https://orcid.org/0000-0002-6910-3468
ABSTRACT
Among individuals who have recovered from COVID-19 around the world, there is a substantial number who would need support in finding their way back to meaningful and productive work. The aims of this paper are to demonstrate the multitude of factors that shape return to work (RTW) practices across and within several countries, and argue for the need to explore RTW from an international perspective during an on-going pandemic, focusing on working age adults who have recovered from COVID-19. Conditions for RTW differ across countries. Occupational therapy has a central role in medical rehabilitation after injury and illness (including COVID-19), but the occupational therapy community has, to the best of our knowledge, yet to raise awareness and advance evidence regarding its role in post-COVID RTW processes. A robust evidence-based knowledge on RTW that can be utilised by occupational therapists during the present and future pandemics is needed.
Introduction
This paper is about return to work (RTW) after COVID-19. Resource effective screening with passive, active and/ or sentinel surveillance as well as public health measures such as vaccination, physical distancing, mask-wearing, hand hygiene and self-isolation when presenting symptoms are central to counteract the spread and devastating effects of SARS-CoV2 (the virus resulting in COVID-19). These actions during the pandemic are necessary to support crucial societal function, avert health care overload, reduce number of persons developing post COVID-19 condition (PCC) and of course to save the lives of those at risk of developing severe COVID-19 (WHO, Citation2021). The World Health Organisation (WHO, Citation2021) has defined PCC as,
condition occurs in individuals with a history of probable or confirmed SARS CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms and that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time.
The aim of this paper is to demonstrate the multitude of factors that shape RTW practices across and within several countries (Japan, the Philippines, Slovenia, Spain, Sweden, and the United States of America). We will argue for the need to explore RTW among working age adults who have recovered from COVID-19 from an international perspective. Our intention is however not to compare countries.
Country contexts
The following segment offers a brief context for work and RTW in different countries. Our intention is not to compare countries or to imply that one system has succeeded better or worse than another, but rather to illustrate a diversity of conditions for RTW. Because conditions for work and RTW differ vastly between countries, it is challenging to present an exhaustive overview of data. We have thus chosen to present data gathered through publicly available sources, as well as narrative presentations of country contexts based on literature, our respective professional experiences within these country contexts, and our access to finding and reading literature in the respective local languages ().
Table 1. Country comparison of COVID-19 morbidity and mortality rates.
Some data appeared to be similar across all country contexts, such as public employment organisations for persons needing support in RTW and rehabilitation services for those in need of such based on physician referrals. Although these similarities between country contexts appear consistent across countries in official documents, there are more differences than can be elaborated on in this paper with regard to details in how these public offices and rehabilitation services actually are operationalised for each individual. We thus urge the reader to see these examples as an illustration of the diversity of practices and RTW conditions across countries rather than prescriptive numbers of how it is in a particular country. Following the country presentations, we conclude with a discussion about the need for occupation-based knowledge that will have implications for practice ().
Table 2. Country comparison of return to work conditions for COVID-19 recoverees.
Japan
In Japan, as in reports from other countries, symptoms associated with PCC have been reported (Miyazato et al., Citation2020; Wakayama Prefecture, Citation2020), yet population statistics related to sick leave and RTW due to COVID-19 are lacking within a Japanese context today. In Japan, not limited to COVID-19, there are two processes to RTW after disability. For those receiving support through a hospital, rehabilitation services can include goals addressing RTW. Persons can receive follow-up support from the same hospital; however, this can depend on the hospital and region. Persons can also receive support through a community organisation. Community organisations include the welfare office (e.g. employment transition support office) or specialised institutions for vocational rehabilitation (e.g. vocational training centre for the disabled). They provide support to improve work ability and support a process of job matching and coordination with potential workplaces. In some cases, hospital-based and community-based processes can be combined (Nakajima et al., Citation2021).
Although statistics about sick leave and return to work after COVID-19 are still unavailable in Japan, some reports about prolonged and late-onset symptoms of COVID-19 have been presented (Hirahata, Citation2021). The Japanese government has also presented criteria for RTW after COVID-19 (Ministry of Health, Labour and Welfare of Japan [MHLW], Citation2021a). However, the focus has mostly been from the perspective of preventing the spread the disease and not on individuals’ work ability. Moreover, due to a lack of specificity of the criteria, some organisations have provided alternative reinstatement criteria in their own guidelines (Japanese Society of Travel and Health & Japan Society for Occupational Health, Citation2021). At present, there are no published case reports or processes to support RTW among working-age adults who are recovering from COVID-19 in Japan. MHLW (Citation2021b) did, however, release guidelines for managing prolonged and late-onset symptoms of COVID-19. This guideline includes recommendations that stakeholders such as workers, employers, and primary physicians should collaborate in RTW processes for workers (MHLW, Citation2021b). On an overarching level these guidelines follow the same principles as for another disease in terms of supporting RTW, i.e. remuneration for work training available for all persons with disability. This is an initial guide for medical staff in Japan, and further information and updates are encouraged. For workers, a consultation service on labour issues for persons with COVID-19 has been set up by the Japanese government (MHLW, Citationn.d.).
Philippines
Statistics from the Philippine Department of Health (Citation2021) reported that a large proportion (78%) of COVID-19 survivors are working individuals aged 20–64 years. The Department of Health (Citation2020) has since released guidelines for the management and prevention of COVID-19, as well as recommendations for RTW of individuals who had or were suspected to have COVID-19. However, it focused on establishing safety standards to curb the spread of infection within the workplace and RTW after quarantine, with little to no mention of support for recoverees with persistent symptoms.
Several agencies are relevant to RTW after COVID-19 in the Philippines. Persons recovering from COVID-19 who still have restricted work ability have different levels of available support. The Philippine Labor Code does not require employers to grant sick leave, with the exception of five days applicable to workers employed for at least one year (Department of Labor and Employment, Citation2017). Moreover, the Social Security Law (Citation1997) provides sick benefits for hospital confinement of >3 days and disability benefits for disabilities declared permanent. Specific to workers affected by COVID-19, the Department of Labor and Employment (Citation2020) provides a one-time financial assistance payment worth Php 5,000 (US$ 100) and assistance in finding new employment if relevant. The Employees’ Compensation Commission (ECC, Citation2013) is the national agency providing medical (including rehabilitation) benefits for work-related illness or injuries, but self-employed individuals are excluded from these benefits. For those employed in large private companies, recoverees may also receive benefits beyond the aforementioned ones, i.e. private health insurances and paid/unpaid sick leave. For the unemployed and self-employed, rehabilitation is generally paid out-of-pocket (Dayrit et al., Citation2018). Thus, therapies may be perceived as a financial burden rather than a nexus between disability and ability to work (Yao et al., Citation2020). Moreover, the lack of referrals to work rehabilitation for recoverees is most likely exacerbated by the designation of several large national and provincial hospitals with rehabilitation units as COVID-19 referral centres (Department of Health, Citation2020), which have focused on active cases and immediate discharge of persons with COVID-19 without rehabilitation.
Slovenia
Data from the first wave of the pandemic in Slovenia show that 47% of those infected were either employed or self-employed (Zupanič et al., Citation2021). About one third (32%) of the reported infected persons were among those working in health and social care, followed by the manufacturing and processing industry (17%), commerce (11%) and education (6%). This suggests that those who were most at risk were those who could not work from home due to the nature of their work, or had jobs that required a high level of interpersonal contact (Zupanič et al., Citation2021). Since the beginning of the pandemic, an estimated 120 patients have been admitted to the University Rehabilitation Institute following severe COVID-19 and 63 of those were working age (under 65 years).Footnote1 Patients rehabilitated at the Institute were those with the most serious consequences of COVID-19 who required specialist input. When admitted from intensive care units, they were mostly dependent in mobility, transfers and ADLs. Due to the limited capacity of the University Rehabilitation Institute (which is the only institution of its kind in the country), patients who were considered more functional, were sent to their home environments, or referred to medical rehabilitation in spas.
People in Slovenia recovering from COVID-19 have access to physical and cognitive rehabilitation, as well as medical rehabilitation in spas and vocational rehabilitation, as long as they have a valid health insurance. Those who have both compulsory health insurance and supplementary insurance are treated free of charge, while those who do not have supplementary insurance need to pay for certain medical services that are not included in the basic insurance. Patients are charged for the additional medical services after discharge, which they are informed about (and must agree to) prior to treatment. If the cost of treatment is expected to be high, a person must pay a deposit before being admitted to the rehabilitation facility. An estimated 99.9% of the population has compulsory health insurance and a further 95% has supplementary health insurance (Keber et al., Citation2003).
In 2020, the Slovenian National Institute for Public Health (Citation2021) recorded 72,116 cases of COVID-19 in the working population or 7.98 cases per 100 workers.Footnote2 COVID-19 resulted in 927,919 days of sick leave in 2020 (Jeren & Kofol-Bric, Citation2021). In a recent study by the National Institute of Public Health that included 1,022 adults (conducted between October 12-15, 2021), results showed that 66% of those infected had symptoms of PCC for at least one month after infection and 73.3% reported difficulties in the areas of work, domestic activities and relationships with others (Grom et al., Citation2021). Surprisingly, more than two thirds (70.2%) of persons with symptoms of PCC did not consult their general practitioner about the ongoing difficulties they were experiencing.
In keeping with the 46th article of the Act on Intervention Measures to Assist in Mitigating the Consequences of the Second Wave of the COVID-Citation19 Epidemic (Citation2020), workers are entitled to 100% of their salary for the duration of sick leave if they get infected at work (despite using all the protective equipment), as this is considered a work-related disease. While the first 30 days of sick leave are usually covered by the employer (and after that from the social security), for COVID-19, sick leave is covered from the national budget from day one. If the employee must remain in quarantine due to a high-risk contact and the contact occurred at work, the worker is also entitled to 100% compensation (Government of the Republic of Slovenia, Citation2021).
Spain
The Spanish Ministry of Health incorporated a new legislation, which considers COVID-19 an occupational accident that supports reporting to insurance enterprises and social security (Law 2/2021). The law recognises that PCC poses challenges and uncertainties in diagnosis and treatment and the impact on quality of life and addresses these concerns by improving social benefits to individuals affected. Upon return to their job, workers diagnosed with PCC are evaluated by health staff of the Prevention Service. This evaluation focuses on workplace risks and preventive needs assessment to respond to emerging health situations, protect workers from aggravated state of health, and, when appropriate, adapt work tasks and environments. Additionally, the National Institute of Social Security Subdirectorate General for Legal Assistance and Organisation (Citation2021) has enacted new contingency measures for the financial benefit from temporary incapacity due to PCC. In the case of the health professionals, who were recorded to have taken long periods of sick leave in Spain (Suárez-García et al., Citation2020), they are entitled to the same benefits that the Social Security system grants to people affected by an occupational disease (Spanish Ministry of Health, Citation2021).
The Spanish social and healthcare system provides general vocational rehabilitation services in private or public settings. Several studies indicated the multidisciplinary team approach, including occupational therapy that follows on-site job training and/or assessment or modification of workplace environment, was effective when supporting the RTW of different profiles of patients in Spain (García-Pérez et al., Citation2021; Torres et al., Citation2009). Besides, recent research showed that rehabilitation programmes that include occupational therapy improve the levels of autonomy in individuals with PCC in Spain (Llarch-Pinell et al., Citation2021).
However, multiple gaps in care and referrals were observed, particularly for occupational therapy services before and after individuals are diagnosed with PCC. Especially during the first onset of the pandemic, there was no clear legislation about the specificity of RTW policies, which paralysed the Spanish labour workforce. At the same time, many workers with temporary employment contracts suffered high precariousness and vulnerability of their work status, which further aggravated their health conditions. Workers who, besides COVID-19, live with social, mental, physical or sensory difficulties are most vulnerable to work instability (ILO, Citation2021). However, there is no data on how many workers lost their jobs because of sick leave due to COVID-19. Moreover, there is no data on how many workers were under the rehabilitation services due to COVID-19 or suffered PCC with RTW needs.
Sweden
The spread of the COVID-19 was high in March and April 2020. The number of people that applied for sick leave during March 2020 was twice as many compared with the previous year (Swedish Social Insurance Agency, Citation2021a). During the period of March–September 2020 (Swedish Social Insurance Agency, Citation2021a), 71% out of the 21,492 persons who were registered on sick leave secondary to COVID-19 were between the ages 18–54 years. For those who had received intensive care, the median number of days on sick leave was 76 days, and for those who had been hospitalised but not received intensive care, the median number of days on sick leave was 35 days. Moreover, the severity of COVID-19 (needing in-patient care), prior sick leave, and age all seem to predict the likelihood of longer sick leave (Westerlind et al., Citation2021).
In Sweden, sick leave resulting from illness or disability lasting more than 14 days is grounds for eligibility to apply for financial benefits through the Swedish Social Insurance Agency (Försäkringskassan), which is publicly funded through taxes and governmental contributions. Financial benefits through the Swedish Social Insurance Agency rests on evidence of reduced ability to work and lack of capability to secure stable income. This is often provided through medical statements from a physician and current employer. In some cases, the Swedish Social Insurance Agency may also require additional verifications to confirm the level of disability.
The amount of financial compensation provided through Swedish Social Insurance Agency is based on a so-called sickness benefit qualifying income (SGI), which is based on the applicant’s yearly earnings through paid employment. It is thus required to have had previous income when applying for benefits or to be expected to earn a minimum of 11,400 SEK per year (Swedish Social Insurance Agency, Citation2021b). If a person is granted financial compensation through the Swedish Social Insurance Agency, a maximum of 80% of the SGI will be paid out in benefits, but no more than 378,400 SEK yearly, as of year 2021 (Swedish Social Insurance Agency, Citation2021b). If an applicant can work, but not 100% (full time) of the expected working hours, partial benefits can be granted. Moreover, in some cases Swedish companies provide their employees with complementary private health insurance that can provide additional security.
While receiving financial benefits from Swedish Social Insurance Agency, it is mandatory to attend regular medical follow-ups to ensure that all possible efforts are being taken into action to aid occupational ability. These actions may include attending regular physical and cognitive rehabilitation, trying modified assignments at the current workplace or enrolling in a job searching programme through the Public Employment Service (Arbetsförmedlingen) to find a more suitable occupation for the circumstances. Employers may also apply for financial compensation to examine, plan and initiate necessary actions to facilitate their employee’s RTW. This compensation may be used for rehabilitation services such as occupational health services or to implement physical adaptations at the workplace, but must be carried out through providers approved by Swedish Social Insurance Agency.
United States of America
Although the federal government created new provisions for sick leave specific to COVID-19 in 2020 through the federal Families First Coronavirus Response Act (Long & Rae, Citation2021; U.S. Department of Labor, Citationn.d.), not all employees are covered by or are aware of the benefits (Jelliffe et al., Citation2021). Data regarding the number of people who accessed sick leave due to COVID-19 are not readily available, given the variety of state-level sick leave policies that complemented federal legislation and produced separate statistics. It also remains unclear how many people with PCC have accessed sick leave (Berger et al., Citation2021). Lack of data on these points complicates efforts to understand the current state of COVID-19 RTW processes, which are of importance given the proportion of people experiencing PCC (Raveendran et al., Citation2021; Wanga et al., Citation2021; Weerahandi et al., Citation2021).
As a recognised disability (Centers for Disease Control and Prevention, Citation2021), PCC qualifies individuals for accommodations under the Americans with Disabilities Act, but specific provisions for RTW are made on an individual basis in light of physician recommendations (Batiste, Citation2021). Combined with the fact that most RTW guidelines focus on symptomatology and minimising disease spread risk in the work environment, rather than on the specific supports needed by people with PCC (Shaw et al., Citation2020), needs for a concerted focus on supporting RTW are evident. Models of care for patients with PCC vary widely, with occupational therapy not universally represented on care teams (Verduzco-Gutierrez et al., Citation2021). Initial evidence regarding the role of occupational therapy in supporting RTW processes for persons with PCC suggests potential contributions along a continuum, from activity grading to technology provision to more formal vocational rehabilitation (CDC, Citation2021; Parker et al., Citation2021; Wilcox & Frank, Citation2021). Further research is needed to understand the possible scope and impact of the profession’s role in this arena, especially relative to vocational rehabilitation professionals (Wong et al., Citation2021).
Discussion
RTW is considered a set of processes to ensure that employees return to the workplace and work duties (International Labour Organisation [ILO]), especially after illness or acquiring a disability. However, upon a closer look at RTW after COVID-19, the RTW processes across the countries involved in this article vary in terms of implementation, human and material resources, funding, and outcome measurement. Nearly 2 years after the first reported cases of COVID-19, the pandemic has led to the loss of 255 million full-time jobs and economic recovery (based on GDP per capita) remains uncertain for many regions in the world (United Nations, Citation2021). RTW likely means entering a new job for some people and perhaps a job that requires new skills. Employers and insurance agents, within government and private institutions, lack information about how to support persons in the RTW process when an illness or syndrome is novel or emerging. Moreover, it is important to recognise the role of the public in reifying and navigating the RTW process for continuity and sustainability.
Healthcare providers may have knowledge about how to support RTW in relation to other conditions, but in a pandemic situation, all regular routines are on hold to prioritise the most acute needs with limited resources. As can be seen in documents from several countries reviewed for this paper, much of the occupational therapy efforts have been placed on ADL, cognition, and hand function. Although this can be relevant and appropriate, there are also consequences when other potentially important problems are given attention much later, and in many cases, only after the person is already completely discharged from services originally associated with COVID-19. This makes the RTW process difficult to follow.
Occupational therapists’ role in COVID-19 rehabilitation has been outlined from acute care to outpatient and primary care. In the six countries included in this study, occupational therapy had a clear role in in-patient rehabilitation settings and, in some cases, also in acute health care settings. In in-patient settings, occupational therapy was reported to be helpful in the prevention and treatment of post-intensive care syndrome (PICS, post-ICU syndrome), including prevention of lesions; multisensory stimulation; cognitive stimulation, as well as motor training, and functional re-education and participation in ADL. In Spain for instance, the role of occupational therapy during hospitalisation was to facilitate patients for independence, prepare them for discharge, and address cognitive changes (Muñoz-Valverde & Martínez-Zujeros, Citation2020). In Japan and Sweden, assessments targeted areas such as ADL, hand function, cognition, and occupational performance with subsequent interventions focusing on advising patients and other healthcare staff about self-care, energy conservation techniques (e.g. timing for rest), mobility, life balance, and maintaining cognitive function (Japanese Association of Occupational Therapy, Citationn.d.; Mizuguchi, Citation2021; Swedish Association of Occupational Therapists, Citation2020a). In Slovenia, a study conducted by Prosič et al. (Citation2021) compared progress in occupational therapy between patients with critical illness myopathy (CIM) after COVID-19 and patients with CIM due to other causes. The Canadian Occupational Performance Measure, Goal Attainment Scaling, and Functional Independence Measure (FIM) were used to collect data. In both groups, most difficulties were identified in the area of self-care. The authors found that the COVID-19 CIM group progressed slightly better in the area of toilet and bed transfers than the general CIM group as assessed by FIM. However, the overall difference between the groups was not statistically significant. It was also noted that the goal-setting process was more challenging in the COVID-19 group due to limited knowledge about the disease and its potential complications.
In some countries, occupational therapy services are disproportionately distributed in segments of healthcare that has led to work rehabilitation being understaffed. In the Philippines, occupational therapists are largely employed in the pediatric settings, which has led to the disproportionate distribution of practitioners for physical rehabilitation, specifically in work rehabilitation – an area that remains underdeveloped for service delivery, training, and scholarship (Sy et al., Citation2021). Among countries that did extend services into the community such as Sweden (Swedish Association of Occupational Therapists, Citation2020b) and Spain (Navarro-Correal et al., Citation2021), assessments and interventions in primary care settings were basically the same as for in-patient care, however a battery of work related assessments were more explicit in Sweden. Overall, support for RTW after COVID-19 appears to be scarce even as time goes and differs vastly by country context. This is in contrast to a more homogenous description of occupational therapy and rehabilitation services during the acute and post-acute in-patient phases.
While disability status has been defined during pre-pandemic times, the eligibility requirements to gaining disability status after COVID-19, including mental health disabilities, remains underdeveloped (Brown & O'Brien, Citation2021). Health-seeking behaviours of people may have changed because non-urgent medical care (i.e. rehabilitation services) was not prioritised along with a growing fear of contracting COVID-19 during a doctor’s visit (Uy et al., Citation2021). In terms of the rehabilitation process, those who may use RTW services within the context of COVID-19 would require multiple services from different healthcare providers. Countries like Japan, Philippines, USA, and Spain provided financial assistance for COVID-19 recoverees that could be used for rehabilitative services, while in Sweden and Slovenia, rehabilitative services varyied from physical, cognitive, and vocational rehabilitation.
Given the nature of RTW after COVID-19, it is a practice area that still remains unexplored although it could inform practice in which similar symptoms are experienced by the persons in need of receiving support in RTW. Moreover, Models of care for PCC can be explored further. In a preliminary systematic review on models of care related to PCC, occupational therapists along with respiratory therapist, psychologist, psychiatrist, physiotherapist, and social worker were the most mentioned professions. Care model principles are characterised by multi-disciplinary teams, integrated care, and self-management, including components such as standardised symptom assessment, referral system, follow-up, and telehealth to name a few (Decary et al., Citation2021), however it is too early to make any claim about what this can mean for practice. Physicians are most often at the frontline of directing care, however even within occupational medicine there is a lack of studies about the impact of PCC on work, and thus on informing decisions about assessments and referrals for RTW (Rayner & Campbell, Citation2021).
When exploring conditions for RTW against the backdrop of six country contexts, it was striking how the RTW process is largely ameliorative rather than transformative in nature. According to Evans et al. (Citation2007), an ameliorative approach denotes ‘health, human, and community services that care for people who have already been afflicted by some psychological, physical, or social ailment’, whereas a transformative approach focuses on identifying people’s strengths, preventive care, empowerment, and changing community conditions. Although it cannot be helped to initiate and underpin the RTW process with ameliorative practices, occupational therapy together with interprofessional teams has a pivotal role in integrating transformative practices in the practice area of RTW in an ongoing pandemic as well as post-pandemic society.
Conclusion
In this paper we have put forth how a multitude of factors such as social insurance policies, guidelines for employers, guidelines for practitioners, and national regulations to name some that can shape RTW practices across and within several countries where such conditions as languages, socioeconomics, and legal systems differ. Although our intent has not been to compare countries, we argue for the need to explore RTW among working age adults who have recovered from COVID-19 in an international perspective because the differences/similarities in systems and practices highlight factors that in some cases merit change and in other cases can be built upon. This is necessary to develop evidence-based knowledge on RTW that can be utilised by occupational therapists in the future.
Acknowledgment
We would like to thank and acknowledge the contributions of Angelica Bäcklin for texts concerning economic compensation and sick leave in the Swedish context and Atty. E. Patrice Jamaine T. Barron of the Employees' Compensation Commission for her work in checking the accuracy of the benefits available to workers in the Philippine context.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Correction Statement
This article has been republished with minor changes. These changes do not impact the academic content of the article.
Notes
1 Internal records of the University Institute of Rehabilitation.
2 Data for 2021 will become available in 2022.
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