Refining the first global strategy for the occupational therapy workforce: results from a mixed-methods survey and multimodal expert feedback

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Jesus, Claudia Zweck, Sydney Larson, Sutanuka Bhattacharjya, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4462309/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background The occupational therapy workforce remains underdeveloped and inequitably distributed, against the backdrop of increasing population needs. The World Federation of Occupational Therapists (WFOT) led a multistage development process to launch the first global strategy for this workforce. An initial draft Strategy was previously reviewed for utility by country representatives, then redrafted. Here, we assess the perceived utility of the redrafted Strategy for refinements before its launch. Methods Mixed-methods online survey of country representatives (e.g., delegates to the WFOT) complemented by experts’ feedback, including from outside the profession. The survey asked for a utility rating (0–10) for each strategic direction ( n = 7) and associated specific actions (total n = 21). A comment box was provided for scoring rationale, concerns, or improvement suggestions. Experts that were previously engaged in a situational analysis provided improvement suggestions for the Strategy , first in writing individually and then through an online focus group. Data was analyzed by descriptive statistics (e.g., average scores > 8 considered high ) and thematic analyses. Results Forty-five country representatives (45%) completed the surveys, 40% from low- and middle-income countries (LMICs). All major strategies (average ranges: [9.13–9.33]; SD ranges: [0.80–1.20]) and specific strategies (average ranges: [8.29–9.33]; SD ranges: [0.87–2.03]) received high utility scores. The mode value was “10” for all items. From the survey comments, the central theme was: “ account for context-sensitive priorities ”. From the experts’ feedback, the central theme was: “ provide additional framing ”, such as contextualizing the Strategy as a global framework that helps guide but does not dictate local priorities or action plans. Conclusions The strategies for the global strengthening of the occupational therapy workforce were positively appraised by country representatives. Altogether, the multimethod, multi-stakeholder evaluation helped refine the Strategy and tailor its report according to the feedback of global experts and its potential end-users. It also provided insights on the need for context-specific implementation plans. Health Workforce Health Planning Occupational Therapy Consultation Background Occupational therapists are health professionals that aim to meet the health and occupational needs of the populations. 1 Specifically, occupational therapists promote the functional performance and occupational engagement for individuals or communities experiencing (or at risk of experiencing) physical, mental, and other impairments that intersect with a disabling environment. 2 , 3 Current global data estimates that 2.4 billion people have health conditions or disabilities that would benefit from rehabilitation. 4 Furthermore, the population need for rehabilitation and occupational therapy services has been increasing significantly over time (e.g., 17% per capita worldwide, since 1990), 5 which has been observed across countries of varying income levels 5 , 6 . Given this trend is a consequence of increased life expectancy, global ageing of the population, and rising rates of chronic and non-communicable conditions, the growing population need for occupational therapists is likely to continue to increase over time, particularly in low- and middle-income nations (LMICs). 5 , 7 – 9 For meeting these high and increasing population needs worldwide, policymakers, health planners and other interested parties need to assure that health systems have a sizeable, accessible, and competent rehabilitation workforce that includes occupational therapists. 10 – 12 However, the global occupational therapy workforce remains underdeveloped, inequitably distributed (within and across nations), and scarce, if present at all in many LMICs. 12 For example, WFOT’s data shows that 54 of member organizations (61%) had < 1 occupational therapist per 10,000 population, including nations with < 0.001. 13 In contrast some high-income countries (HICs) can have up to 22 occupational therapist per 10,000 population. 13 Moreover, many LMICs have no occupational therapy education programmes or professional regulation, 12 , 13 which complicates efforts to strengthen the workforce. The workforce in many countries is also maldistributed. For example, in South Africa most occupational therapists are deployed in urbanized provinces, with 74.8% employed in the private sector which serves 16% of the South African population. 14 Disparities exist even among high-income countries (HICs), with the population-adjusted supply of occupational therapists as much as 10 times lower in some areas within a nation, 13 in addition to substantive rural-urban differences. 15 Within the context described, WFOT has led a research-based, multistage development process to launch the first global strategy for strengthening this workforce. The process started with a multipronged scoping review of the occupational therapy workforce to synthesize: a) the scope and limited growth of this the research; 16 b) the types of findings generated, including the topics remaining unaddressed across nations 17 and c) the reported limitations or recommendations regarding which workforce data and other improvements need to be made. 18 Based on an integrated synthesis of these findings, a situational analysis was conducted that included the input of an advisory board with health workforce experts from within and outside the profession. 12 A large pool of strategic actions ( n = 62) was initially drafted in response to the situational analysis for inclusion in the Workforce Strategy , and then assessed using a survey of country representatives (e.g. WFOT national delegates) regarding perceived utility. The survey was followed by focus group discussions with the country representatives. 19 As a result of the feedback provided, substantive changes were made to the draft strategic actions; the actions were reduced in number, reorganized (e.g., some of the actions were included as examples within other actions), and combined with new content regarding the context of need for the workforce Strategy . In this paper, we aim to report on the results of activities to 1) re-survey country representatives on the utility of a redrafted version of the Strategy , as well as 2) consult with experts from the advisory board on final refinements. These steps enable the Strategy ’s launch. Methods Design: A mixed-methods online survey of WFOT occupational therapy representatives was undertaken, complemented by feedback from an expert advisory group - first individually in written form, then in a focus group (with written consent to use their anonymized expert opinions for scientific report purposes). An ethics review was submitted to the Institutional Review Board of The Ohio State University which determined that this research was not human subjects research. This Board noted participants provided their expert-based feedback as part of program development work. The country representatives and reviewers who provided feedback regarding the Strategy were not the subjects of the research. Online Survey: Supplementary Appendix 1 provides the survey that was sent to the country representatives, including the introductory content and instructions. The survey was sent to all 100 WFOT member organisations representing individual countries or territories (the entire population, no sampling). To do so, the WFOT used internal communication channels, which are regularly used to obtain feedback on program development activities of the WFOT. The survey could be completed by the formal delegates to the WFOT, alternate delegates, or another formal representative of the member organisation assigned by a delegate. Only one representative could respond per member organization. The survey asked for a utility rating (0–10) for each strategic direction ( n = 7) and associated specific actions ( n = 21). The number of specific actions ranged from two to four per strategic direction, for a total of 28 strategies that were surveyed. An open-ended question was asked at the end of the survey to explain concerns, improvement suggestions or the rationale for given answers. Eight weeks were provided for member organizations to respond to the survey, with a reminder for participation sent after 6 weeks. For the analysis, descriptive statistics (e.g. average utility ratings; standard deviations; modal response) were used for the analysis of the quantitative data. In the previous survey examining the initial draft of strategies, a cutoff of 8 indicates high or very high levels of agreement. 20 We also developed a sensitivity analysis at the county level, focused on the average score of the total set of strategies relative to the cutoff point and for the group of countries that were LMICs versus HICs. The country-level analysis enabled gaining an understanding of whether the global Strategy was useful or varied across countries and their economic development contexts. For the open qualitative comments in the survey, we used an inductive thematic analysis, 21 conducted by two researchers (TJ, SL). The transcripts were read by the two researchers for familiarization, followed by open coding for generating initial codes, 22 and then by axial coding in which the two researchers collaborated to organize the data into related themes, including emergent meanings. 23 To enhance the trustworthiness of the analysis, a third researcher (SK) was involved to ensure the accurate representation of the raw data into the developing themes. Two-phased experts’ feedback: Three experts, who participated in a preceding situational analysis, 12 were invited to take part in the provision of: 1) individual written feedback regarding the redrafted Strategy and 2) collective feedback through participation in a focus group discussion. The experts included two occupational therapists with experience and a track record in publishing on occupational therapy workforce topics, collectively across LMICs and HICs. The third expert was a health workforce scholar that is not an occupational therapist (health economics background), with expertise across LMICs and HICs. As a group, the experts provided occupational therapy, human resources policy and management, and health policy and economic expertise across major global regions. The invitation to provide feedback was made through email in follow-up to initial participation in the preceding situational analysis. The invitation for the preceding situational analysis included the WFOT terms of reference that described expectations for the experts’ volunteer participation. Of note, like in the previous situational analysis, 12 one of the occupational therapist experts was also a coauthor in this work (KM). While this author had substantive roles in the study conception, design and report, he had no roles in the drafting or redrafting of the Strategy , hence could provide an outside view regarding the content. The need to engage an expert from the authorship team partly arose from the low availability of workforce experts within the profession, particularly one with expertise across national contexts. The dearth of occupational therapy workforce researchers was identified in the initial scoping review, 16 and noted as a weakness of the profession in the preceding situational analysis. 12 For the individual written feedback, the experts were provided with the full redraft of the Strategy . Experts had three weeks to provide their feedback (in comments alongside the document, through suggested tracked edits, or in overall qualitative comments), by replying to the email invitation. Each expert was blinded to the feedback provided by others. Any feedback requesting clarification or generating concerns were flagged to be immediately refined or reworded. Suggestions for elements to be added or eliminated were summarized to be collectively discussed through a focus group discussion. The focus group discussion was conducted by the lead research author (TJ) through an online, one-hour, recorded videoconference, assisted by two others (CvZ, RL) in moderation as well as one another author (SL) taking notes to support the analysis. The topics discussed included: 1) concerns arising from the qualitative comments and synthesized thematic analysis of feedback from the online survey; 2) suggestions for additional content from the individual, written experts’ feedback; and 3) refinements or additions suggested by the research authors in response to the feedback obtained in the previous phases. The overarching goal of the discussion was to increase the utility, acceptability, and feasibility of the Strategy, as well as develop a mechanism for its communication and dissemination. Transcripts of the focus group were thematically analyzed using the same process as described for the qualitative comments of the online survey. Results 1.1 Online survey – respondents: Of the 45 respondents, 71% ( n = 32) were the primary country delegates to the WFOT. The other respondents were the alternate delegate ( n = 4), or a member organization’s representative other than delegate or alternate such as from the secretariat ( n = 9). In country representation, 18 (40%) were LMICs (including three low-income countries), while the remaining 60% were HICs including emergent HICs in eastern Europe, Latin America or the eastern Mediterranean region. 1.2 Online survey – quantitative results: Table 1 provides the results from the survey for all country representatives. All strategies had high average utility scores. For instance, the seven strategic directions obtained average scores that ranged from 9.13 to 9.33] (SD ranges: [0.80–1.20]). The 21 specific actions had average scores that ranged between 8.29 to 9.33. (SD ranges: [0.87–2.03]). The lowest scoring specific action (average 8.29, SD: 2.03) was: promote the development of new regulatory/licensing bodies, where absent to collect and report on minimum datasets for the occupational therapy workforce. The highest scoring were “strengthening occupational therapy workforce data” as a main strategy and “ produce scientifically-sound, population-centered, and solution-oriented occupational therapy workforce research ”. Sixteen of the 28 items (57%) had a median value of “10”, with the remaining having a median value of “9”. Finally, the mode value was “10” for all items. Table 1 Quantitative results of the online survey on the utility ratings, all country-representatives combined. Strategies surveyed (main strategies in bold) Average Median Mode SD 1 Strengthening occupational therapy workforce data 9.33 10 10 0.93 1.1 Develop an international framework and toolkit that outlines a minimum workforce dataset, a supplemental dataset and ways to collect, integrate and report on the information. 9.18 9 10 0.96 1.2 Advocate for occupational therapy supply data to be included in (inter)national monitoring of health workforce data, tools and classification systems. 9.29 10 10 1.04 1.3 Promote the capacity of existing regulatory/licencing bodies to collect and report on minimum occupational therapy workforce datasets. 8.89 10 10 1.48 1.4 Promote the development of new regulatory/licensing bodies, where absent to collect and report on minimum datasets for the occupational therapy workforce. 8.29 9 10 2.03 2 Determining supply shortages in the occupational therapy workforce 9.22 10 10 1.20 2.1 Determine current and future population needs for occupational therapists and any shortages, surplus, or geographic disparities within and across nations. 9.20 10 10 1.08 2.2 Examine the demand for occupational therapists to determine supply gaps and labour-market imbalances. 9.16 10 10 1.38 2.3. Conduct comprehensive analyses of occupational therapy human resources as a single profession and as part of a broader health workforce. 9.20 10 10 1.16 3 Investing in the expansion of the occupational therapy workforce 9.13 10 10 1.18 3.1 Quantify investment needs for the expansion of the occupational therapy workforce, identifying costs and potential benefits. 8.51 9 10 1.71 3.2 Advocate and translate expansion needs into occupational therapy workforce investment programmes and policy decisions. 8.67 9 10 1.73 3.3. Build occupational therapy education and deployment capacity. 8.76 10 10 1.82 4 Improving workforce distribution for equitable access 9.24 10 10 1.25 4.1 Monitor the distribution of occupational therapists to address inequities in population access to occupational therapy services. 9.00 9 10 1.22 4.2 Identify contributing factors and intervention programmes to address inequities in access to occupational therapy. 9.02 10 10 1.32 4.3 Develop and implement innovative service delivery models and workforce strengthening measures that extend access to the occupational therapy workforce. 9.00 10 10 1.54 5 Assuring workforce competency, engagement and diversity 9.22 10 10 0.97 5.1 Develop or strengthen mechanisms that assure that occupational therapists continuously meet key competency and practice standards. 9.09 9 10 1.06 5.2 Strengthen human resources management practices for improving the performance and job satisfaction of occupational therapists. 8.93 9 10 1.16 5.3 Improve the equitable diversity and representation of the occupational therapy workforce and foster acceptability by diverse communities, cultures, and populations. 8.82 9 10 1.35 6 Developing and using occupational therapy workforce research 9.31 10 10 0.92 6.1 Produce scientifically-sound, population-centred, and solution-oriented occupational therapy workforce research. 9.33 10 10 0.88 6.2 Develop funding mechanisms, research structures, research training structures, and networks to build national and cross-national capacity to advance occupational therapy workforce research. 9.24 10 10 1.09 6.3 Engage interested parties in the development and use of occupational therapy workforce research. 9.07 9 10 1.07 7 Building workforce leadership and planning capacity 9.24 9 10 0.80 7.1 Promote capacity-building programmes for local, national, and cross-national occupational therapy workforce leaders and advocates. 8.96 9 10 1.15 7.2 Occupational therapy workforce leaders foster profession-specific situation analysis and workforce strengthening plans as well as participate in cross-professional workforce policy, planning, and programmatic developments. 8.91 9 10 1.14 In the country-level analysis, four of 45 country representatives (8.9%) provided scores whose average was < 8, while two others provided scores that averaged exactly “8”. Of these six countries, only one (16.7%) was an LMIC. 1.3 Online survey – qualitative results: For the qualitative delegate’s comments, the Supplementary Appendix 1 provides the thematic analysis, including illustrative (not exhaustive) quotes. In a synthesis, an overarching theme emerged: Account for context-sensitive priorities. These focused on prioritizing or customizing the strategies for their local context of need. For LMICs, the focus was on leadership, advocacy and preventing unethical international recruitment. On the latter matter, one commented suggested a more explicit account was needed in the Strategy , and that refinement was made. This notion of unethical international recruitment was present in the initial drafts of the Strategy but eroded through the progressive draft refinements toward parsimony. This comment helped restore and reinforce that explicit inclusion into the Strategy . 2.1 Experts Feedback – individual written feedback Qualitative appraisals from each expert were consistently positive, particularly for comprehensiveness: It looks good , the draft looks great and very comprehensive and strategy document is fairly comprehensive . In addition to positive appraisals, improvement suggestions were received and included three types. The first was to include clarifying statements or keywords (e.g., “ attrition rates ”) to the examples of action to attain the strategies, i.e., not the surveyed strategies themselves. These comments were directly amended or flagged for refinement and not included in focus group discussion. A second type of improvement suggestion was to edit the wording of some of the main strategies, without changing their scope. These suggestions were selected for the experts’ focus group discussion. A third type of improvement suggestion was made to add sections such as an extended abstract / executive summary to the Strategy document. These suggestions were also brought to the focus group discussion, in addition to the synthesis of the survey results (e.g., discussion of the lower scoring strategy). 2.2 Experts Feedback – online focus group For the qualitative delegate’s comments, the Supplementary Appendix 2 provides the thematic analysis, including illustrative (yet not exhaustive) quotes. The overarching theme was: provide additional framing . The three themes within were: Contextualize the scope of the Strategy, including how it might be used, keeping it separate from country-specific implementation needs, plans, and supports. Strengthen the Strategy by summarizing (e.g., adding an executive summary) and provide further legitimacy through a strengthened Methods section. Slightly refine some of wording or content for greater coverage and acceptability. Importantly, all these refinement suggestions were amenable to and indeed incorporated into the launched Strategy . Discussion A multistage, mixed-methods consultation process with experts and country-representatives helped provide key refinements into the first global strategy for the occupational therapy workforce, right before its launch. This activity was preceded by a comprehensive process that involved a multi-pronged scoping review, a situational analysis, a first-level advisory consultation, Strategy drafting, mixed-methods survey of country representative on the first draft, subsequent focus groups discussions (e.g. on areas of lower perceived relevancy), and a redraft according to the feedback. Here, the mixed-methods survey and multimodal expert feedback helped to refine the redrafted Strategy based on perceived utility. In short, the full set of major and specific strategies got high average utility ratings, including top modal ratings for all, while the qualitative comments informed in refinements. The refinements that were made from the findings were small in quantity but non-trivial. For example, although implicitly addressed, some key concepts were not explicitly stated in the surveyed strategies themselves (e.g., international movement or recruitment) or in the full Strategy report with more detailed accounts within each strategy (e.g., attrition rates). Overall, for a process with multiple refinement layers, including for parsimony, some key notions may be eroded in explicit display through that needed process; however, a last assessment by interested parties from diverse backgrounds or contexts helped restore the explicit (beyond implicit) statement of those key concepts. Not the least, the comments from the country representatives seemed to unravel some perceived conflict between the scope of a global strategic framework with the local need to establish context-sensitive priorities and action plans. The subsequent feedback and focus group discussion with the experts helped to shed light on those issues and on remedies such as to emphasize, right from the initial parts of the Strategy document, how the Strategy document might be used as a guiding framework only, not replacing but rather facilitating the needed local situational assessment and planning. Hence, the key experts’ advice was to provide additional explanation of the intended use of the Strategy , which was then incorporated into the full Strategy document. Among the major strategic directions, strengthening occupational therapy workforce data achieved the greatest average utility rating among country-representative delegates. Not surprisingly so. The availability of occupational therapy workforce data on key national and global databases is lagging relative to many other health professions. For instance, major international analyses and projected shortages for human resources for health either do not account for or do not stratify data for occupational therapists (e.g., instead are aggregated with other health workers). 24 , 25 This lack of occupational therapy data is applicable to displays or analyses for five major cadres, 24 for an enlarged set of 16 cadres, 24 or even for a broader set of over 40 cadres of health workers currently available in the data portal from National Health Workforce Accounts. 25 , 26 For example, among 40 specific cadres National Health Workforce Accounts, one can observe stratified data for physiotherapists or for speech and language pathologists as related professions, or even for non-professional physiotherapy assistants. But no data is available for occupational therapists, whatsoever. This lack of occupational therapy data may segregate recognition of population-based needs to strengthen access to the profession apart from the mainstream health workforce developments. Part of the reason for this lack of occupational therapy data relates to the International Standard Classification of Occupations which does not have a specific code for categorizing occupational therapists. 12 Global workforce datasets and underlying census or national workforce data collections are often based on ISCO categories. 25 , 26 To complicate the data issue further, many occupational therapists perform their role as a health professional with individual clients or communities outside the traditional health care environment, often employed in the social or educational sector, in local municipalities, or working for disability non-governmental organizations. 27 This adds just another layer of complexity for monitoring the occupational therapy workforce, especially if not purposive strengthening actions occur. These data strengthening activities inclusive of the occupational therapy workforce are not necessarily covered by - and thereby might complement - ongoing workforce developments in the broader health and rehabilitation field. 28 , 29 Complementary yet separated from a Strategy , further and more detailed resources such as implementation tools, workforce collection guides, among others, might be further developed to help deploy the global Strategy, including in a context-sensitive way. That direction also came in alignment with the experts’ feedback received. The Strategy was also assessed on its perceived utility and refined by the input of representatives of various national professional associations, whose input was collected and integrated also in previous development phases. 19 National leaders of the profession have experiential knowledge of the workforce challenges experienced by this profession in their own context, hence could appraise whether a global Strategy can be useful across implementation contexts. These national leaders are also one of the target end-used of the Strategy, hence their participation partly fitted a user-centered design, as well. 30 , 31 Relatedly, one of the highest rated strategies was on building workforce leadership and planning . That strategic direction implies strengthening the leadership capacity (e.g., of emerging professional leaders) on health-workforce development matters - for an evidence-based, population-oriented professional advocacy and development action. In turn, those activities might benefit from all the other workforce development activities; that is, the other six major strategies surveyed here, including to produce the data and evidence needed to strengthen this often-neglected workforce. In short, this Strategy – with its synergies among components – is meant to have value as a whole, beyond the sum of its parts. Limitations: As a guiding global framework, the Strategy should not be understood as: an ‘how to guide’, a set of priorities, or setting local action plans (which might be context sensitive). Accordingly, the Strategy does provide answers to who should do what, how, or when. Even when formal commitments are established, actual implementation and accountability can be different matters. 32 Also, the Strategy might not be fixed or rigid over time but periodically updated or even a living Strategy that incorporates both evidence and interested parties’ input over time, including any interested parties not directly consulted within this initial development process. The Likert-type ratings only reflect perceived and anticipated utility, hence might be understood under those subjectivity lenses. The experts involved in the multimethod, sequential feedback did it so in an advisory and consultation role; that cannot be understood as formal or wide consensus-reaching process. Finally, while the identified gaps of the data and evidence on the occupational therapy workforce provided a ground for the Strategy development (e.g., areas in need for improvement), 12 it also implies that the profession-specific evidence base supporting actions within each of the strategies requires further strengthening. This Strategy aims to contribute to promote more systematic developments in the development and use of evidence (i.e., strategic direction #6). Conclusion The surveyed strategies for the global strengthening of the occupational therapy workforce were positively appraised by country representatives. Altogether, the multimethod, multi-stakeholder evaluation helped refine the Strategy and tailor its report according to the feedback of potential end-users and global experts. Enabled by this last development process, a first-ever global Strategy for strengthening the occupational therapy workforce was launched in a refined version. This Strategy can serve as a guiding framework for local, regional, national and international global agents that have the incumbency including due to unmet population needs) to develop this often-neglected health workforce. . Declarations Author Contribution T.S.J. developed the conceptualization, led the study design, developed project management and team coordination, supervised the investigation, led the analysis, and wrote the first draft of the main manuscript.C.V.Z. contributed to the conceptualization, study design, investigation, data collection, data curation, and critically edited the manuscript.S.L. provided one major data analytical role for the qualitative data and critically edited the manuscript.S.B. contributed to the conceptualization, study design, data collection forms, and critically edited the manuscript.S.K. contributed to the conceptualization, study design, confirmatory analytical roles, and critically edited the manuscript.K.M contributed to the conceptualization, study design, investigation, and critically edited the manuscript.R.L. contributed to the conceptualization, study design, investigation, data collection, project oversight, and critically edited the manuscript. 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The global health workforce stock and distribution in 2020 and 2030: a threat to equity and 'universal' health coverage? BMJ Glob Health. Jun 2022;7(6)doi: 10.1136/bmjgh-2022-009316 World Health Organization. Custom Data Query: National Health Workforce Accounts Data Portal. WHO. https://apps.who.int/nhwaportal/ Jesus TS, Landry MD, Dussault G, Fronteira I. Human resources for health (and rehabilitation): Six Rehab-Workforce Challenges for the century. Hum Resour Health. Jan 23 2017;15(1):8. doi: 10.1186/s12960-017-0182-7 World Health Organization. Guide for rehabilitation workforce evaluation. WHO. Accessed February 15, 2024, 2024. https://www.who.int/teams/noncommunicable-diseases/sensory-functions-disability-and-rehabilitation/guide-for-rehabilitation-workforce-evaluation World Health Organization. Global strategy on human resources for health: Workforce 2030 . 2020. https://www.who.int/publications/i/item/9789241511131 Katsulis Z, Ergai A, Leung WY, et al. Iterative user centered design for development of a patient-centered fall prevention toolkit. Appl Ergon. Sep 2016;56:117–26. doi: 10.1016/j.apergo.2016.03.011 Caverly TJ, Skurla SE, Klamerus ML, et al. Applying User-Centered Design to Develop Practical Strategies that Address Overuse in Primary Care. Journal of general internal medicine. Apr 2022;37(Suppl 1):57–63. doi: 10.1007/s11606-021-07124-6 Ogunfolaji O, Ghaith HS, Djoutsop OM, et al. A Plea for More Robust Accountability Structures in the Global Strategy on Human Resources for Health: Workforce 2030. Int J Public Health. 2023;68:1605603. doi: 10.3389/ijph.2023.1605603 Additional Declarations No competing interests reported. Supplementary Files Supplementaryappendix1.docx SupplementaryFile2.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 17 May, 2026 Reviews received at journal 17 Mar, 2026 Reviewers agreed at journal 24 Feb, 2026 Reviewers agreed at journal 30 May, 2025 Reviewers invited by journal 05 Jun, 2024 Submission checks completed at journal 24 May, 2024 Editor assigned by journal 24 May, 2024 First submitted to journal 22 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Jesus","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDACZjDJBiIYH8AEJfDp4EHSwmxAnBYkNhtcJV4t9uzMj198YOCTk5+R/qziw5/D0fwNzAdv8+DRwsPMZmY5g4HN2OBGjtnNmW2Hc2ccYEu2xq+FwcyYh4EtcYNEDttt3obDuRsYeMyk8Wth/wbSUj8f6LBinj8gLfzfCGjhMX4M1JLAcCPBjJmHDWwLG34th3nKGGcYsBluOPPGWHJmW3rujMNsxpZz8Ghh7z+++cOHimPy8u3pDz98+GOd29/e/PDGGzxaGMDRYXAMic+MXzlYyQcGhhrCykbBKBgFo2DkAgCAbkOYt5xlfwAAAABJRU5ErkJggg==","orcid":"","institution":"The Ohio State University","correspondingAuthor":true,"prefix":"","firstName":"Tiago","middleName":"S.","lastName":"Jesus","suffix":""},{"id":311011906,"identity":"fcd872bf-f889-4566-ae9c-4e57302a7b01","order_by":1,"name":"Claudia Zweck","email":"","orcid":"","institution":"World Federation of Occupational Therapists","correspondingAuthor":false,"prefix":"","firstName":"Claudia","middleName":"","lastName":"Zweck","suffix":""},{"id":311011908,"identity":"38d4e609-1b37-4caf-9442-fa078c8e9798","order_by":2,"name":"Sydney Larson","email":"","orcid":"","institution":"The Ohio State University","correspondingAuthor":false,"prefix":"","firstName":"Sydney","middleName":"","lastName":"Larson","suffix":""},{"id":311011910,"identity":"7927c45f-38c9-4c60-95e0-dea1f480ffd5","order_by":3,"name":"Sutanuka Bhattacharjya","email":"","orcid":"","institution":"Georgia State University","correspondingAuthor":false,"prefix":"","firstName":"Sutanuka","middleName":"","lastName":"Bhattacharjya","suffix":""},{"id":311011912,"identity":"8b4bb30f-4c9d-4438-9b80-b9a1044ceb16","order_by":4,"name":"Suresh Kamalakannan","email":"","orcid":"","institution":"Northumbria University","correspondingAuthor":false,"prefix":"","firstName":"Suresh","middleName":"","lastName":"Kamalakannan","suffix":""},{"id":311011913,"identity":"06cd9aac-6b39-4ac4-bc3e-9d87ce7d2868","order_by":5,"name":"Karthik Mani","email":"","orcid":"","institution":"University of Texas Medical Branch","correspondingAuthor":false,"prefix":"","firstName":"Karthik","middleName":"","lastName":"Mani","suffix":""},{"id":311011915,"identity":"7bc3a741-de6e-4284-8e8a-8bea0f070a3a","order_by":6,"name":"Ritchard Ledgerd","email":"","orcid":"","institution":"World Federation of Occupational Therapists","correspondingAuthor":false,"prefix":"","firstName":"Ritchard","middleName":"","lastName":"Ledgerd","suffix":""}],"badges":[],"createdAt":"2024-05-22 16:40:59","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4462309/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4462309/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":57840955,"identity":"0c4d76df-08f6-4e52-a264-60d8cbff2046","added_by":"auto","created_at":"2024-06-06 09:54:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":648557,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4462309/v1/3e91248c-203c-4b8d-a883-1b3da824d98a.pdf"},{"id":57840388,"identity":"549b4532-6dea-4f06-b939-f8e1e4673d9c","added_by":"auto","created_at":"2024-06-06 09:46:52","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":16521,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryappendix1.docx","url":"https://assets-eu.researchsquare.com/files/rs-4462309/v1/cbb3a010d1ce37d2a9e69642.docx"},{"id":57840386,"identity":"ca8251b0-bd40-4fbf-a353-b162925225c7","added_by":"auto","created_at":"2024-06-06 09:46:52","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":19370,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryFile2.docx","url":"https://assets-eu.researchsquare.com/files/rs-4462309/v1/6eab4d005b8f82a58c566277.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Refining the first global strategy for the occupational therapy workforce: results from a mixed-methods survey and multimodal expert feedback","fulltext":[{"header":"Background","content":"\u003cp\u003eOccupational therapists are health professionals that aim to meet the health and occupational needs of the populations.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Specifically, occupational therapists promote the functional performance and occupational engagement for individuals or communities experiencing (or at risk of experiencing) physical, mental, and other impairments that intersect with a \u003cem\u003edisabling\u003c/em\u003e environment.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Current global data estimates that 2.4\u0026nbsp;billion people have health conditions or disabilities that would benefit from rehabilitation.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Furthermore, the population need for rehabilitation and occupational therapy services has been increasing significantly over time (e.g., 17% per capita worldwide, since 1990),\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e which has been observed across countries of varying income levels\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Given this trend is a consequence of increased life expectancy, global ageing of the population, and rising rates of chronic and non-communicable conditions, the growing population need for occupational therapists is likely to continue to increase over time, particularly in low- and middle-income nations (LMICs).\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor meeting these high and increasing population needs worldwide, policymakers, health planners and other interested parties need to assure that health systems have a sizeable, accessible, and competent rehabilitation workforce that includes occupational therapists.\u003csup\u003e\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e However, the global occupational therapy workforce remains underdeveloped, inequitably distributed (within and across nations), and scarce, if present at all in many LMICs.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e For example, WFOT\u0026rsquo;s data shows that 54 of member organizations (61%) had\u0026thinsp;\u0026lt;\u0026thinsp;1 occupational therapist per 10,000 population, including nations with \u0026lt;\u0026thinsp;0.001.\u003csup\u003e13\u003c/sup\u003e In contrast some high-income countries (HICs) can have up to 22 occupational therapist per 10,000 population.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Moreover, many LMICs have no occupational therapy education programmes or professional regulation,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e which complicates efforts to strengthen the workforce. The workforce in many countries is also maldistributed. For example, in South Africa most occupational therapists are deployed in urbanized provinces, with 74.8% employed in the private sector which serves 16% of the South African population.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Disparities exist even among high-income countries (HICs), with the population-adjusted supply of occupational therapists as much as 10 times lower in some areas within a nation,\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e in addition to substantive rural-urban differences.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWithin the context described, WFOT has led a research-based, multistage development process to launch the first global strategy for strengthening this workforce. The process started with a multipronged scoping review of the occupational therapy workforce to synthesize: a) the scope and limited growth of this the research;\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e b) the types of findings generated, including the topics remaining unaddressed across nations\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e and c) the reported limitations or recommendations regarding which workforce data and other improvements need to be made.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Based on an integrated synthesis of these findings, a situational analysis was conducted that included the input of an advisory board with health workforce experts from within and outside the profession.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eA large pool of strategic actions (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;62) was initially drafted in response to the situational analysis for inclusion in the \u003cem\u003eWorkforce Strategy\u003c/em\u003e, and then assessed using a survey of country representatives (e.g. WFOT national delegates) regarding perceived utility. The survey was followed by focus group discussions with the country representatives.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e As a result of the feedback provided, substantive changes were made to the draft strategic actions; the actions were reduced in number, reorganized (e.g., some of the actions were included as examples within other actions), and combined with new content regarding the context of need for the workforce \u003cem\u003eStrategy\u003c/em\u003e. In this paper, we aim to report on the results of activities to 1) re-survey country representatives on the utility of a redrafted version of the \u003cem\u003eStrategy\u003c/em\u003e, as well as 2) consult with experts from the advisory board on final refinements. These steps enable the \u003cem\u003eStrategy\u003c/em\u003e\u0026rsquo;s launch.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign:\u003c/h2\u003e \u003cp\u003eA mixed-methods online survey of WFOT occupational therapy representatives was undertaken, complemented by feedback from an expert advisory group - first individually in written form, then in a focus group (with written consent to use their anonymized expert opinions for scientific report purposes). An ethics review was submitted to the Institutional Review Board of The Ohio State University which determined that this research was not human subjects research. This Board noted participants provided their expert-based feedback as part of program development work. The country representatives and reviewers who provided feedback regarding the \u003cem\u003eStrategy\u003c/em\u003e were not the \u003cem\u003esubjects\u003c/em\u003e of the research.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eOnline Survey:\u003c/h2\u003e \u003cp\u003e \u003cb\u003eSupplementary Appendix 1\u003c/b\u003e provides the survey that was sent to the country representatives, including the introductory content and instructions. The survey was sent to all 100 WFOT member organisations representing individual countries or territories (the entire population, no sampling). To do so, the WFOT used internal communication channels, which are regularly used to obtain feedback on program development activities of the WFOT. The survey could be completed by the formal delegates to the WFOT, alternate delegates, or another formal representative of the member organisation assigned by a delegate. Only one representative could respond per member organization.\u003c/p\u003e \u003cp\u003eThe survey asked for a utility rating (0\u0026ndash;10) for each strategic direction (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7) and associated specific actions (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;21). The number of specific actions ranged from two to four per strategic direction, for a total of 28 strategies that were surveyed. An open-ended question was asked at the end of the survey to explain concerns, improvement suggestions or the rationale for given answers. Eight weeks were provided for member organizations to respond to the survey, with a reminder for participation sent after 6 weeks.\u003c/p\u003e \u003cp\u003eFor the analysis, descriptive statistics (e.g. average utility ratings; standard deviations; modal response) were used for the analysis of the quantitative data. In the previous survey examining the initial draft of strategies, a cutoff of \u0026lt;\u0026thinsp;8 as an average score (rated 0\u0026ndash;10) was used to identify the strategies that raised most concerns and were \u003cem\u003ehot\u003c/em\u003e topics for focus groups discussion.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e Here we use the same cutoff, assuming that \u0026gt;\u0026thinsp;8 indicates \u003cem\u003ehigh\u003c/em\u003e or \u003cem\u003every high\u003c/em\u003e levels of agreement.\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e We also developed a sensitivity analysis at the county level, focused on the average score of the total set of strategies relative to the cutoff point and for the group of countries that were LMICs versus HICs. The country-level analysis enabled gaining an understanding of whether the global \u003cem\u003eStrategy\u003c/em\u003e was useful or varied across countries and their economic development contexts.\u003c/p\u003e \u003cp\u003eFor the open qualitative comments in the survey, we used an inductive thematic analysis,\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e conducted by two researchers (TJ, SL). The transcripts were read by the two researchers for familiarization, followed by open coding for generating initial codes,\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e and then by axial coding in which the two researchers collaborated to organize the data into related themes, including emergent meanings.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e To enhance the trustworthiness of the analysis, a third researcher (SK) was involved to ensure the accurate representation of the raw data into the developing themes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eTwo-phased experts\u0026rsquo; feedback:\u003c/h2\u003e \u003cp\u003eThree experts, who participated in a preceding situational analysis,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e were invited to take part in the provision of: 1) individual written feedback regarding the redrafted Strategy and 2) collective feedback through participation in a focus group discussion. The experts included two occupational therapists with experience and a track record in publishing on occupational therapy workforce topics, collectively across LMICs and HICs. The third expert was a health workforce scholar that is not an occupational therapist (health economics background), with expertise across LMICs and HICs. As a group, the experts provided occupational therapy, human resources policy and management, and health policy and economic expertise across major global regions.\u003c/p\u003e \u003cp\u003e The invitation to provide feedback was made through email in follow-up to initial participation in the preceding situational analysis. The invitation for the preceding situational analysis included the WFOT terms of reference that described expectations for the experts\u0026rsquo; volunteer participation. Of note, like in the previous situational analysis,\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e one of the occupational therapist experts was also a coauthor in this work (KM). While this author had substantive roles in the study conception, design and report, he had no roles in the drafting or redrafting of the \u003cem\u003eStrategy\u003c/em\u003e, hence could provide an outside view regarding the content. The need to engage an expert from the authorship team partly arose from the low availability of workforce experts within the profession, particularly one with expertise across national contexts. The dearth of occupational therapy workforce researchers was identified in the initial scoping review,\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e and noted as a weakness of the profession in the preceding situational analysis.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eFor the individual written feedback, the experts were provided with the full redraft of the \u003cem\u003eStrategy\u003c/em\u003e. Experts had three weeks to provide their feedback (in comments alongside the document, through suggested tracked edits, or in overall qualitative comments), by replying to the email invitation. Each expert was blinded to the feedback provided by others. Any feedback requesting clarification or generating concerns were flagged to be immediately refined or reworded. Suggestions for elements to be added or eliminated were summarized to be collectively discussed through a focus group discussion.\u003c/p\u003e \u003cp\u003eThe focus group discussion was conducted by the lead research author (TJ) through an online, one-hour, recorded videoconference, assisted by two others (CvZ, RL) in moderation as well as one another author (SL) taking notes to support the analysis. The topics discussed included: 1) concerns arising from the qualitative comments and synthesized thematic analysis of feedback from the online survey; 2) suggestions for additional content from the individual, written experts\u0026rsquo; feedback; and 3) refinements or additions suggested by the research authors in response to the feedback obtained in the previous phases. The overarching goal of the discussion was to increase the utility, acceptability, and feasibility of the Strategy, as well as develop a mechanism for its communication and dissemination. Transcripts of the focus group were thematically analyzed using the same process as described for the qualitative comments of the online survey.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Online survey \u0026ndash; respondents:\u003c/h2\u003e \u003cp\u003eOf the 45 respondents, 71% (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;32) were the primary country delegates to the WFOT. The other respondents were the alternate delegate (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4), or a member organization\u0026rsquo;s representative other than delegate or alternate such as from the secretariat (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9). In country representation, 18 (40%) were LMICs (including three low-income countries), while the remaining 60% were HICs including emergent HICs in eastern Europe, Latin America or the eastern Mediterranean region.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Online survey \u0026ndash; quantitative results:\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e provides the results from the survey for all country representatives. All strategies had \u003cem\u003ehigh\u003c/em\u003e average utility scores. For instance, the seven strategic directions obtained average scores that ranged from 9.13 to 9.33] (SD ranges: [0.80\u0026ndash;1.20]). The 21 specific actions had average scores that ranged between 8.29 to 9.33. (SD ranges: [0.87\u0026ndash;2.03]). The lowest scoring specific action (average 8.29, SD: 2.03) was: \u003cem\u003epromote the development of new regulatory/licensing bodies, where absent to collect and report on minimum datasets for the occupational therapy workforce.\u003c/em\u003e The highest scoring were \u003cem\u003e\u0026ldquo;strengthening occupational therapy workforce data\u0026rdquo;\u003c/em\u003e as a main strategy and \u0026ldquo;\u003cem\u003eproduce scientifically-sound, population-centered, and solution-oriented occupational therapy workforce research\u003c/em\u003e\u0026rdquo;. Sixteen of the 28 items (57%) had a median value of \u0026ldquo;10\u0026rdquo;, with the remaining having a median value of \u0026ldquo;9\u0026rdquo;. Finally, the mode value was \u0026ldquo;10\u0026rdquo; for all items.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuantitative results of the online survey on the utility ratings, all country-representatives combined.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrategies surveyed (main strategies in bold)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAverage\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMode\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 Strengthening occupational therapy workforce data\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.1 Develop an international framework and toolkit that outlines a minimum workforce dataset, a supplemental dataset and ways to collect, integrate and report on the information.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.2 Advocate for occupational therapy supply data to be included in (inter)national monitoring of health workforce data, tools and classification systems.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.04\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.3 Promote the capacity of existing regulatory/licencing bodies to collect and report on minimum occupational therapy workforce datasets.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.4 Promote the development of new regulatory/licensing bodies, where absent to collect and report on minimum datasets for the occupational therapy workforce.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e2.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 Determining supply shortages in the occupational therapy workforce\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.1 Determine current and future population needs for occupational therapists and any shortages, surplus, or geographic disparities within and across nations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.08\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.2 Examine the demand for occupational therapists to determine supply gaps and labour-market imbalances.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.3. Conduct comprehensive analyses of occupational therapy human resources as a single profession and as part of a broader health workforce.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 Investing in the expansion of the occupational therapy workforce\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.1 Quantify investment needs for the expansion of the occupational therapy workforce, identifying costs and potential benefits.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.71\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.2 Advocate and translate expansion needs into occupational therapy workforce investment programmes and policy decisions.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.73\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3.3. Build occupational therapy education and deployment capacity.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e4 Improving workforce distribution for equitable access\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.1 Monitor the distribution of occupational therapists to address inequities in population access to occupational therapy services.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.2 Identify contributing factors and intervention programmes to address inequities in access to occupational therapy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4.3 Develop and implement innovative service delivery models and workforce strengthening measures that extend access to the occupational therapy workforce.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.54\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e5 Assuring workforce competency, engagement and diversity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.1 Develop or strengthen mechanisms that assure that occupational therapists continuously meet key competency and practice standards.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.2 Strengthen human resources management practices for improving the performance and job satisfaction of occupational therapists.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5.3 Improve the equitable diversity and representation of the occupational therapy workforce and foster acceptability by diverse communities, cultures, and populations.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6 Developing and using occupational therapy workforce research\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.92\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.1 Produce scientifically-sound, population-centred, and solution-oriented occupational therapy workforce research.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.88\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.2 Develop funding mechanisms, research structures, research training structures, and networks to build national and cross-national capacity to advance occupational therapy workforce research.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6.3 Engage interested parties in the development and use of occupational therapy workforce research.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e7 Building workforce leadership and planning capacity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.1 Promote capacity-building programmes for local, national, and cross-national occupational therapy workforce leaders and advocates.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7.2 Occupational therapy workforce leaders foster profession-specific situation analysis and workforce strengthening plans as well as participate in cross-professional workforce policy, planning, and programmatic developments.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cp\u003eIn the country-level analysis, four of 45 country representatives (8.9%) provided scores whose average was \u0026lt;\u0026thinsp;8, while two others provided scores that averaged exactly \u0026ldquo;8\u0026rdquo;. Of these six countries, only one (16.7%) was an LMIC.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003e1.3 Online survey – qualitative results:\u003c/h3\u003e\n\u003cp\u003eFor the qualitative delegate\u0026rsquo;s comments, the \u003cb\u003eSupplementary Appendix 1\u003c/b\u003e provides the thematic analysis, including illustrative (not exhaustive) quotes. In a synthesis, an overarching theme emerged: \u003cem\u003eAccount for context-sensitive priorities.\u003c/em\u003e These focused on prioritizing or customizing the strategies for their local context of need. For LMICs, the focus was on leadership, advocacy and preventing unethical international recruitment. On the latter matter, one commented suggested a more explicit account was needed in the \u003cem\u003eStrategy\u003c/em\u003e, and that refinement was made. This notion of unethical international recruitment was present in the initial drafts of the Strategy but eroded through the progressive draft refinements toward parsimony. This comment helped restore and reinforce that explicit inclusion into the \u003cem\u003eStrategy\u003c/em\u003e.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Experts Feedback \u0026ndash; individual written feedback\u003c/h2\u003e \u003cp\u003eQualitative appraisals from each expert were consistently positive, particularly for comprehensiveness: \u003cem\u003eIt looks good\u003c/em\u003e, \u003cem\u003ethe draft looks great and very comprehensive\u003c/em\u003e and \u003cem\u003estrategy document is fairly comprehensive\u003c/em\u003e. In addition to positive appraisals, improvement suggestions were received and included three types.\u003c/p\u003e \u003cp\u003eThe first was to include clarifying statements or keywords (e.g., \u0026ldquo;\u003cem\u003eattrition rates\u003c/em\u003e\u0026rdquo;) to the examples of action to attain the strategies, i.e., not the surveyed strategies themselves. These comments were directly amended or flagged for refinement and not included in focus group discussion. A second type of improvement suggestion was to edit the wording of some of the main strategies, without changing their scope. These suggestions were selected for the experts\u0026rsquo; focus group discussion. A third type of improvement suggestion was made to add sections such as an extended abstract / executive summary to the \u003cem\u003eStrategy\u003c/em\u003e document. These suggestions were also brought to the focus group discussion, in addition to the synthesis of the survey results (e.g., discussion of the lower scoring strategy).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Experts Feedback \u0026ndash; online focus group\u003c/h2\u003e \u003cp\u003eFor the qualitative delegate\u0026rsquo;s comments, the \u003cb\u003eSupplementary Appendix 2\u003c/b\u003e provides the thematic analysis, including illustrative (yet not exhaustive) quotes. The overarching theme was: \u003cem\u003eprovide additional framing\u003c/em\u003e. The three themes within were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eContextualize the scope of the Strategy, including how it might be used, keeping it separate from country-specific implementation needs, plans, and supports.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eStrengthen the Strategy by summarizing (e.g., adding an executive summary) and provide further legitimacy through a strengthened \u003cspan refid=\"Sec2\" class=\"InternalRef\"\u003eMethods\u003c/span\u003e section.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSlightly refine some of wording or content for greater coverage and acceptability.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eImportantly, all these refinement suggestions were amenable to and indeed incorporated into the launched \u003cem\u003eStrategy\u003c/em\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eA multistage, mixed-methods consultation process with experts and country-representatives helped provide key refinements into the first global strategy for the occupational therapy workforce, right before its launch. This activity was preceded by a comprehensive process that involved a multi-pronged scoping review, a situational analysis, a first-level advisory consultation, \u003cem\u003eStrategy\u003c/em\u003e drafting, mixed-methods survey of country representative on the first draft, subsequent focus groups discussions (e.g. on areas of lower perceived relevancy), and a redraft according to the feedback. Here, the mixed-methods survey and multimodal expert feedback helped to refine the redrafted \u003cem\u003eStrategy\u003c/em\u003e based on perceived utility. In short, the full set of major and specific strategies got high average utility ratings, including top modal ratings for all, while the qualitative comments informed in refinements.\u003c/p\u003e \u003cp\u003eThe refinements that were made from the findings were small in quantity but non-trivial. For example, although implicitly addressed, some key concepts were not explicitly stated in the surveyed strategies themselves (e.g., international movement or recruitment) or in the full Strategy report with more detailed accounts within each strategy (e.g., attrition rates). Overall, for a process with multiple refinement layers, including for parsimony, some key notions may be eroded in explicit display through that needed process; however, a last assessment by interested parties from diverse backgrounds or contexts helped restore the explicit (beyond implicit) statement of those key concepts. Not the least, the comments from the country representatives seemed to unravel some perceived conflict between the scope of a global strategic framework with the local need to establish context-sensitive priorities and action plans. The subsequent feedback and focus group discussion with the experts helped to shed light on those issues and on remedies such as to emphasize, right from the initial parts of the Strategy document, how the Strategy document might be used as a guiding framework only, not replacing but rather facilitating the needed local situational assessment and planning. Hence, the key experts\u0026rsquo; advice was to provide additional explanation of the intended use of the \u003cem\u003eStrategy\u003c/em\u003e, which was then incorporated into the full Strategy document.\u003c/p\u003e \u003cp\u003eAmong the major strategic directions, \u003cem\u003estrengthening occupational therapy workforce data\u003c/em\u003e achieved the greatest average utility rating among country-representative delegates. Not surprisingly so. The availability of occupational therapy workforce data on key national and global databases is lagging relative to many other health professions. For instance, major international analyses and projected shortages for human resources for health either do not account for or do not stratify data for occupational therapists (e.g., instead are aggregated with other health workers).\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e This lack of occupational therapy data is applicable to displays or analyses for five major cadres,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e for an enlarged set of 16 cadres,\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e or even for a broader set of over 40 cadres of health workers currently available in the data portal from National Health Workforce Accounts.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e For example, among 40 specific cadres National Health Workforce Accounts, one can observe stratified data for physiotherapists or for speech and language pathologists as related professions, or even for non-professional physiotherapy assistants. But no data is available for occupational therapists, whatsoever. This lack of occupational therapy data may segregate recognition of population-based needs to strengthen access to the profession apart from the mainstream health workforce developments. Part of the reason for this lack of occupational therapy data relates to the International Standard Classification of Occupations which does not have a specific code for categorizing occupational therapists.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e Global workforce datasets and underlying census or national workforce data collections are often based on ISCO categories. \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eTo complicate the data issue further, many occupational therapists perform their role as a health professional with individual clients or communities outside the traditional health care environment, often employed in the social or educational sector, in local municipalities, or working for disability non-governmental organizations.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e This adds just another layer of complexity for monitoring the occupational therapy workforce, especially if not purposive strengthening actions occur. These data strengthening activities inclusive of the occupational therapy workforce are not necessarily covered by - and thereby might complement - ongoing workforce developments in the broader health and rehabilitation field.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e,\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Complementary yet separated from a \u003cem\u003eStrategy\u003c/em\u003e, further and more detailed resources such as implementation tools, workforce collection guides, among others, might be further developed to help deploy the global Strategy, including in a context-sensitive way. That direction also came in alignment with the experts\u0026rsquo; feedback received.\u003c/p\u003e \u003cp\u003eThe \u003cem\u003eStrategy\u003c/em\u003e was also assessed on its perceived utility and refined by the input of representatives of various national professional associations, whose input was collected and integrated also in previous development phases.\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e National leaders of the profession have experiential knowledge of the workforce challenges experienced by this profession in their own context, hence could appraise whether a global Strategy can be useful across implementation contexts. These national leaders are also one of the target end-used of the Strategy, hence their participation partly fitted a user-centered design, as well.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e Relatedly, one of the highest rated strategies was on \u003cem\u003ebuilding workforce leadership and planning\u003c/em\u003e. That strategic direction implies strengthening the \u003cem\u003eleadership\u003c/em\u003e capacity (e.g., of emerging professional leaders) on health-workforce development matters - for an evidence-based, population-oriented professional advocacy and development action. In turn, those activities might benefit from all the other workforce development activities; that is, the other six major strategies surveyed here, including to produce the data and evidence needed to strengthen this often-neglected workforce. In short, this \u003cem\u003eStrategy\u003c/em\u003e \u0026ndash; with its synergies among components \u0026ndash; is meant to have value as a whole, beyond the sum of its parts.\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eLimitations:\u003c/h2\u003e \u003cp\u003eAs a guiding global framework, the Strategy should not be understood as: an \u0026lsquo;how to guide\u0026rsquo;, a set of priorities, or setting local action plans (which might be context sensitive). Accordingly, the Strategy does provide answers to who should do what, how, or when. Even when formal commitments are established, actual implementation and accountability can be different matters.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e Also, the Strategy might not be fixed or rigid over time but periodically updated or even a \u003cem\u003eliving\u003c/em\u003e Strategy that incorporates both evidence and interested parties\u0026rsquo; input over time, including any interested parties not directly consulted within this initial development process. The Likert-type ratings only reflect perceived and anticipated utility, hence might be understood under those subjectivity lenses. The experts involved in the multimethod, sequential feedback did it so in an advisory and consultation role; that cannot be understood as formal or wide consensus-reaching process. Finally, while the identified gaps of the data and evidence on the occupational therapy workforce provided a ground for the Strategy development (e.g., areas in need for improvement),\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e it also implies that the profession-specific evidence base supporting actions within each of the strategies requires further strengthening. This \u003cem\u003eStrategy\u003c/em\u003e aims to contribute to promote more systematic developments in the development and use of evidence (i.e., strategic direction #6).\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe surveyed strategies for the global strengthening of the occupational therapy workforce were positively appraised by country representatives. Altogether, the multimethod, multi-stakeholder evaluation helped refine the \u003cem\u003eStrategy\u003c/em\u003e and tailor its report according to the feedback of potential end-users and global experts. Enabled by this last development process, a first-ever global \u003cem\u003eStrategy\u003c/em\u003e for strengthening the occupational therapy workforce was launched in a refined version. This \u003cem\u003eStrategy\u003c/em\u003e can serve as a guiding framework for local, regional, national and international global agents that have the incumbency including due to unmet population needs) to develop this often-neglected health workforce. \u0026lt;The full Strategy document will be available at the WFTO\u0026rsquo;s website soon and we will mention here the link from which it can be downloaded\u0026gt;.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eT.S.J. developed the conceptualization, led the study design, developed project management and team coordination, supervised the investigation, led the analysis, and wrote the first draft of the main manuscript.C.V.Z. contributed to the conceptualization, study design, investigation, data collection, data curation, and critically edited the manuscript.S.L. provided one major data analytical role for the qualitative data and critically edited the manuscript.S.B. contributed to the conceptualization, study design, data collection forms, and critically edited the manuscript.S.K. contributed to the conceptualization, study design, confirmatory analytical roles, and critically edited the manuscript.K.M contributed to the conceptualization, study design, investigation, and critically edited the manuscript.R.L. contributed to the conceptualization, study design, investigation, data collection, project oversight, and critically edited the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData is provided within the manuscript or supplementary information files\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Federation of Occupational Therapists. \u003cem\u003eOccupational Therapy Human Resources\u003c/em\u003e. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wfot.org/resources/occupational-therapy-human-resources\u003c/span\u003e\u003cspan address=\"https://www.wfot.org/resources/occupational-therapy-human-resources\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Federation of Occupational Therapists. \u003cem\u003eOccupational Therapy and Human Rights (Revised)\u003c/em\u003e. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCieza A, Sabariego C, Bickenbach J, Chatterji S. 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Int J Public Health. 2023;68:1605603. doi:\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/ijph.2023.1605603\u003c/span\u003e\u003cspan address=\"10.3389/ijph.2023.1605603\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health Workforce, Health Planning, Occupational Therapy, Consultation","lastPublishedDoi":"10.21203/rs.3.rs-4462309/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4462309/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe occupational therapy workforce remains underdeveloped and inequitably distributed, against the backdrop of increasing population needs. The World Federation of Occupational Therapists (WFOT) led a multistage development process to launch the first global strategy for this workforce. An initial draft Strategy was previously reviewed for utility by country representatives, then redrafted. Here, we assess the perceived utility of the redrafted \u003cem\u003eStrategy\u003c/em\u003e for refinements before its launch.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eMixed-methods online survey of country representatives (e.g., delegates to the WFOT) complemented by experts\u0026rsquo; feedback, including from outside the profession. The survey asked for a utility rating (0\u0026ndash;10) for each strategic direction (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7) and associated specific actions (total \u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;21). A comment box was provided for scoring rationale, concerns, or improvement suggestions. Experts that were previously engaged in a situational analysis provided improvement suggestions for the \u003cem\u003eStrategy\u003c/em\u003e, first in writing individually and then through an online focus group. Data was analyzed by descriptive statistics (e.g., average scores\u0026thinsp;\u0026gt;\u0026thinsp;8 considered \u003cem\u003ehigh\u003c/em\u003e) and thematic analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eForty-five country representatives (45%) completed the surveys, 40% from low- and middle-income countries (LMICs). All major strategies (average ranges: [9.13\u0026ndash;9.33]; SD ranges: [0.80\u0026ndash;1.20]) and specific strategies (average ranges: [8.29\u0026ndash;9.33]; SD ranges: [0.87\u0026ndash;2.03]) received \u003cem\u003ehigh\u003c/em\u003e utility scores. The mode value was \u0026ldquo;10\u0026rdquo; for all items. From the survey comments, the central theme was: \u0026ldquo;\u003cem\u003eaccount for context-sensitive priorities\u003c/em\u003e\u0026rdquo;. From the experts\u0026rsquo; feedback, the central theme was: \u0026ldquo;\u003cem\u003eprovide additional framing\u003c/em\u003e\u0026rdquo;, such as contextualizing the \u003cem\u003eStrategy\u003c/em\u003e as a global framework that helps guide but does not dictate local priorities or action plans.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe strategies for the global strengthening of the occupational therapy workforce were positively appraised by country representatives. Altogether, the multimethod, multi-stakeholder evaluation helped refine the \u003cem\u003eStrategy\u003c/em\u003e and tailor its report according to the feedback of global experts and its potential end-users. It also provided insights on the need for context-specific implementation plans.\u003c/p\u003e","manuscriptTitle":"Refining the first global strategy for the occupational therapy workforce: results from a mixed-methods survey and multimodal expert feedback","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-06 09:46:47","doi":"10.21203/rs.3.rs-4462309/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"260728390228425668064978558742368704905","date":"2026-05-17T22:22:20+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T16:32:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163685127003663701080693191401284971272","date":"2026-02-24T13:31:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337197922956386984870911238006705864022","date":"2025-05-30T06:20:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-05T14:00:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-24T06:25:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-24T06:25:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"Human Resources for Health","date":"2024-05-22T16:39:39+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"human-resources-for-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"hrhe","sideBox":"Learn more about [Human Resources for Health](http://human-resources-health.biomedcentral.com)","snPcode":"12960","submissionUrl":"https://submission.nature.com/new-submission/12960/3","title":"Human Resources for Health","twitterHandle":"@HRH_Journal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d29c90bb-0da6-4c09-93e8-a41a280a57e6","owner":[],"postedDate":"June 6th, 2024","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"260728390228425668064978558742368704905","date":"2026-05-17T22:22:20+00:00","index":74,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-06-06T09:46:47+00:00","versionOfRecord":[],"versionCreatedAt":"2024-06-06 09:46:47","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4462309","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4462309","identity":"rs-4462309","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}