which excluded relevant publications from the study. As the province of Quebec is at the forefront of community based occupational therapy in Canada (Filiatrault & Richard, 2005) , the examination of French-language historical works demonstrating the development of these centers may have added a perspective missed in the present analysis. A second limitation was the travel restrictions posed by the COVID-19 pandemic. Due to these restrictions, the research team was unable to visit and search through numerous archives. This potentially limited the number of historical documents that were retrieved and may have impeded the understanding of the social contexts surrounding the development of occupational therapy and public health in Canada. This narrative analysis has demonstrated that a century's worth of the work literature has recognized the potential contributions occupational therapy may have to the field of public health. For this potential to be realized, a new approach to collaboration is needed. Occupational therapists should advocate for systems-level policy change to enable public health work to fall under the legislated scope of occupational therapy, thereby supporting the use of occupational therapists' registered title in public health work. Additionally, future curriculum and policy development should emphasize efforts of improved education on public health topics. Further research should be conducted to continue developing this history and to begin exploring new routes for increasing collaboration. Efforts should be taken to include resources from all areas of Canada. Additionally, exploring international perspectives on the development of occupational therapy and public health, and comparing how other professions integrated into the public health sector, will enable a more fulsome history to be written and will solidify our understanding of previous barriers. Future research should also build upon our findings by explicitly exploring practical ways to continue cultivating the relationship between occupational therapy and public health. Increasing the evidence base (e.g. cost-benefit studies) demonstrating that occupational therapists promote health and reduce rates of hospital admissions, can combine with the findings of this research to provide sound rationale for collaboration. The results of this analysis demonstrate that authors have been describing the potential benefits of inclusion of occupational therapy in public health since the early 1900s. However, major cultural, financial, and systematic events have resulted in recurrent periods of malalignment. To fulfill these calls for collaboration, thoughtful, strategic, and extensive changes to the current approach are required. Drawing upon this understanding of historical factors limiting collaboration, occupational therapists should advocate for change on policy and funding levels to move into the public health sector. While there have been calls for collaboration between the fields of public health and occupational therapy for the last century, a cacophony of systematic, cultural, and financial changes has led to recurrent periods of malalignment. Increasing collaboration between occupational therapy and public health is not straightforward, as the current approach has been in place for 40 years and it has not worked enough to significantly change occupational therapy inclusion in public health. 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(2020) NVivo (released in A historical review of occupational therapy's role in preventative health and wellness Occupational therapy education in health promotion and disease prevention Zotero [Computer Software This is public health: A Canadian history Public health nursing: Occupational therapy in a public health nursing organization The scope of occupational therapists in the community in the future A congruent model for health promotion in occupational therapy Enabling occupation II: Advancing occupational therapy vision for health, well-being, and justice through occupation Working together: Using a unique approach to evaluate an interactive and clinic-based longitudinal interprofessional education experience with 13 professions Exploring the nexus between health promotion and occupational therapy: Synergies and similarities: Explorer le lien entre la promotion de la santé et l'ergothérapie: Synergies et similarités Position statement: Occupational therapy and human rights (revised) We are very grateful for insights and feedback received from Dr Judith Friedland, Myrene Lychek, and Jim Arklay. Their reviews of earlier drafts of this paper and conversations about key points made the article clearer and encouraged us to continue with the project. This work has been presented at the 2020 James A. Barnes Graduate History Conference, and the Canadian Association of Occupational Therapists 2020 Conference. Kathryn E. Lewis was an MScOT student at the University of Toronto.