Community Occupational Therapists' Competencies in Neurorehabilitation

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This entry is adapted from the peer-reviewed paper 10.3390/ijerph19106096

More than three million people in Chile suffer from neurological conditions, and many of these become permanent users of health services with a community approach. Interventions are essentially on a personal and microsocial level, focusing first on pathology and treatment, and later comprehending the interactions with a patient’s close social environment, such as family, schoolmates, and workmates and their physical environment at home, school, and the workplace. Although the final objective of community intervention is present in the discourse as being able to generate structural changes that favor well-being and social inclusion, concrete competencies are not appreciated on a macrosocial level.

occupational therapy neurological rehabilitation community integration social inclusion

1. Neurological Disease and Occupation

Approximately one in every six people suffer from a neurological condition in the world, which includes side effects of acquired brain damage, neuropathies, cerebrovascular illnesses, neurological infections, Parkinson’s disease, epilepsy, Alzheimer’s and other dementias, among others. Therefore, this figure represents more than three million people in Chile ^[1]^[2].

These conditions impact the occupational performance of people in activities of daily life, the productivity associated with study and work, and in their free time and leisure, significantly reducing their quality of life and that of their families and caregivers ^[3]^[4]^[5].

2. Competencies in Occupational Therapy

Competencies are defined as a set of technical skills, knowledge, clinical reasoning, and reflection of daily practice for the benefit of the individual and their communities.

The Pan American Health Organization ^[6] indicates that the identification of health competencies is a high priority, since society is informed about what professionals must know and do. They must have the capacity to use in practice, the knowledge, skills, attitudes, values, and abilities of the profession in the prevention and resolution of health problems ^[6]^[7].

According to the World Federation of Occupational Therapists, occupational therapy is a client-centered health profession, concerned with promoting health and wellbeing through occupation. The primary goal of this discipline is to enable people to participate in everyday-life activities. To achieve this goal, occupational therapists work with individuals, in an individual and collective manner, by performing interventions to enable their participation in meaningful occupations, enhancing their skills and/or adapting the environment or characteristics of the occupation as needed ^[8].

There is a series of international publications on occupational therapist profiles and competencies ^[9]^[10]^[11]^[12]^[13]^[14], but there are no specific studies regarding the competencies of the community approach toward neurorehabilitation. However, the World Federation of Occupational Therapy ^[15] indicates that professional abilities can add value to community interventions, favoring the approach to problems from different perspectives and facilitating the processes from planning to implementation. In line with this evidence, occupational therapists have adhered to practice that is centered on community.

3. Community Occupational Therapy

The practice of occupational therapy in communities is a methodological model that contributes to guiding collective strategies ^[16] and has the particularity of having specific knowledge of the occupation as a determinant of health that impacts wellbeing ^[15].

Therefore, this community approach includes characteristics of a community’s territory, networks, and key actors in the design and implementation of clinical care. This approach focuses on the participation of people in their health processes ^[17] by linking the community’s capacity to systematically and strategically integrate health-related actions with services located in a given territory ^[18].

In this manner, occupational therapists work to favor people’s participation in collective occupations that promote community health ^[14]^[19]^[20] and social inclusion, committed to the rights of all people. The purpose of these practices is to encourage users to build their future through occupation, as active members of their family, community, and social life, as well as carry out their different roles and responsibilities ^[21]^[22]. It is also expected that populations and communities can generate instances of diversity acceptance and promote accessible spaces in physical, social, and cultural contexts ^[23].

Consequently, to carry out meaningful and effective processes, an occupational therapist must develop different competencies that allow him/her to facilitate positive, creative, and culturally relevant environments, such that the communities themselves can address their own problems ^[14]^[19]^[20].

In Latin America, a paradigm shift is underway regarding occupational therapy practice since cultural belonging has been identified as deriving from the knowledge and recognition of a territory’s history. To visualize people holistically, in addition to being a practice centered on the client, a practitioner should not forget that there are structural determinants that can have categorical impacts on health situations and can therefore hinder rehabilitation processes ^[24].

One of the theoretical references used to support community processes in occupational therapy is Paulo Freire. This reference is used both because of its emancipatory character and its participatory methodologies that facilitate reflective and process awareness about the socio-political conditions that influence the quality of life of users and their community ^[25]^[26]. Paulo Freire’s work enriches the professional practice of occupational therapists who seek the active participation of communities in their change processes. As Nunes and Esquerdo ^[25] mention, ‘Freire’s concepts and proposals can support a critical professional approach intended to engender vulnerable populations and social transformation movements in the dialectical relationship between micro- and macrosocial aspects’.

4. Experiences of Community Occupational Therapy

In the literature, there are several studies with positive results regarding experiences and research about professional practice in community occupational therapy in neurorehabilitation and its impact on people’s health.

Among them is a study on non-pharmacological treatments (NPT). These treatments have emerged as a solution to manage certain clinical symptoms that do not necessarily require the consumption of chemicals to improve health in users with mild cognitive impairment and dementia. In addition, NPTs have few side effects and can be used with other treatments. Hence, NPTs have been shown to have a positive impact on cognition, wellbeing, mood, and quality of life in users with neurodegenerative pathologies ^[27].

Vibholm, Christensen, and Pallesen ^[28] conducted a systematic review on the benefits of nature-based rehabilitation for adults with acquired brain injury, finding evolutionary activity and ecological approaches, among others, as the main theoretical foundations. Social and therapeutic horticulture has also been part of procedural intervention strategies. It is emphasized that this type of intervention must be appropriate for each case.

Öst Nilsson et al. ^[29] described the intervention process during nine months of occupational therapy in workers with a history of stroke, theoretically based on a person-centered approach to improve the potential, performance, and level of reentry into the participant’s workforce. At the procedural level, this study considered both the individual and his/her community environment since co-workers intervened and modifications were made to the workplace. From an attitudinal point of view, the professionals who performed the rehabilitation agreed on the objectives and interventions with the patients. After a three-month follow-up, the results indicated that the participant’s performance in the work environment was favorable upon returning to work.

In addition, another study focused on the relationship between environmental factors and the social participation of children with cerebral palsy (CP). These factors include elements such as physical environments and institutions showing that community and social attitudes play a relevant role in encouraging patient participation. Furthermore, negative attitudes may prevent parents or caregivers from wanting to accompany or encourage the child to move independently or with assistive devices, ultimately reducing their social participation. Generally, environmental modifications and adaptations at home, in the community, and at school can increase the social participation of these children ^[30].

In Australia, Kendall et al. ^[31] detailed the transition of people with spinal cord injuries from hospital to home in rural areas, where they are referred to local health services. In this situation, patients indicated that the transition was challenging, overwhelming, and complicated because moving from a professional to a not-so-professional place, according to their perceptions, generated feelings of uncertainty. Considering this, the urgency of generating participatory processes, connecting people with local health services before the transition, and providing specialized education on these local devices is recognized. As an attitudinal element, this study emphasizes that the approach should be carried out through a multidisciplinary team, and from a cultural perspective, understanding and facilitating experiences of transition, considering aspects that are specific and unique to the rural environment ^[31].

To bring rehabilitation closer to communities and increase accessibility after hospitalization, following a community health model, the World Health Organization (WHO), developed the community-based rehabilitation (CBR) strategy, which seeks to promote inclusive local development. Another aim of this strategy is to generate a comprehensive rehabilitation process for individuals, their families, social organizations, communities and different government and non-governmental agencies in health, education, labor and social spheres, among others ^[21]. Public health adheres to a holistic model of family and community health care, moving toward the implementation of territorial and multidisciplinary health teams, where occupational therapists can be found in addition to a community-based rehabilitation network at all levels ^[32].

There is evidence that the CBR strategy has been beneficial for people who have had neurological diseases, especially for early access and a comprehensive approach to their healthcare needs ^[33]^[34]^[35]^[36]. These conclusions are supported by the fact that CBR professionals are in a continual training process, as mentioned by Guajardo et al. ^[37], in a study carried out in Chile. This study demonstrated that in rehabilitation, at a theoretical and practical level, professionals are well trained. The latter, along with the strategies and techniques used, allows them to reach their users and obtain positive results in their rehabilitation. However, regarding knowledge linked to the community and territory where they work, these aspects must continue to be strengthened.

Another study carried out by González-Bernal et al. ^[38] noted that community occupational therapy plays an important role in both physical and social spheres. This approach highlights promoting the equality of conditions, as well as the promotion of decision making and reduction of exclusion due to disability, with a practical, client-centered model.

Finally, Bianchi and Serrata ^[39] carried out qualitative research on the professional performance of Latin American community occupational therapists. Their results indicate that practices are articulated at the micro- and macrosocial levels, involving the strengthening of social networks and construction of bonds through occupation.

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Subjects: Rehabilitation; Neurosciences

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MARÍA DEL MAR FERNÁNDEZ-MARTÍNEZ

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