There is a need to identify the diversity and gaps in the educational and practice systems to better understand how to improve paediatric occupational therapy education and ongoing mentorship worldwide. This quantitative research aims to examine paediatric occupational therapy education from academics and clinicians through two separate surveys.
An educational survey was sent to the World Federation of Occupational Therapy (WFOT)-approved programs in 78 countries to quantify educational and training hours provided in the paediatric field. An additional clinician survey was sent to occupational therapists to learn about their perspective on paediatric practice and continuing education.
The educational survey results from 56 WFOT programs in 32 countries indicated that the total percentage of academic curriculum specific to paediatric content was on average five percent. A four-year bachelor (n = 32) was the most prevalent entry level to the profession. Most of programs also indicated that more than 50% of occupational therapists in their respective countries work in paediatrics. The clinician survey (n = 141) had responses from 32 countries, with the majority working full time in paediatrics (n = 103, 72.5%). These results are consistent with the 2021 WFOT Education Survey.
From the clinician survey, paediatric feeding (70% of respondents) was the most requested area of continuing education, followed by transitions and positioning for play for children birth to three (18% of respondents). This will help guide future efforts for providing education and mentorship. As a result of both surveys, it was confirmed that more than half of occupational therapists are practicing in paediatrics across the globe. In response, academic curriculums should reflect the current practice trend; however, paediatric-specific education is relatively low.
Global survey on paediatric education and practice in occupational therapy
Occupational therapy is a holistic health care profession that promotes health and wellbeing for daily living [World Federation of Occupational Therapists (WFOT), 2012]. The intention of this article is to reveal the spectrum of occupational therapy education and practice in the field of paediatrics across the globe and current continuing education needs.
Literature review
In paediatric occupational therapy, prevention and intervention can only occur with adequate occupational therapy education specific to paediatrics throughout the globe. Information on paediatric-specific content within occupational therapy programs has not been published since 2006. Studies examining occupational therapy academic curricula showed an average of 21.5% of the content was dedicated to paediatrics in South Africa (Brown et al., 2006), 20% in New Zealand and Australia, 12% in Canada (Rodger et al., 2006) and less than five percent in the UK (Brown et al., 2005).
A more recent study in the Philippines demonstrates the need for a more universal paediatric occupational therapy curriculum specifically for inclusive education in the public schools (Sagun et al., 2020). Findings suggested occupational therapists needed knowledge of not only inclusive education but also for advocacy for policy change. Sagun et al. (2020) emphasized the critical need for paediatric occupational therapists to expand their knowledge from individual treatment to providing a systems-level service approach. In the USA, academic programs have seen additional language in the accreditation standards (Accreditation Council for Occupational Therapy Education®, 2018) and the most recent Occupational Therapy Practice Framework: Domain and Process 4th edition (American Occupational Therapy Association, 2020) to both include population health.
It is important to find the similarities and gaps in the educational and practice systems worldwide to better understand how to improve the diversity and unicity of paediatric occupational therapy education across the globe. The WFOT is leading the profession to be more diverse, equitable and inclusive through its commitment to developing resources and tools to empower occupational therapy practitioners to increase the quality of life of paediatric clients and their families. One of challenges for developing resources, such as continuing education programs, is the varying requirements individual countries have to maintain licensure. There is also a shortage of research on continuing education within the field of occupational therapy (Jesus et al., 2023). With the expansion of new occupational therapy programs, especially across Africa within the past ten years, there is a growing number of occupational therapy practitioners in need of continuing education (Szymcyk and Barlow, 2021), especially within the field of paediatrics.
There is a need for an international collaborative approach to develop guidelines and processes to ensure sustainability relating to occupational therapy education and practice. Developing a global paediatric occupational therapy guideline is an important step to ensure adequate service delivery to children receiving occupational therapy. A study by Clark and Kingsley (2020) investigated occupational therapy practice guidelines for early childhood from birth to five years old and revealed that occupational therapy supports the development of cognitive, social-emotional, motor and self-care skills for these children. The findings of this study should be used to inform evidence-based practice provided by occupational therapy practitioners working with children from birth to five years old in various settings and can be used as a model for a global guideline (Clark and Kingsley, 2020).
Occupational therapy education is enhanced by being explicit about the desired graduate attributes that underpin curriculum design and delivery. Embedding graduate attributes within curriculum development will warrant that occupational therapy education contributes to the development of competent clinicians and individuals who are able to make a valuable contribution to their societies (Plastow and Bester, 2020). The first aim of this study was to quantify the amount of education dedicated to paediatrics in WFOT-approved programs, both in the classroom and on fieldwork. The second aim was to quantify the percentage of occupational therapists working in paediatrics and thirdly to know what the continuing education needs are of the therapists working in paediatrics. The purpose is to create a bridge between occupational therapy education and excellence in paediatric occupational therapy practice, especially in countries where the occupational therapy profession is still developing.
Methods
An online cross-sectional descriptive survey was conducted with the aim to collect and analyse data on occpational therapy education from academics and clinicians around the world. The long-term objective is to provide free continuing education in paediatrics. Ethical approval was granted by the American International College institutional review board (#2022 1-1) through exempt procedures.
Study procedure
An online survey is a set of structured questions that the respondent completes over the internet, generally by filling out a form. The key benefits of online surveys are accuracy, ease of participation and low cost. For example, large samples of participants from remote locations can be involved, respondents can be flexible and honest and data can be analysed easily and quickly. Six of the authors, from four different countries and three continents, created both online surveys. Due to varying accreditation standards and entry level degrees for occupational therapy programs around the world, the six authors had to develop a universal language for survey completion. The surveys were purposefully kept brief, with a goal of under 10 questions, in an attempt to acquire a large number of responses. The clinician survey was sent to four colleagues from four different continents to trial, and the education survey was trialled by colleagues from two different continents. After feedback was provided, corrections were made, and the survey was launched. The survey for WFOT-approved education programs composed of two demographic questions 1) country of program and 2) entry-level degree to practice in the country. Four additional questions were to identify the quantity of educational and training hours they provide to their students in the paediatric field (see Appendix 1). The clinician survey composed of three demographic questions:
country where degree was earned;
highest degree earned; and
year therapist began practicing occupational therapy.
The clinician survey consisted of six additional questions asking about paediatric practice (see Appendix 2).
The survey remained open to collect responses for nine months. Microsoft Forms was utilized to send both online anonymous surveys via email. The education program survey was sent to WFOT-approved programs listed on the WFOT website. Four of the authors of this study also sent a personal email to at least one WFOT-approved program per country, as listed on the WFOT website to recruit a response.
The clinician survey inclusion criteria included: must be an adult, 18 years and older and have graduated from a fully approved WFOT occupational therapy program. Participants were recruited via referral snowball sampling. Known contacts received emails, social media was utilized, as well as the “OT ECHO” international mentoring program to promote the survey.
Data analysis
For data analysis, descriptive statistics were used to analyse items from both surveys utilizing Statistical Package for the Social Sciences (version 25; IBM Corp., Armonk, NY). All quantitative data was reviewed, cleaned and put in Microsoft Excel before analysis. The data was characterized through median scores and standard deviations to understand variability (Portney and Watkins, 2015).
Results
Global survey on paediatric education in World Federation of Occupational Therapy-approved programs
A total of 740 programs were emailed the survey. A total of 61 responses from 32 countries were received, of which 56 were valid. A response from an occupational therapy assistant program was excluded from analysis. Multiple responses were received from several countries, such as Brazil, Kenya, Malaysia, Saudi Arabia, Jordan, Kuwait and the USA.
Entry level to the profession
The prevalent entry level to the profession indicated by the respondents is 4-year bachelor (57.1%), followed by 3-year diploma (14.3%), 3-year bachelor (10.7%), master (8.9%) and clinical doctorate OTD (7.1%).
The responses on the number of hours in occupational therapy programs in total and in paediatrics were heterogeneous and inconsistent. A variety of answers were received – contact hours, total hours including self-study, credit hours, weeks, years. This led to an enormous range between the minimum and the maximum thus making them incomparable. To reduce the existing variation, credit hours were transformed into contact hours by multiplying them with 15. The equivalent is based on the general regulations in the USA, Europe and most other countries worldwide, according to which one credit corresponds to 15 h of teaching. The extreme values were excluded.
Total hours in the World Federation of Occupational Therapy-approved programs
A great variety of answers was received related to the total number of hours in the program ranging from 4.5 to 7,200. In the analysis of the data, values below 1,000 and above 4,800 were excluded. This resulted in 33 valid answers out of 56 received. The total hours in the programs ranged from 1,230 to 4,800 h with a mean of 2,537 h. The median is 2,070, indicating the majority of programs are below the mean (see Table 1). Some respondents gave detailed explanations in words, while others provided number of years, weeks or units.
Number of hours from WFOT-approved programs in total and in paediatrics
| Degree level | Total hours in the program | Contact hours in paediatrics | Hours in clinical placement specific to paediatrics |
|---|---|---|---|
| Total sample | |||
| N | 33 | 47 | 45 |
| Mean | 2,537.15 | 132.94 | 233.51 |
| Median | 2,070.00 | 117.00 | 200.00 |
| SD | 1,015.075 | 93.524 | 157.578 |
| Range | 3,570 | 390 | 540 |
| 3-year degree program | |||
| N | 6 | 9 | 11 |
| Mean | 3,869 | 93 | 349.5 |
| Median | 2,070 | 105 | 318 |
| SD | 1,015 | 93.524 | 205 |
| Range | 1,230–4,800 | 10–400 | 159–707 |
| 4-year bachelor program | |||
| N | 19 | 22 | 24 |
| Mean | 1,404 | 104 | 358 |
| Median | 91 | 91 | 170 |
| SD | 105 | 105 | 521 |
| Range | 5–400 | 5–400 | 4–2,290 |
| 2-year master’s program | |||
| N | 4 | 3 | 4 |
| Mean | 784 | 42 | 33 |
| Median | 63 | 60 | 32 |
| SD | 1,447 | 30 | 22 |
| Range | 13–300 | 8–60 | 8–60 |
| Clinical doctorate | |||
| N | 3 | 4 | 4 |
| Mean | 1,159 | 98.8 | 304 |
| Median | 119 | 103 | 335 |
| SD | 1,802 | 94 | 225 |
| Range | 118–3,240 | 10–180 | 25–520 |
Contact hours in paediatrics spent in the classroom
More valid answers about the contact hours specific to paediatrics (n = 47) were received in comparison to the total hours. The contact hours specific to paediatrics spent in the classroom ranged from 10 to 400 h. The mean was 132.94 with a median of 117, slightly below the mean. Responses from Canada, Guyana, Bosnia and Herzegovina, and Greece also contained detailed description of the content of paediatric education in occupational therapy. Of these countries, Canada requires a two-year master’s degree, while the remaining countries require a 4-year bachelor degree to practice at the entry level. The variety of responses of different universities from the same country indicate even bigger differences than those in the total hours of the program. The data revealed WFOT-approved programs vary on their emphasis of paediatric education within the field of occupational therapy.
Hours in fieldwork/internship/clinical placement specific to paediatrics
Several programs responded their students spent more than 1,000 h on paediatric fieldwork; however, this figure is most likely the total number of hours in fieldwork, not just those specific to paediatrics. For this reason, values above 540 h were excluded from the data related to hours in paediatric placements. The mean was 234 h, and the median indicates a greater distribution below the mean. In Canada and the UK, paediatric placements are not a mandatory requirement, so many students do not receive a paediatric placement. Data also varied by program design; some programs reported placements specific to paediatrics, while other programs incorporated paediatrics into other clinical placements. Most of the respondents indicated a paediatric placement varied according to the preference of the student.
Percentage of occupational therapists working in the paediatrics field
Of the 56 responses, 39% (n = 22) stated that more than 50% of occupational therapists in their respective countries worked in paediatrics and 1% of respondents stated the information was not available. More than a quarter (26%, n = 15) of respondents indicated that between 60 and 70% of occupational therapists work in paediatrics (see Figure 1). The survey indicated a high percentage of occupational therapists working in paediatric worldwide. Multiple responses from the same country ranged across different percentages, e.g. Kuwait – 20–70% and Uganda – 20–60%.
Clinician survey on paediatric education in World Federation of Occupational Therapy-approved programs
Demographics
A total of 150 responses from 32 countries were received; 141 of them valid. The largest number of responses were received from the USA (38), followed by Kenya (13), Romania (9) and Uganda (9). Multiple responses, ranging from two to eight, were received from 13 countries and the remaining 15 countries had one response.
The highest degree earned by most of the respondents was a master’s degree (38%), followed by 4-year bachelor (26.8%), 3-year diploma (17.6%), 3-year bachelor (6.3%), clinical doctorate (5.6%) and PhD (3.5%). Occupational therapists were also asked the year in which they entered the profession. Responses received (n = 138) ranged from 1979 to 2023. 50% of therapists who responded began practicing in the last ten years. A quarter of the responses had less than two years of practice. 2021 was the mode, the mean was 2012 and the median was 2014, which is very close. This information is important in relation to when the curriculum was developed, as accreditation standards and program design change over time.
Working in paediatrics
The prevalent number of respondents work professionally within the paediatric field (89.5%, n = 127), with 16.9% (n = 25) working part-time in paediatrics. Less than 10% of respondents (n = 14) reported not working in paediatrics and one respondent gave “other” as an answer.
Satisfaction with paediatric training
Occupational therapy clinicians were asked, “How satisfied are you with your paediatric training from your academic setting (including clinical and classroom opportunities in your degree?)”. Of the 140 responses, the majority (n= 68) were generally satisfied, answering with somewhat satisfied (48.5%, n = 68) and very satisfied (22.5%, n = 32). Other answers consisted of neither satisfied nor dissatisfied (11.2%), somewhat dissatisfied (12%) and very dissatisfied (5%). We didn’t find any correlation between the degree earned and the satisfaction of paediatric training, as the three most presented groups have similar results. Master graduates (n = 54) were 51% somewhat satisfied, 4-year bachelor degree (n = 39) were 49% satisfied and colleagues with and 3-year diploma (n = 13) with 57% satisfied. All three level of degree participants responded they were very satisfied between 18 and 26%.
Continuing education
Occupational therapists (n = 143) were asked to rank areas of paediatric content that they would most like additional training in. A ranking choice was given as an option for response to determine what was the largest areas of need for continuing education. Most respondents (72.5%, n = 110) indicated that "paediatric feeding" was the highest area of need, followed by “transitions and positioning for play for children birth to three” (18%) and “sensory integration and modulation strategies” (16%). Infant reflexes and hand development and handwriting, each received 13% of the vote. Other selections included assessments (9%) and neurodevelopmental treatment (8%). The option of “other” was selected by 14% of respondents and the following topics were noted multiple times: school-based occupational therapy, socio-emotional and cognitive development, splinting and the “Developmental, Individual-differences, and Relationship-based model (DIR) Floortime.”
Discussion
In this paper, we aimed to quantify paediatric occupational therapy education trends within WFOT-approved programs. The program survey results indicated there is great discrepancy in WFOT-approved programs regarding the paediatric education provided, even when comparing similar entry level degrees and when comparing similar degrees within the same country. More specifically, there is high variability in fieldwork requirements and time spent in paediatric-specific practice settings. Furthermore, the percentage of curriculum dedicated to paediatrics was approximately 5% on average, which is similar to findings in the UK almost 20 years ago (Brown et al., 2005).
Whether or not a program requires a paediatric fieldwork also varies by country, which adds to the varying levels of hours spent focused on paediatric fieldwork. In the USA, the Level I fieldwork experiences are to match the content covered within the classroom; however, it is not specific, and a paediatric Level II experience is not required in the USA (Accreditation Council for Occupational Therapy Education®, 2018). This is similar to Canada, whose standards state that students should participate in experiences with a variety of ages and settings (Canadian Association of Occupational Therapists, 2022), which confirms our results indicating that a paediatric fieldwork experience was not required.
The academic programs also reported approximately half of the clinicians within their respective country were practicing in the area of paediatrics. In the USA, working in paediatrics is now the largest practice area, with 21.4% in clinic-based or early intervention and 20.6% in the school system (National Board for Certification in Occupational Therapy, 2022). The WFOT (2022) Human Resources Project also cited the vacancy rate was the second highest for working in education/learning disabilities.
Practitioner survey results indicated most of the respondents practice in paediatrics at full time (72.5%) capacity, yet only 22.5% of respondents reported feeling “very satisfied” with the paediatric education and training they received from their educational program. The results indicate room for improvement in academic programs’ ability to adequately prepare practitioners for paediatric practice. Survey data also suggested several factors contributed to variability in educational experiences and subsequent preparedness of paediatric occupational therapists. The variability in paediatric education across programs and countries, including numerous entry levels to the profession, may be a contributing factor.
Future research should review and compare paediatric curriculum within diploma and bachelor-level programs. The WFOT (2021) Education Survey reported 17% of their respondents had a diploma-level entry to the profession, which is similar to this study’s response of 14%. Knowing WFOT is advocating for occupational therapy diploma programs to transition to a bachelor’s degree, creates a unique window of opportunity to examine the academic content within the programs. Further exploration of academic content not only allows for a review of the relevance of the content but also the amount of education dedicated to specific practice areas to reflect practice trends. This sentiment matches the previous findings in the UK where the researchers express their concern that “it is important for universities to review and update curricula regularly and to dedicate resources appropriately to curricula strands such as paediatrics” (Brown et al., 2005, p. 463).
Limitations
This study had a small sample size for both surveys. The information provided by the academic programs regarding the percentage of therapists working in paediatrics may be subjective.
Practical implications
Results from this study indicate there is significant variability in the paediatric education provided by occupational therapy programs worldwide and a need for academic programs to review the percentage of content dedicated to paediatrics to reflect current practice trends. Given the high percentage of occupational therapists practicing in paediatrics with varying entry-levels to the profession and exposure to paediatric-specific content, ongoing paediatric professional development, mentorship programs and free continuing education opportunities should be explored and promoted. WFOT-approved programs with similar entry level degrees are recommended to work collaboratively to build a cohesive set of standards to promote unicity of paediatric education, considering the diverse and worldwide variability of practice.
Conclusion
This study found the total percentage of academic curriculum specific to paediatric content was on average five percent. There is great variability across WFOT-approved programs in the number of both classroom and clinical hours dedicated to paediatrics. Many occupational therapy clinicians working in the paediatric setting have different entry-level requirements, practical training and specific educational content to prepare them for the field of paediatrics. This study highlights the need for ongoing research on the content within the paediatric curriculum and an effort to unify the education provided. This will ensure educational programs are meeting the evolving needs of the profession and the populations they serve on a global scale. With the majority of respondents working in paediatrics, occupational therapy programs are recommended to review the percentage of curriculum dedicated to paediatrics to stay up to date with practice trends to adequately prepare entry-level clinicians. There is also a need for paediatric-specific continuing education and training, as well as mentorship to bridge the current gap between professionals. Working towards achieving more consistency in global standards can ultimately improve the outcomes and quality of care for patients.
References
Appendix 1. Global survey on paediatric education in WFOT-approved programs
By completing this survey, I understand that this survey is anonymous, and completion is voluntary.
This study is being conducted by Kate Barlow, OTD (USA), Marinela Rata, PhD, OT/PT (Romania), Liliya Todorova, PhD, OT (Bulgaria), Petya Mincheva, PhD, OT/PT (Bulgaria), Said Nafai, OTD (Morocco/USA) and Allyson Bates, OTD (UK/USA).
The purpose of the study is to learn more about paediatric education in occupational therapy programs around the world. We are inquiring how many hours are provided in paediatric therapy in each program across all WFOT-approved programs. Our long-term objective is to provide free continuing education in paediatrics. Please complete the 5-question, online survey through the link below, we would greatly appreciate it.
This study was approved by the American International College Institutional Review Board. You are being asked to take part in this study by completing the following online survey. You will be asked a series of questions pertaining to education in paediatric occupational therapy.
Your participation will take approximately 10–15 min. Please be aware that you are not required to participate in this research and you may discontinue your participation at any time without penalty. You may also omit any questions you prefer not to answer. The possible risks associated with participation in this study are minimal; however, you may feel uncomfortable answering questions pertaining to your educational practices. Your responses will be provided confidentiality to protect your privacy. Your name will not be used in any reports of this research and will not be associated with any of your answers.
If you should experience any discomfort or have any questions or concerns related to your study participation, and/or would like to be informed of the results when the study is completed, please feel free to contact the study’s principal investigator, Dr Kate Barlow at Kate.Barlow@aic.edu.
If you agree to voluntarily participate in this research project as described, please indicate your agreement below. If you select yes, you will be directed to the survey. Please print a copy of this consent form now for your reference, and thank you for your consideration.
Do you volunteer to take part in this research study?
Yes, I volunteer.
No, I do not volunteer.
Program Country: __________________
What is the entry level to the profession, to work as an OT?
How many hours in your OT program in total?
How many contact hours specific to paediatrics are spent in classrooms in total?
How many hours specific to paediatrics are spent in fieldwork/internship/clinical placement in total? (This includes all observation and hands-on clinical experiences).
If available, what is the percentage of occupational therapists working in the paediatrics field in your country?
Appendix 2. Clinician survey on pediatric education in WFOT-approved programs
By completing this survey, I understand that this survey is anonymous, and completion is volunteer.
This study is being conducted by Kate Barlow, OTD (USA), Marinela Rata, PhD, OT/PT (Romania), Liliya Todorova, PhD, OT (Bulgaria), Petya Mincheva, PhD, OT/PT (Bulgaria), Said Nafai, OTD (Morocco/USA) and Allyson Bates, OTD (UK/USA).
The purpose of the study is to learn more about pediatric education in occupational therapy programs around the world. We are inquiring how many hours are provided in pediatric therapy in each program across all WFOT-approved programs. Our long-term objective is to provide free continuing education in pediatrics. If you could please complete the 9-question, online survey through the link below, we would greatly appreciate it.
This study was approved by the American International College Institutional Review Board. You are being asked to take part in this study by completing the following online survey. You will be asked a series of questions pertaining to education in pediatric occupational therapy.
Your participation will take approximately 10–15 min. Please be aware that you are not required to participate in this research and you may discontinue your participation at any time without penalty. You may also omit any questions you prefer not to answer. The possible risks associated with participation in this study are minimal; however, you may feel uncomfortable answering questions pertaining to your educational history and practices. Your responses will be provided confidentiality to protect your privacy. Your name will not be used in any reports of this research and will not be associated with any of your answers.
If you should experience any discomfort or have any questions or concerns related to your study participation, and/or would like to be informed of the results when the study is completed, please feel free to contact the study’s principal investigator, Dr Kate Barlow at Kate.Barlow@aic.edu.
If you agree to voluntarily participate in this research project as described, please indicate your agreement below. If you select yes, you will be directed to the survey. Please print a copy of this consent form now for your reference, and thank you for your consideration:
Do you volunteer to take part in this study?
Country you earned your OT Degree (first degree that permitted you to practice OT):
What year did you start practicing as an OT? (The year in which all school and clinician requirements completed).
What is your highest earned degree?
Do you professionally work in pediatrics as an OT?
Approximately how many contact classroom hours in pediatrics did you complete in your OT training? (Please write in the hours below. This information can often be found in your school's course curriculum. If you do not know or the information is unavailable, please state unknown).
Approximately how many fieldwork/internship/clinical placement hours in pediatrics did you complete during your OT training? (This includes all observation and hands-on experiences). Please write in the hours below. This information is often found in your school's course curriculum. If you do not know or the information is unavailable, please state unknown).
How satisfied are you with your pediatric training from your academic setting (including clinical and classroom opportunities in your degree)?
If you were to receive any additional training in pediatrics, please rank in order which area you would like training in?
If you are interested in participating in further OT research or free continuing education in the area of pediatrics, please provide your name and email address. This information will be removed from the survey before analysis.
