Abstract
Results of this survey research quantify limitations in the participation of occupational therapists and occupational therapy students and the relationship of occupation to social determinants of health.
Occupations are based on and related to social structures and access to the means of participation, so human occupation could be said to be inherently political (Pollard et al., 2008). Moreover, occupational therapy consists of a citizenship exercise whose aim is to create citizens who integrate into society (Guajardo Córdoba & Galheigo, 2015). In this way, occupational therapists become political agents who contribute to transforming people’s lives (García Ruiz, 2016).
According to Carrasco and Olivares (2008), occupation is the result of a dynamic interaction with the environment. Therefore, the meaning that each person gives to occupations is influenced by social criteria (Gomez Lillo, 2003). According to Vélez et al. (2014), the “the circumstances in which people are born, grow up, live, work and grow old, including the health care system” become particularly relevant in relation to social determinants of health, and “these circumstances are the result of distribution of wealth, power and resources on a global, national and local level, which in turn depend on the policies adopted” (p. 53). Occupational therapy professionals should take into account that the social determinants of health answer to the social reality: Participation and social conditions have an effect on health (Vélez et al., 2014).
The global social reality that emerged from the coronavirus disease 2019 (COVID-19) pandemic was one in which governments worldwide were forced to implement measures that affected people’s daily life and occupations. On March 11, 2020, the World Health Organization (WHO) made a plea to governments, asking them to take measures to avoid the spread of the virus and an increase in infections. Countries then began to adopt lockdown measures, the general premise of which was to remain at home and go out only for essential activities. These measures caused occupational changes that affected the routines and roles of people the world over. In the social reality of lockdown, social distancing, and restricted participation, people experienced difficulties or changes in cognition, mobility, self-care, interactions with other people, life activities, and participation, regardless of their health status. In this sense, the measures adopted to mitigate COVID-19 directly affected the social determinants of health of the world’s population.
The International Classification of Functioning, Disability and Health (ICF; WHO, 2001) makes it possible to know or predict contextual and functional factors that prevent participation in activities and how, at times, disability is created by conditions established by the environment and context. The ICF supplies the ideal framework through which to analyze the interaction between a person’s health status and the context in which that person gets along in all areas of their life (Ayuso-Mateos et al., 2006). The ICF, and specifically the WHO Disability Assessment Schedule (WHODAS) 2.0 questionnaire (Üstün et al., 2010), is therefore particularly suited to the unique context of a pandemic. The latter assesses the difficulty of participation in a culturally sensitive manner and is therefore one of the best instruments for an in-depth analysis of the limitations in participation faced by occupational therapists and occupational therapy students during the COVID-19 crisis, regardless of their country of residence.
Because the ICF is the model that is usually used by governments for national legislation on health and health-related conditions (WHO, 2001), the main objective of this study was to explore the limitations of functioning, focusing specifically on participation as experienced by occupational therapists and occupational therapy students as a consequence of the lockdown measures. A parallel objective was to investigate whether these limitations were related to the social determinants of health.
Method
Design
We conducted a cross-sectional, descriptive study by means of a questionnaire consisting of two sections. The first section contained 17 items designed to obtain information about respondents’ sociodemographic profile and any changes that affected their routine during lockdown. Items 21 and 25 are particularly relevant. (Note that numbering corresponds to that given by Google Forms; there were jumps in questions depending on the answer given to a question.)
Item 21 asked respondents how socioeconomic, cultural, environmental, and employment conditions, as well as lifestyle and social and community networks, had been affected by lockdown measures. Specifically, Item 21 contained six questions about socioeconomic conditions (e.g., decent housing or access to goods and services), cultural conditions (e.g., daily habits, routine, or religious beliefs), environmental conditions (e.g., housing, urban environment, or mobility), working conditions (e.g., workplace environment, demands, or salary), lifestyles (e.g., habits and personal decisions), and social and community networks (e.g., attending a meeting or a party or chatting with friends).
Item 25 asked respondents the extent to which they agreed with the following statements: “The lack of occupation negatively affects health,” “Lockdown has negative repercussions on health,” “I am concerned about my financial status,” “I can perform all occupations that make me feel good,” and “I have decision-making capacity over the activities I wish to perform.” Respondents rated all questions on a 5-point Likert-type scale that ranged from 1 (does not affect or strongly disagree) to 5 (strongly affects or strongly agree). Items 21 and 25 were based on both the components of social determinants of health and the history and evolution of the occupational therapy profession and the science of occupation (De la Torre-Ugarte-Guanilo & Oyola-García, 2014; Wilcock, 2007).
The second part of the questionnaire consisted of the WHODAS 2.0. We used the 36-item version, which has a Cronbach’s α value of >.94, with scores generally >.93, and an intraclass coefficient correlation of .98 (Paniagua, 2017). The WHODAS 2.0 contains two disability dimensions defined in the ICF, covering six domains: (1) cognition (understanding and communication), (2) mobility (moving and getting around), (3) self-care (attending to one’s hygiene, dressing, eating, and staying alone), (4) getting along (interacting with other people), (5) life activities (domestic responsibilities, leisure, work and school), and (6) participation (joining in community activities, participating in society). Disability summary scores were computed using the algorithm developed by WHO that weights items and provides a standardized summary score for each domain that ranges between 0 (least difficulty) and 100 (most difficulty), with higher scores indicating greater severity of disability (0–4 = no difficulty, 5–24 = mild difficulty, 25–49 = moderate difficulty, 50–95 = severe difficulty, 96–100 = extreme difficulty).
Participants
Participants were recruited using chain referral or snowball sampling. The questionnaire was sent to 57 occupational therapy bodies (professional associations, occupational therapy organizations, and universities), who were asked to distribute it to their members. Five declined. Although the remainder did not fully confirm that they had distributed the questionnaire, the participants’ nationalities confirm that it was widely disseminated. The inclusion criteria required respondents to be occupational therapy students or practitioners who freely agreed to answer all the items in the questionnaire. Those who did not have an occupational therapy qualification or who were not studying to obtain one in 2019–2020 were excluded.
Four hundred ninety-three people accessed the questionnaire, and 488 agreed to participate. Of these, 447 were female and 41 were male; 31 different nationalities were represented. Spain (n = 304) and Chile (n = 74) had the largest number of participants. Participants’ mean age was 29.7 yr (SD = 10). Table 1 shows the sociodemographic profile of participants.
Sociodemographic Profile of Participants (N = 488)
Note. COVID-19 = coronavirus disease 2019; OT = occupational therapy/occupational therapist.
Procedure
The survey was prepared in three languages—English, Spanish, and Portuguese—using Google Forms and was distributed via email between April 10 and June 7, 2020, to 21 occupational therapy bodies, such as the European Network of Occupational Therapy in Higher Education, the Consejo General de Colegios Profesionales de Terapeutas Ocupacionales de España (General Council of Occupational Therapy Professional Associations in Spain), and the Asociación Española de Estudiantes de Terapia Ocupacional (Spanish Association of Students of Occupational Therapy). Of all 21 contacted, 8 confirmed that they had distributed the survey to their members and 4 declined to participate because of internal organizational issues. The survey was also published and shared on social media: Twitter, Facebook, Instagram, and LinkedIn.
The survey was self-administered and required approximately 15 min to complete. The procedure to be followed when filling in the survey satisfied the parameters listed in the Declaration of Helsinki and did not include procedures that could affect participants’ physical or moral integrity. Moreover, the anonymous processing of data was guaranteed, according to the Spanish Data Protection Act and Guarantee of Digital Rights (Organic Law 3/2018 of 5 December). This study was authorized by the Ethics Committee for Research on Medicinal Products of the Principality of Asturias (No. 2020.203). Before starting the survey, an item asked participants whether they freely agreed to participate in the study; participants had to answer “yes” to access the questionnaire.
Results
Table 2 shows the results for the WHODAS 2.0 questionnaire. Overall, moderate difficulty in functioning was found, as reflected by the overall WHODAS global score without questions about paid work (M = 26.02, SD = 14.29). For the WHODAS domains, moderate limitations were observed in the getting along domain (M = 33.95, SD = 23.87), followed by the life activities domain (M = 28.18, SD = 24.29), specifically for the questions associated with work and school (M = 37.89, SD = 27.09). Similar difficulties were observed in the domains of cognition (M = 27.93, SD = 17.91) and participation (M = 27.54, SD = 18.10). The self-care domain reflected the least difficulties (M = 10.49, SD = 14.07).
WHODAS 2.0 Summary Scores by Domain (N = 488)
Note. WHODAS 2.0 = World Health Organization Disability Assessment Schedule 2.0.
In this study, reliability (Cronbach’s α) for the whole WHODAS 2.0 was .92. Scores <.70 were observed for the domains of self-care (α = .54) and getting along (α = .61). Welch’s t tests showed significant differences in global WHODAS 2.0 scores, t(486) = −2.34, p = .02, d = −0.30, 95% confidence interval (CI) [−0.63, 0.02], between men (M = 22.03, SD = 11.10) and women (M = 26.39, SD = 14.50), with women’s global scores in the moderate limitation range and men scores in the mild difficulty range.
Regarding the differences between continents, we analyzed only the differences between Europe and South America because they were the groups with a significant number of participants. Welch’s t test again showed significant differences, t(156.27) = 3.33, p < .01, d = 0.38, 95% CI [−0.15, 0.60], with South American participants scoring higher (M = 30.26, SD = 14.60) than European participants (M = 24.90, SD = 14.02).
With regard to the items associated with how lockdown measures affected different aspects of daily life (Table 3), participants reported a mean influence of 3.35 (SD = 1.43) for socioeconomic conditions, 3.91 (SD = 1.14) for cultural conditions, 3.73 (SD = 1.28) for environmental conditions, 4.01 (SD = 1.27) for working conditions, 4.00 (SD = 1.12) for lifestyle, and 4.08 (SD = 1.19) for social–community network. The influence on daily life varied depending on the respondent’s place of residence, with participants in South America reporting the greatest difficulties.
Descriptive Results for Items 21 and 25 for the Entire Sample and as a Function of Continent (N = 486)
Note. ns = nonsignificant.
For the item “the lack of occupation negatively affects health,” the mean score was 4.79 (SD = 0.59); for “lockdown has negative repercussions on health,” it was 4.42 (SD = 0.82); and for concern about financial status, it was 3.33 (SD = 1.37). Moreover, the mean score for performing all occupations that made them feel good was 2.49 (SD = 1.15), and for decision-making capacity over the activities they wanted to perform, it was 3.20 (SD = 1.22).
Mean differences were analyzed using Welch’s t tests because the comparison groups had unequal variances and unequal sample sizes. Cohen’s d was used as the effect size for the differences. Spearman’s rank correlation coefficient was used to analyze the relationships between variables.
As shown in Table 3, significant differences were observed between continents, with North and South American participants indicating more effects than European participants for the questions regarding socioeconomic conditions, t(152.04) = −2.59, p = .01, d = 0.30, 95% CI [0.08, 0.52], and fear about the economic consequences of the pandemic (i.e., participant’s economic situation, loss of income), t(179.17) = 6.06, p < .001, d = 0.63, 95% CI [0.39, 0.86]. In contrast, South American participants indicated that they had more decision-making capacity over activities to perform than European participants, t(157.16) = 2.79, p < .01, d = 0.32, 95% CI [0.09, 0.54].
Finally, we carried out a correlational analysis to explore the relationship between the intensity of the perceived effects of lockdown and limitations in functioning in the six WHODAS domains (Figure 1). Globally, significant correlation coefficients were low (≤.30), denoting small strength of association between the studied variables. Nevertheless, the pattern of correlations was interesting.
Correlogram representing Spearman’s rank correlation coefficients among Items 21 and 25 (perceived effects of lockdown and statements regarding health and occupation) and WHODAS 2.0 domain and global scores.
First, the lockdown’s perceived effects on cultural (rs = .20, p < .001), environmental (rs = .22, p < .001), and lifestyle (rs = .20, p < .001) conditions, as well as concerns about financial status (rs = .24, p < .001), showed small positive relationships with the WHODAS 2.0 global score. In addition, small negative correlations were observed for items that assessed the ability to perform occupations (rs = −.21, p < .001) that lead to well-being and the ability to make decisions (rs = −.23, p < .001) about the activities to be performed, denoting an interesting link between impairment in functioning and limitations on occupational decisions imposed by the coronavirus lockdown. It is noteworthy that these correlations were also specifically observed for the participation domain.
Second, specific difficulties in the cognition domain showed small positive correlations with the lockdown’s perceived effects on cultural (rs = .18, p < .01) and lifestyle conditions (rs = .20, p < .001) and also with concerns about one’s health (rs = .16, p < .05) and financial status (rs = .30, p < .001). The latter is also related to other domains such as life activities at home or work and participation.
Finally, we observed a consistent, small negative relationship between the restricted ability to make decisions about activities to be performed and most of the WHODAS domains (excluding self-care): cognition (rs = −.16, p < .05), mobility (rs = −.16, p < .05), getting along (rs = −.20, p < .01), life activities (rs = −.17, p < .05), life activities–work (rs = −.18, p < .001), and participation (rs = −.23, p < .001).
Discussion
Lockdown measures have forced people to change their ways of life, roles, and routines. This occupational disruption has to a greater or a lesser extent changed the occupational balance for people all over the world (Mynard, 2020). Therefore, quantifying how lockdown has affected people’s daily lives is useful to occupational therapy practitioners in promoting people’s well-being using methods and techniques that help them to feel purpose and significance through participation in occupations (Hammell, 2020) and enabling them to start rebuilding their lives.
Our results show that all participants felt some kind of restriction in participation during lockdown. Although the greatest difficulties arose in the getting along domain (M score = 33.95), the difficulties experienced in the life activities domain are significant when one looks at the items related life activities–work and study (M score = 37.89). These work-related limitations may also explain the results obtained for items related to respondents’ financial concerns. These results also coincide with those of Terry-Jordán et al. (2020), who found that all essential workers suffered limitations in performing basic self-care activities. Moreover, the difficulties found in the participation and getting along domains are also related to the lack of occupation and limitations in performing leisure activities.
The relationships observed between the responses to the WHODAS 2.0 regarding difficulties in participation and those to the other questionnaire items emphasize the relationship between health and occupation and the effect of social determinants on health. One clear example observed in this study is the impact of the perceived effects of lockdown and concerns about health and financial status on the cognition domain. This result is consistent with those of previous studies that have found a relationship between lockdown and emotional or cognitive (dysexecutive) symptoms in healthy young adults (Lahiri et al., 2020) and also worsening mood among people with cognitive impairment (Barguilla et al., 2020).
This study also found small but significant differences in how participants from Europe and North and South America (mainly South America) perceived the impact of the lockdown on socioeconomic conditions, fear related to the economic consequences of the pandemic, and capacity to decide which activities to perform. Therefore, we agree with Arango Soler et al. (2013), who said that the occupational therapy profession shows particular characteristics depending on the economic, political, social, ideological, and cultural contexts in which it is performed.
We believe it is relevant to point out that although health care workers’ risk of getting COVID-19 is 3 times that of people in other professions (Barroso et al., 2020), in the case of the therapists and students surveyed, only 6.1% had been diagnosed with the disease; this result is similar to that of Arenas et al. (2020) in Spain, who found that only 9% of Spanish occupational therapists had contracted the disease. When interpreting the data, changes in work experienced by occupational therapists during the pandemic need to be taken into consideration because only 20% of respondents continued working as usual. In this sense, occupational therapy services in Spain, the country with the highest number of participants in this study, were gravely affected, with one-third of therapists being furloughed (Arenas et al., 2020).
Implications for Occupational Therapy Practice
This study has the following implications for occupational therapy practice: Macroeconomic policies have had repercussions on the occupation of all citizens, consequently affecting economic actors and welfare-state policies. COVID-19 has made vulnerable people even more vulnerable. Practitioners must not forget that occupational therapy must respond to the problems of society. As occupation professionals, occupational therapists should be a part of primary health care services to minimize the impact of both the disease itself and the repercussions of lockdown and the recommendation to stay at home that affect routines. The role of the occupational therapist in different social and health care resources can mitigate or neutralize the effects of the coronavirus and also help to prevent it through health promotion and commitment to and participation in occupations. Despite the multiple roles occupational therapists could play in the current pandemic, 17% (n = 83) of the respondents had stopped working as a result of it. The work setting with the highest prevalence of COVID-19 among respondents was geriatrics (n = 67), followed by neurological rehabilitation (n = 34). We should note that none of the participants indicated that they worked in the field of health care policies. Occupational therapists must take advantage of the emergency situation caused by COVID-19 to demonstrate the value of occupational therapy in responding to contextual factors that limit social participation.This study shows the repercussions that confinement had on occupational therapists and occupational therapy students, as well as the limitations placed on participation. Occupational therapy practitioners and students must not forget that, as the experts in this field, the profession aims to promote participation and occupational balance. It would be interesting to expand this study to look at the long-term repercussions of the pandemic on the health of occupational therapists and occupational therapy students. COVID norms to return to “normal” differ across countries and currently prevent such a comparison.
Conclusion
The lockdown measures adopted by different governments because of the COVID-19 pandemic have meant that for the first time in recent history, citizens across the globe have seen their participation in occupations restricted, regardless of their economic, social, cultural, or health status. This circumstance has caused changes in the way different occupations are performed, which has involved disrupting roles and routines. The state of emergency experienced by the world’s population during the pandemic, and the results of this study, can help the profession to place more value on occupation and strengthening occupational therapy interventions in public health.