Occupational therapy productions in times of pandemic: a systematic review of occupational therapeutic actions against the new coronavirus (COVID-19) epidemic

Introduction

The coronavirus disease 2019 (COVID-19) pandemic, caused by the SARS-CoV-2 virus, impacts the daily lives of people, families and communities, as well as having an emergency impact on public health worldwide. In view of this, challenges arise for the multidisciplinary teams working on the front line to fight the virus, to adopt patient-centered approaches and care during the acute phase of the disease and after-care¹.

COVID-19 spreads through contact with droplets on contaminated surfaces followed by direct contact with eyes, nose or mouth. The main symptoms of the disease are high temperature, continuous cough, and loss or change to sense of smell or taste². Emergency measures have been adopted to slow down the contagion curve and prevent health systems from being overloaded. Social distancing has been the main measure used to reduce the spread of the virus; however, social distance and isolation has had a negative impact on people's daily lives².

According to the World Federation of Occupational Therapists³, there are several changes to and consequences of the way people perform their occupations in times of isolation, including access to resources in terms of activities of daily living (ADLs), mobility, communication, social interaction and well-being. The COVID-19 pandemic has had a devastating impact on the occupations of millions of people around the world. In this sense, occupational therapy, as part of the multidisciplinary team on the front line to face the crisis, presents itself as a fundamental specialty in reducing the repercussions of symptoms, hospitalization and social isolation⁴.

Throughout history, occupational therapy has been important when dealing with social emergency scenarios, starting after the first world war, when thousands of people had physical and / or mental disabilities. In the current situation, all knowledge accumulated over the years must be accessed, mainly because in the beginning of the pandemic, health professionals did not know which strategies would be better for treating the symptoms and consequences of COVID-19. It is worth noting that occupational therapists use evidence-based practices to ensure effective treatment and improve the quality of life of their patients⁵.

Following this, the aim of this article was to perform a systematic review of scientific publications that make reference to occupational therapy during the COVID-19 pandemic. This was in order to provide guidance for the clinical practice of occupational therapy professionals and students.

Methods

Results and discussion

Of an initial 733 articles found, 44 were included in the analysis (Figure 1), of which 21 were in Portuguese, 19 in English and two in Spanish. These were categorized into three categories, being scientific articles in journals (19), performance guides (18) and technical notes published by entities representing occupational therapy (7) (Figure 1). The 19 scientific articles were divided into experience reports and original articles.

Figure 1. Research flowchart as recommended by PRISMA.

The 18 performance guides found were produced by associations and official entities of occupational therapy around the world. They address guidelines for the performance and operation of occupational therapy services during the pandemic. The main texts found were from the American Occupational Therapy Association (AOTA).

The technical notes found are responsible for clarifying doubts of occupational therapists in matters regarding COVID-19. They aim at being a quick communication channel between representative entities and professionals, in addition to demonstrating their position on governmental decisions.

The articles were separated into five thematic axes, namely: guidelines for occupational therapy services; quality of life during isolation; telehealth; social context; and possibilities of occupational therapy.

The publications of the guidelines for occupational therapy services (Table 1) have an important documentary role in assisting therapists in understanding measures to deal with the pandemic, addressing the main strategies implemented to treat the symptoms and consequences of COVID-19. The publications on occupational therapy are also important to stimulate reflections and decision making of professionals about the consequences of COVID-19 and social isolation in carrying out daily activities. From this theoretical framework, the concern of the representative entities is to provide information to offer several possibilities of how professionals should perform hospital, outpatient and home care for the treatment of the physical and psychological health of people with COVID-19.

Occupational therapy aims to weave support networks in the fight against COVID-19 that go beyond the hospital context in order to achieve balance and occupational justice in a harmonious way that promotes social and family satisfaction, and reduces stressful environments that provide panic, anxiety, and other distressing emotions. The current scenario offers occupational therapists the opportunity to contribute their knowledge through governmental and non-governmental programs that aim to mitigate the side effects of social isolation that directly affect people's occupational performance⁷.

Regarding quality of life (Table 2), the studies found show the negative effects of the routine change in the subjects' lives, mainly due to the abrupt break and modification in their daily routine. This shows the need for reflection on and adaptation of habits to prevent social isolation. The English-language texts address aspects such as low quality of life due to decreased income, lack of sleep and unstructured routine. The authors allow us to observe financial losses, which part of the population are facing, as well as repercussions on mental health, work activities and physical health. Guidelines and reflections about a quality routine are the main points addressed which may help populations that are experiencing occupational disorders. The main suggestions for enhancing quality of life focus on structuring a good routine, including personal care, home care, work (in person or online), leisure activities, exercise, developing new hobbies, and receiving psychological support with professionals online. There is an emphasis on structuring a routine with schedules, pleasurable activities, exercise and home maintenance, for physical, mental and emotional health.

The articles in Portuguese deal with the issue of quality of life and isolation, emphasizing issues such as the professional identity of occupational therapists regarding their role in the pandemic, and discuss different isolation processes that may vary according to socioeconomic class and other contextual factors. They also point out the challenges of the academic community in developing strategies to continue undergraduate teaching of occupational therapy, in addition to providing psychosocial support to students.

The construction of the thematic axis of quality of life during isolation, made it possible to reaffirm the competence of the occupational therapist in identifying impairments in patient independence, setting treatment goals, increasing autonomy and performance capacities in the activities of daily life⁸.

Finally, the articles compile actions taken by occupational therapists in order to promote a better quality of life during social isolation, such as reorganizing daily routine, promoting self-care, and providing support networks to help maintain mental and physical health.

Given the high degree of infection by COVID-19, telehealth, which is shown in Table 3, was one of the main strategies adopted to continue remote treatments to guarantee the safety of professionals and patients. The Canadian Association Of Occupational Therapy defines telehealth as the provision of health services through telecommunications, which may vary according to the user's skills⁹.

The articles addressing this theme involved occupational therapists’ reflections on the introduction of telehealth in their practice. When using remote means of communication, therapists need to improve their skills in order to identify patient needs in distant care. This might be achieved by the therapist paying greater attention to the tone of the patient's voice and their way of communicating for example. The use of telehealth in occupational therapy impacts the way therapists interact with their patients for appointments regarding a range of issues including mental health, hand and upper limb therapy, group therapy, the use of sensory diet as a form of intervention, and assessing elderly people with cancer.

The advantages of telehealth have the potential to optimize the time and costs of services, the possibility of expanding the reach of the health team in remote areas and the increased potential for rehabilitation. In addition to being more practical for the patient, call centers enables the care and monitoring of a greater number of patients. Telehealth could also be used in an educational program through daily dialogues that expand the understanding of patient’s health conditions and encourage them to make changes in their lives to make them healthier and more independent³⁶.

The articles in Table 4 show occupational therapy actions in the social context, pointing out the inequalities observed in vulnerable populations in coping with COVID-19 due to the pre-existence of disadvantages in social and economic factors³⁷.

One of the groups cited is the LGBTQIA+ community. This community has faced daily situations of stigma, prejudice, social isolation, and increased mental health problems, due to the interruption of support groups and therapy aimed at mental health during the COVID-19 pandemic³⁸. People living in the suburbs and with low incomes are also more affected, due to the lack of resources to obtain individual protective items and hand and object hygiene³⁹. Many people have lost their jobs during the pandemic, which has compromised the basic livelihood of many families³⁹. Also highlighted are the elderly, who are at risk of having severe symptoms and requiring hospitalisation. Although they are in this high risk group, many elderly people in Brazil have not obeyed the isolation guidelines and have continued to frequent places with crowds of people during the pandemic, such as markets and shopping centers³⁹.

The study by Pereira et al.⁴⁰ describes a strategy created by students and professionals in occupational therapy during the pandemic, which aimed to provide social support for these groups, not only in this moment of social isolation, but also for after the pandemic. This involved socio-educational support for children and youth in communities via distance learning, promoting the strengthening of socio-community ties and assisting the organization of collecting and donating basic supplies to poor communities in various regions of Brazil.

For possibilities of occupational therapy during the pandemic (Table 5), 12 papers were found divided into scientific articles, performance guides and technical notes that discuss mental health, assistive technology, hospital care, primary health care, worker health, and rehabilitation, written in all three languages.

Primarily, articles that dealt with hospital care included strategies that are being applied in the institutions, including training for the correct use of personal protective equipment (PPE), remote work strategies, reorganization of the units, individualized care, interventions with the patient’s family, priority screening and construction of informative booklets on the disease and protective measures for non-contamination. Some papers provided resources more directed to care in bed, such as postural information, how to communicate during therapy, and attention to clinical conditions, especially the respiratory system¹.

With regard to mental health, contents were found that dealt with the impact of the pandemic and social isolation in particular. Some articles commented on changes in the mental health of professionals who are on the front lines. These studies pointed out ways to support health professionals since many of them have had to leave their homes and isolate themselves to avoid contaminating their families. In addition there has been an intensification in working hours due to the very high demand for health services worldwide for a small number of professionals on the front line. These variables were observed as potentially stressful factors for professionals⁴¹.

The assistive technology addressed in the publications refers to adaptations in the masks and respirators used to prevent the spread of COVID-19, focusing on the low cost and availability of equipment, guaranteeing the population's access to these tools². As far as rehabilitation is concerned, the action guide found seeks to guide occupational therapy for patients discharged from the ICU after infection, prioritizing sequelae in the respiratory and musculoskeletal system that can affect occupational performance. The guide was based on the Person-Environment-Occupation (PEO) model to promote better patient follow-up and rehabilitation⁴².

As for the performance of professionals in primary health care, the study by Falcão, et al. carried out remote work at a family health unit (USF) and at a family health support center (NASF) with the objective of continuing the monitoring of mildly symptomatic patients. Health education groups, assessment and guidance in carrying out ADLs, and monitoring of mental health were created. In remote service, through the internet, they carried out environmental organization, listening and solving problems that patients reported, assistance in triage, urgency classification and order of care, including emergencies due to mental illness⁴³.

The article by Barroso et al. discusses the teaching of occupational therapy students and reflects on the safety and health of workers during the pandemic period, addressing issues regarding legislation and worker rights. Work is considered a potential source of spreading the virus due to workplaces often not providing self-protection resources, such as protective masks, gloves and alcohol gel. There are also often shifts with large numbers of workers and inadequate distance between staff. In addition, many workers use public transport to get to work, and this is also a potential source of contagion. Therefore, for workers to guarantee their rights in having protection against catching COVID-19 at work, it is necessary to discuss the regulations and organizational measures of each active job, according to its level of exposure, thus guaranteeing the safety of workers⁴⁴.

Since this review searched for papers in three languages, the number of papers found was small compared to the initial expectation of the study. This can be considered a negative and aggravating point for the recognition of the profession, since occupational therapists are part of the essential team on the front line of the COVID-19 pandemic. Studies about the work and contributions of occupational therapy for the affected public are of great use to support discussions, and enable students and professionals to access information about what actions can be taken by therapists, as well as drawing attention to the profession, which as shown in this review, is important in the face of health emergencies.

Conclusion

This review found that both professionals and professional associations showed the concern to report and scientifically disseminate the experiences and guidelines of occupational therapists during the COVID-19 pandemic. The resulting 44 papers demonstrate the quick response of the profession to the challenges and barriers that have been imposed during this time, promoting scientifically based strategies to provide the best assistance to patients within the pandemic. The contributions addressed include positioning in bed, the humanization of care, and the restructuring of a daily routine after recovery of the infected person or just for those who are at home due to social distancing measures.

There were some limitations of the review such as the low number of papers found, the high concentration of papers from magazines and specific organizations, as well as the lack of preparation and visibility of the profession in public health emergency contexts. Further, this review had structural limitations due to the lack of qualitative and quantitative analysis. These analyses were not done due to the types of study included (technical notes, performance guides and reflection articles) which do not work for meta-analysis or qualitative evaluation. Another limitation is that we did not see any risk of bias, due to the lack of qualitative and quantitative analyses. Finally, the search time was short; we are aware that there was an accelerated production of new articles published after the end of the survey carried out by the authors.

We believe that this review serves as a basis for further research in this area, instigating students, researchers, professionals and other agents of occupational therapy to produce and discuss the profession's practices in public health emergencies with a focus on infectious agents like COVID-19.

Data availability

All data underlying the results are available as part of the article and no additional source data are required.