A Western tool in a non-Western context: critically exploring the application of the Canadian Occupational Performance Measure in rural IndiaAbstract
Introduction As most occupational therapy tools have been developed in the Western world, there is a paucity of tools that are contextually relevant for non-Western settings. Tensions arise when engaging Western tools in non-Western settings. We encountered such tensions as employees and partners of an Indian non-governmental organization engaged in program evaluation and development of a community-based early intervention service for children.
Objectives In this article, we reflect on our experience of working to support local needs in the absence of contextually relevant tools through an examination of opportunities and challenges presented by use of the Canadian Occupational Performance Measure (COPM) in rural India.
Method To employ critical reflexivity to examine experiential and literature evidence pertaining to the use of this Western tool in an Indian (non-Western) context.
Results Numerous challenges were identified in the COPM’s fit to context. However, COPM use also facilitated beneficial team learning and achievement of program objectives.
Conclusion Countering Western hegemony in practice can be complex. A balance between such an objective and meeting organizational needs may be necessary in the short term while working toward impactful long-term development of contextually relevant practices.
Keywords:
Outcome Assessment; Critical Thinking; Western World; Social Environment
Resumo
Introdução Como a maioria das ferramentas de terapia ocupacional foi desenvolvida no mundo ocidental, há uma escassez de ferramentas que sejam contextualmente relevantes para ambientes não ocidentais. Surgem tensões quando se utilizam ferramentas ocidentais em ambientes não ocidentais. Encontramos tais tensões como funcionários e parceiros de uma organização não governamental indiana envolvida na avaliação de programas e no desenvolvimento de um serviço comunitário de intervenção precoce para crianças.
Objetivos Refletir sobre nossa experiência de trabalho para apoiar as necessidades locais na ausência de ferramentas contextualmente relevantes, por meio de uma análise das oportunidades e desafios apresentados pelo uso da Medida Canadense de Desempenho Ocupacional (COPM) na Índia rural.
Método Como uma equipe de parceiros indianos e canadenses, empregamos reflexividade crítica para examinar evidências empíricas e bibliográficas relativas ao uso dessa ferramenta ocidental em um contexto indiano (não ocidental).
Resultados Foram identificados inúmeros desafios na adequação da COPM ao contexto. No entanto, o uso da COPM também facilitou o aprendizado benéfico da equipe e o alcance dos objetivos do programa.
Conclusão Combater a hegemonia ocidental na prática pode ser complexo. Pode ser necessário um equilíbrio entre esse objetivo e o atendimento às necessidades organizacionais no curto prazo, enquanto se trabalha para o desenvolvimento impactante a longo prazo de práticas contextualmente relevantes.
Palavras-chave:
Avaliação de Resultados; Pensamento Crítico; Ocidente; Contexto Social
Introduction
There is growing recognition within occupational therapy of the Western underpinnings of most professional theories and tools, and the need to develop and value those that emerge from and are relevant to local contexts (Córdoba & Malfitano, 2023; Gretschel & Galvaan, 2017; Guajardo et al., 2015; Lim & Duque, 2011; Price & Pride, 2023; Pride et al., 2025; Simaan, 2021). Admittedly, such work takes time. Meanwhile, organizations have needs to support their clients in a timely, ethical manner with relevant, quality services. In this article, we critically engage with our experience as employees and partners of an Indian organization, Amar Seva Sangam (ASSA), that sought a family-centred assessment tool, and in finding none authored locally, opted to employ the Canadian Occupational Performance Measure (COPM) (Law et al., 2014).
Over the years, occupational therapy in India has had an increasing focus on biomedical approaches largely informed by Western medicine (Dsouza et al., 2017; Murthi, 2019; Lim & Duque, 2011) and Western models of occupational therapy practice (Lim & Duque, 2011; Murthi, 2019; Murthi & Hammell, 2020). There have been calls for occupational therapy in India to move beyond a biomedical focus and embrace a model of practice that would take into account specific cultural, social, and political forces, including caste and socio-economic factors (Benjamin-Thomas et al., 2021; Lim & Duque, 2011; Murthi, 2019; Murthi & Hammell, 2020; Dsouza et al., 2017). At present, there is a dearth of locally developed occupational therapy tools and measures in India, and in Asia as a whole, to support occupational therapists in providing culturally relevant care, although they are increasingly being developed (Lim & Duque, 2011; Murthi, 2019). There is precedent for the COPM being used in India (e.g., Angelin et al., 2021; Padankatti et al., 2011) and while several studies reported finding the COPM useful, there does not appear to have been much critical appraisal of the tool’s relevance to context. Murthi & Hammell (2018, 2020) have raised concerns that the occupational categories used in the COPM, self-care, productivity and leisure, may not resonate in India.
In this article, through examination of our experiences and relevant literature, we employ critical reflexivity to examine tensions, challenges, and benefits of employing a Western tool within a non-Western context. We question whether tools (such as the COPM) and practice concepts (such as family-centred practice) can be applied in the same way in every context and expose some of the power dynamics at play when such an idea is suggested. We make visible some of the complexities involved in applying a value of resisting Western hegemony in action and explore the idea that a tool can be both imperfect and helpful. Finally, we offer reflections on the power dynamics inherent in Global North/Global South partnerships and some of the pitfalls that may be encountered despite strong and collaborative working relationships.
Objectives
By reflecting on our experiences with the COPM at ASSA, we examine the issue of how to support local needs in the absence of contextually relevant tools. We offer insights that may be useful on both local and international levels, to inform program development at ASSA and broader understandings of tensions that may arise in the use of Western-authored tools in non-Western spaces.
Method
We (the authors) have all been involved with ASSA to varying degrees in one or more capacities of program management, service provider or researcher. Our authorship team includes a mix of Indian and Canadian professionals with experience in community-based rehabilitation.
During the implementation of COPM use at ASSA, challenges began being reported, described in further detail in the next section. In an effort to understand these challenges and how they were understood from the perspectives of families and service providers, an internal program evaluation involving interviews and focus groups was conducted (Campbell, 2019). To determine the best course forward, we, as program leaders and international partners, engaged critical reflexivity and participatory engagement with our own reflections and the key themes and findings of the program evaluation report.
The key topics identified in this report that required decisionmaker attention included: family-centred practice at ASSA, COPM scoring, the collection and use of COPM scores, COPM administration time requirements, who should administer the COPM, and training requirements (Campbell, 2019). These topics provided starting points for reflection and discussion over multiple team videoconference meetings. In addition to seeking perspectives from all involved in these meetings (authors on this manuscript) about how to resolve issues with COPM implementation on the ground, the first four authors led team engagement with three main critically reflexive questions addressing the broader meaning and implications of COPM use in this context: 1) How is the status quo played out when employing Western ideas in non-Western settings? 2) How can the imperative to resist Western hegemony be balanced with current/practical organizational needs? 3) How is critical reflexivity integrated within practice and partnerships of the non-governmental organization (NGO)? Following these team discussions, the first four authors met several times to refine and identify lessons stemming from these meetings, which were subsequently brought back to the larger team for discussion.
Engaging in critical reflexivity has been recommended as one way to facilitate contextually-relevant occupational therapy in India (Murthi, 2019). Reflexivity can be a means to mobilize practice transformation in a manner that is contextually relevant and ethical, while also creating opportunities for challenging the hegemonic status-quo (Dutta & de Souza, 2008). A critical theoretical perspective (Crotty, 1998) assists in this regard and supported us in deconstructing dominant and taken-for-granted assumptions and hegemonic ways of doing within cross-cultural rehabilitation practices. Ethics approval for the broader research project (Krishna et al., 2020), from which this article stems, was obtained from the Health Sciences Research Ethics Board, University of Toronto, Toronto, Canada (ref #34653) and the Research and Development Committee at Kalasalingam Academy of Research and Education, Madurai, India and covered the program evaluation report referenced above. It was also registered with an international clinical trial registry, ClinicalTrials.gov (NCT03202966). Ethical review for the team reflexive work of this paper was not required as those who participated are also authors on the paper.
Our story
The context for this experience report is a non-governmental organization (NGO), ASSA, in rural south India. ASSA’s work involves community-based rehabilitation, education, advocacy and vocational training for people with physical, developmental, communication, sensory, and cognitive impairments. Services are provided free of cost or subsidized depending on a person’s income. ASSA frequently collaborates with international funders and volunteers for programming support.
In 2017, ASSA received a grant to scale-up their Enabling Inclusion (EI®) program. This program endeavors to support children’s physical, cognitive, communication, social and emotional development; reduce caregiver burden and empower families; and increase inclusion and participation of disabled children within their families, schools, and communities. Additional information about this program and its evaluation can be found in Krishna et al. (2020) and Muthukaruppan et al. (2022).
In designing the EI® program’s scale-up, our team had to select outcome measures that would support service providers and families in identifying therapy goals and intervention plans as well as demonstrate program effectiveness to funders. Initially, the tools chosen focused primarily on quantitative assessment of developmental milestone achievement. Standardized tools measuring caregiver strain and family empowerment were added, and questionnaires concerning school enrollment, families’ beliefs about disability and childrearing, and service evaluation were developed.
Relying on standardized developmental outcome measures as program evaluation would tie program success to progress on all developmental milestones, which was unrealistic for many of the children enrolled in the program, such as those with spastic quadriplegia or autistic children who are non-speaking. Such assessments would not capture the effectiveness of the program’s inclusion and family support objectives. Further, staff were interested in making their program more family-centred by more intentionally collaborating with families and drawing on their knowledge and values to inform service (Krishna et al., 2020; Muthukaruppan et al., 2022). They sought a tool that would engage caregivers in setting priorities for their children’s therapy and monitoring progress on goal attainment over time.
After a literature search and consultation with service providers at ASSA and other organizations in India, we were unable to find an India-authored, family-centred tool for goal setting that would support quantitative program evaluation. Looking broader, the COPM was identified as a client-centered outcome measure used in 40 countries and translated into more than 35 languages (Canadian Occupational Performance Measure, 2025b). It provides structure that can support collaborative family-centred goal setting (Canadian Occupational Performance Measure, 2019). It had potential to capture goals related to occupational and environmental factors that were unlikely to be captured by other assessment tools. The COPM was deemed the best available tool for meeting the family-centred needs of the program and the evaluation requirements of funders. This took into consideration that ASSA did not have the time or capacity to develop their own tool, nor sufficient experience in using a family-centred tool in their context to know what elements it should contain. Following a promising pilot trial of the COPM, training was provided to service providers and the tool was used broadly across the program.
We initially planned to evaluate COPM use through an experimental research design, and began collecting and analysing quantitative data related to goals set through COPM use and associated performance and satisfaction scores. However, we determined the data was unreliable for analysis due to inconsistencies between scorers, and ongoing confusion among service providers about how the scoring should occur. We learned that many caregivers had difficulty coming up with priority issues to list in the COPM, as caregivers had rarely been previously asked for input about therapeutic outcomes. Recognizing this and social norms that might prompt caregivers to defer to the “expert” service providers, we lacked confidence that the goals documented entirely represented caregiver priorities. Additionally, the Canadian-trained occupational therapists on the team were following critical scholarship about the dominance of Western ideology and values in occupational therapy tools and theory. They became more hesitant about the appropriateness of the COPM for the ASSA context, knowing that it had been authored in Canada, a place different from India in terms of geography, climate, population, politics, culture, religion, and social norms. These revelations prompted us to abandon the experimental approach and engage in a team reflective process about COPM use in the ASSA context.
To inform this process, qualitative program evaluation was conducted, involving interviews and focus groups with ASSA staff and families involved in the program, the findings of which were summarized in an internal report (Campbell, 2019). This report shared many challenges and benefits associated with the use of the COPM at ASSA. We learned that those interviewed liked seeing progress on goals over time and that services were now more family-centred. Additionally, COPM use facilitated family education on expectations for therapy. At the same time, those interviewed acknowledged challenges as the COPM was not available in Tamil, questioned how useful it was with caregivers with lower formal literacy because they often had difficulty with the scoring system, and noted some challenges in adapting to some of the norms of the COPM. For instance, the shift to family-centred goal setting was new and uncomfortable for many caregivers and service providers. Other challenges identified included the time required for explaining the COPM to families, time required for training service providers and questions about how much the goals set were actually informing the therapeutic plan (Campbell, 2019).
Results
In the following, we present our reflections about: 1) COPM use at the NGO, and 2) how this experience informs the broader issue of using Western assessments in non-Western settings.
COPM use at ASSA
The answer of what to do with regards to the COPM at ASSA is not entirely clear to us, even now. We continue to discuss and debate whether to adapt the COPM for the ASSA context or to create our own tool. However, in considering how COPM use informs ASSA’s actions to adopt a family-centred tool, our reflections have led us to several key points of consideration, which are presented in the following paragraphs. Additionally, with a better understanding of family-centred practice in our context, we hope to network with other community-based rehabilitation programs in India that engage in family-centred goal setting. By working together, we will be better able to advance South India-specific approaches.
Points of agreement on lessons learned to date
We are pleased that COPM use supported an increased interest in family-centred care among service providers, initially in the EI® program and then spreading to other ASSA programs. Given the challenges noted in the program evaluation report, we agree that a simpler, more rapidly understood tool is required, which must be in the local language.
Points of debate and discussion
In this section, we discuss some of the ongoing uncertainties that we have about how to proceed with a family-centred goal setting tool in the ASSA context.
How can we Best Capture Family Priorities? We like encouraging caregivers to express what is important to them but recognize that within this specific context this was foreign, uncomfortable, or inaccessible to some. Caregivers might not all be comfortable sharing specific priorities with service providers if they perceive them to have higher social positioning; they may seek to please them rather than share personal concerns. It may, therefore, be challenging to design questions or an approach that taps into issues, barriers, and interests, as perceived by caregivers. If goal setting is not comfortable for caregivers, how much is it appropriate to push them into this role? Critical awareness of power dynamics at play, including those within local social norms, allowed us to question how pushing ahead with the COPM might reinforce these dynamics, rather than centring family voices as was the original intention. This led us to consider: What does a contextually relevant rural South Indian family-centred practice look like? How can it be represented in and supported by an assessment tool? Our ideas to facilitate goal setting include creating a card sorting activity, structured interview, and family education. Existing approaches in the right direction may include strengths-oriented caregiver interviews, the Kawa River Model (Iwama et al., 2009; K. Murthi, personal communication, February 18, 2019), and the Respect Model of Client-Centred Occupational Therapy, which attends to rights, capabilities, culture and context, as well as, importantly, relationships with the service provider (Hammell, 2013a).
Is a Numerical Rating Scale Helpful? Given the significant issues encountered with numerical rating scale data, we debate whether quantitatively measuring goal achievement is relevant, helpful, or realistic. We debate whether using words (e.g., happy/unhappy) or a visual rating scale would be more accessible for families who have faced barriers to accessing formal literacy. Could more concrete guidance for scoring (e.g., a checklist) be helpful? Given the newness of the shift to family-centred goal setting within the program, it may be enough to start with a focus on goals without scoring. The COPM may not be perceived as easy to administer in places where assumptions embedded within it (e.g., comfort with family-centred practice, use of numerical rating scales) are novel for either service providers or caregivers.
How Important is it to use a Recognized, Validated Tool? The COPM supported ASSA to demonstrate the importance of its holistic approach to funders and government. From the perspective of those among us who do organizational fundraising, use of a recognized tool can go a long way towards securing funding. Name and brand are important for credibility. In a country without a universal public health care system, accessing funds can be the difference between a child getting service or not. Grandisson et al. (2016) note that internationally recognized tools can help access funding and enable speaking a shared language with colleagues around the globe. On the other hand, the program managers among us who are involved in advocacy to government say that using a tool with “Canadian” in the name is not helpful as made-in-India is valued. Critical reflexivity on this point supported us in locating systems of power at play in our context, and to recognize differences in what they value. This highlights the complexity and challenge of harnessing power structures to benefit Global South partners.
Using Western tools in non-Western settings
The examination of our reflections on COPM use at ASSA led us to two key lessons with broader applicability about the use of Western tools in non-Western settings. Firstly, we came to understand that it can be possible to move toward meeting program objectives by using an imperfect tool, while simultaneously evaluating the tool and looking ahead toward the development of better alternatives (K. Whalley Hammell, personal communication, February 18, 2019). Unquestioningly employing the COPM at ASSA would have been problematic, as we found many aspects of it did not fit the context well. However, not employing it at all would have been a detriment to advancing the NGO’s objective to provide a more family-centred service, as service providers advanced their understanding of family-centred practice through use of the COPM. Until contextually relevant tools exist, a service still needs to be provided; families have immediate needs. Knowingly and reflexively using a tool that was not perfectly suited to the context enabled our team to meet some of these needs, advance program development, and support organizational change while fueling critical conversations and helping us imagine future possibilities for a contextually relevant tool. From an operational perspective, the introduction of the COPM supported an organizational shift towards family-centred goal setting, a key team goal from the outset. The COPM helped incorporate a shift to engaging caregivers in their child’s therapy and focusing attention on priorities beyond developmental milestone achievement. This supported the EI® program in being more holistic and inclusive, ensuring the program would benefit all children enrolled, especially those not anticipated to make significant milestone progression.
Use of the COPM gave the team experience with using an open-ended family-centred tool, something they had not previously had experience with. As such, the team now has ideas about what worked and what did not, enabling them to imagine alternatives that would better suit local needs, values, capacity, and context from a position of experience. In retrospect, trying to push for a locally authored tool at the outset would have required imagining an alternative to something we did not yet have experience with in this context, and as such, the team might have relied more heavily on Canadian partners’ input, potentially resulting in a tool not significantly better suited to the ASSA context than the COPM. The shift to a family-centred goal setting approach has been beneficial such that we feel delaying employment of a family-centred tool while one was being developed from scratch could have, on balance, been more harmful, with goals important to families continuing to be missed by existing assessments. Context-specific tools can evolve over time as long-term collaborative objectives; they may not always be evident or possible at the outset.
A second key finding involved reflecting deeply on the roles, limits, and responsibilities of Global North partners invited to support partners in the Global South. In conversations about adopting the COPM at ASSA, the Canadian-trained occupational therapists on the team were hesitant and critical of this plan, concerned about possible harms that could come from using a tool developed in a very different context. As these team members considered more carefully the very valid, immediate and tangible operational requirements of this organization, they began to wonder if they were now reproducing Western hegemony in new ways. Through critical reflection, they began to see that pushing to prevent use of the COPM at ASSA could risk obscuring local voices and priorities, and block the organization from meeting their needs. This would run counter to the Canadian-trained occupational therapist team members’ values of both allyship and organization-centred collaboration.
Recognizing that ASSA-based team members are working in a context of significant hierarchical norms, the Canadian-trained occupational therapists wondered if encouraging critical reflexivity and critique of prominent practice tools was, in itself, pushing Western values. However, with further reading and reflection, they recognized that it was the “pushing” part rather than the “critical reflexivity” part that was problematic. Critical approaches are promoted by many Indian scholars, including Murthi (2019), Dsouza (Dsouza et al., 2017), and Thomas (Benjamin-Thomas & Laliberte Rudman, 2018; Benjamin-Thomas et al., 2021). At the same time, Lim & Duque (2011) highlight the significant challenge facing Asian practitioners who are tasked with engaging in critical practice while continuing to function within hierarchical social structures and norms. The Canadian-trained occupational therapist team members became more keenly aware that it is a privilege for them to feel comfortable speaking openly and critically about a prominent practice tool. Such a privilege is not necessarily accessible or acceptable within all cultural norms, or in all contexts, remembering especially organizations in low-income settings that rely on fundraising and a strong public image to acquire resources for service provision. Working for change that differs from the status quo, including social, cultural or practice norms, requires time, energy, resources, support, and not insignificantly, a bit of bravery. Taking this into consideration points to the importance of Global North partners offering their perspectives in a framework of knowledge exchange while centring Global South team members’ perspectives and agency in decision making. Ultimately, like the need to consider the contextual relevance of Western tools, critical reflexivity must also be approached in a manner that is contextually relevant. Critical reflexivity, as practiced in contexts of the Global North, may contradict local practice and social norms in other contexts.
In essence, we arrived at all of these lessons through a sort of “double” critical analysis. Critical reflexivity initially led us to question the applicability of a Western tool in a non-Western context. Re-applying critical reflexivity to this first idea led us to identify harms that might come from a firm “resist the West at all costs” approach. This helped us to centre the needs of ASSA and families they work with, balanced with an awareness of the various social forces at play.
Discussion
The message of this paper is not one of diminishing the value of the COPM but one of acknowledging that one size will never fit everyone, no matter how open and adaptable a tool is. Nothing written by humans can be purely objective or devoid of the values that shaped it, especially when those humans live in and are shaped by societies that lead them to hold values, beliefs, priorities, and norms that are specific to context (Guajardo et al., 2015). As such, something written in one context cannot be expected to resonate in all other contexts, or to all people within a given context, keeping in mind that challenges such as those described in this paper might be encountered within both the Global North and Global South (Carswell et al., 2004; Fisher, 2005). It is important to note that the COPM website acknowledges some of the same limitations to COPM use in non-Western settings that were identified in our program evaluation and reflections (e.g., comfort with client-centred practice, numerical rating scale, etc.; Canadian Occupational Performance Measure, 2025a).
Additionally, the message is one of recognizing the power held by predominant Western tools (Hammell, 2013b; Simaan, 2021), and the complexity involved in introducing them in non-Western contexts. The occupational therapy profession has often unquestioningly assumed that core principles and tools of the profession, authored in the West, will apply across contexts (Hammell, 2013b; Jull & Giles, 2012; Beagan et al., 2025). This experience report reinforces how this assumption is problematic. At the same time, we have highlighted opportunities to take advantage of Western power systems for the benefit of non-Western settings. Use of a Western tool may open doors to resources and positive repute. In this way, a tool can be both imperfect and helpful.
Our reflections also show how easily Western hegemony can be reinforced when not reflected on critically. In the absence of contextually relevant tools, existing Western tools are easily drawn on. On the basis of their claims to universality, therapists may consider it justified to look no further, and miss opportunities to ground services in local knowledge and context.
Our experiences also offer concrete examples of how context influences the application of family-centred (or client-centred) practice. Western conceptions of autonomy that focus on independence, individualism and agency, promoted as a core element of client-centred practice, may not be valued or accessible to many people in the Global South (Gretschel & Galvaan, 2017; Murthi & Hammell, 2020). Murthi & Hammell (2020) identified that therapists cannot always assume that clients have access to choice in occupational engagement. This assumption, required for completion of the COPM as clients express what is important to them, may be true among populations where it is an accepted norm to guide a health professional with one’s needs as they see them, but may not always be so in India where hierarchical social structures and biomedical approaches to therapeutic care are a norm (Lim & Duque, 2011), and where gender (Murthi & Hammell, 2020) and socio-economic status (Murthi & Hammell, 2018) significantly shape occupational opportunities (Benjamin-Thomas et al., 2021). Like our experience, Angelin et al., (2021) and Swaminathan et al. (2014) also found some Indian clients were uncomfortable with client-centred practice and goal-setting. Gretschel & Galvaan (2017) advise employing conscious critique to determine if and how the principles of client-centred practice can be applied in the Global South. At minimum, they must be adapted for contextual relevance (Dsouza et al., 2017; Gretschel & Galvaan, 2017). We echo other scholars, such as Guajardo et al. (2015), who advocate for “an ecology of human occupation-based practices” (Kronenberg et al., 2011, as cited in Guajardo et al., 2015 p. 6), produced by and responsive to socially constructed realities in context. Occupational therapy will not be effective if done the same way everywhere.
Our experiences also highlight some of the complexity involved in therapists trained in the Global North considering how much and in what ways their education and resources are relevant to Global South contexts (Simaan, 2021). Ethical engagement can be supported by taking a critical allyship approach (Nixon, 2019), engaging critical occupational therapy praxis (Restall, 2024), and following tools intended for global health partnership work, such as the Working Group on Ethics Guidelines for Global Health Training (Crump et al., 2010). The importance of equitable and respectful relationships cannot be understated. With awareness of the inequitable power relations that are often present within Global North/Global South partnerships, effective collaboration in our setting required power sharing and trust to be able to exchange knowledge, values, priorities, and economic realities. Through this, greater mutual understanding was achieved, and new possibilities emerged.
Conclusion
Our experience demonstrates that approaches to resisting Western hegemony in practice require contextual relevance, nuance, relationships, and patience. The path toward such an objective may not be direct, and can benefit from critical reflexivity. In bringing an objective of resisting hegemony into practical application, our experience demonstrates how much there is to consider at the intersection where theoretical ideals (i.e., resisting hegemony) and practical organizational needs (i.e., meeting family needs in a timely manner) converge.
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References
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Correspondence
Corresponding author Zoé Campbell e-mail: zcamp081@uottawa.caSection editor
