The effects of occupational disruption during COVID-19 lockdowns on health: a cross-sectional study

Introduction

The declaration by the World Health Organization (WHO) of COVID-19 as a global pandemic, on 11 March 2020, resulted in an unprecedented global decline in participation in daily activities. Countries around the world responded to the pandemic by requiring social distancing, restricting movement, and lockdowns to curb the spread of the disease. Lockdown measures included closing schools, public facilities, shops, restaurants, bars, parks, and airports. There was an abrupt and sharp decline in participation in essential daily activities such as working, attending schools, leisure and recreational activities, participation in communal worship, and socializing, among others. The inability to participate in normal daily activities had far-reaching health implications, but more studies are needed to shed light on how reduced performance in specific activities affected specific health domains.

Occupational therapists, who view activity performance as the means and ends of intervention (McLaughlin Gray, 1998), consider all types of meaningful things people do as occupations. Occupations occupy time with meaningful things people need to, want to, or are required to do (World Federation of Occupational Therapists, 2024). The American Occupational Therapy Association (AOTA) publication “Occupational Therapy Practice Framework, version 4” (OTPF-4) defines occupations as “everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life” (American Occupational Therapy Association, 2020). Occupations are classified into activities of daily living (ADL), instrumental activities of daily living (IADL), health management, rest and sleep, education, work, play, leisure, and social participation. However, the classification has been argued to limit the scope and thinking of occupational therapy practitioners and researchers (Hinojosa, 2007). For instance, OTPF-4 does not include numerous non-sanctioned activities (e.g., drug addiction and violent behaviors), resulting in the false portrayal of occupations as only positive, productive, and healthy activities. This assumption has been challenged by the growing recognition that occupations often have a dark side (Twinley, 2013; Twinley, 2021), particularly when occupations that include addictive activities, impulse control disorders, and violence behaviors are also considered meaningful occupations (Kiepek & Magalhães, 2011; Twinley & Addidle, 2012).

A temporary disruption in participation in everyday activities is termed “occupational disruption” (Whiteford, 2000). This concept has been used to characterize the changes in occupational participation that resulted from COVID-19 restrictions throughout the world (Asbjornslett et al., 2023; Engels, Segaux & Canouï-Poitrine, 2022; Jokic & Jokic-Begic, 2022; Keptner, Ekelman & Milliken, 2023; Rotenberg et al., 2021; Segev-Jacubovski & Fogel, 2022; Wegner et al., 2022). Occupational disruption refers to “a state of impaired performance, which usually resolves itself given supportive conditions” (Whiteford, 2000, p. 201). There is extensive evidence that restricted participation in activities during the COVID-19 pandemic affected health, but it is not clear how occupational disruption, with respect to a specific type of occupation, affected specific health domains such as quality of life, resilience, and mental health.

Methods

Results

Discussion

The purpose of this study was to determine how the changes in daily activity performance, resulting from COVID-19 lockdowns, affected health. Of the sixteen selected types of daily activities included in the survey, changes in five of them during lockdowns significantly correlated with changes in health. The results support our hypothesis that changes in participation in different types of activities would impact health differently depending on the type of activity. Presumably, higher occupational resilience produced better participation in certain activities during COVID-19 lockdowns for some individuals, groups, or communities, but not for others. Subsequent variations in occupational participation contributed to variations in health outcomes between people. The results showed that some types of activity significantly influenced health more than others; therefore, these activities should have priority in policies or other interventions.

The type of activity that affected health the most was rest and sleep, contributing 29.5% of the variance between pre-COVID-19 and lockdown health status. It can seem an oxymoron to describe rest and sleep as occupation, because they often involve minimal consciousness, but the two meet the criteria for occupations (American Occupational Therapy Association, 2020), being things people do that occupy time and are meaningful. Rest and sleep revitalize brain function, making the performance of other occupations possible or better. Rest involves activities that produce a relaxed state in which demanding physical, mental, or social activities are reduced (American Occupational Therapy Association, 2020). Sleep is a state of immobility with reduced responsiveness that enables recovery from the accumulated debt of sleep that builds during wakefulness (Siegel, 2005). Restoration of neural functioning enables rest and sleep to promote physical and emotional health (Khazaie et al., 2023; Matricciani et al., 2019) and improves participation in other activities such as work (Deng et al., 2022; Litwiller et al., 2017) and education (Bono & Hill, 2022). Rest and sleep, by far, more significantly influenced health than any other type of occupation.

The results suggest that changes in play and recreational activities between pre-COVID-19 and lockdowns were associated with significant changes in health status, contributing 8% in variance. This was an expected outcome because the lockdowns forced a reduction in recreational activity options, and these activities are associated with positive subjective well-being (Cummings, 2002) and mental health (Sala et al., 2019; Takiguchi et al., 2023; Yoshida et al., 2021; Zulyniak et al., 2020). Play and recreational activities are often leisure activities, performed when people are free from essential daily activity obligations like work or education. They are done for relaxation, enjoyment, and acquiring skills, among other reasons. Leisure activities have been effective in reducing anxiety, stress, or pain in people in distress, such as those in hospitals (Adam-Castelló et al., 2023). As play and recreational activities differ substantially, their effects on health could vary significantly, as do the mechanisms of action through which they affect health. There are more than 600 such mechanisms, classified under psychological, biological, social, and behavioral processes (Fancourt et al., 2021).

Play and recreational activities are often social, as they are commonly performed with or in the company of other people. But, consistent with the AOTA classification of occupations, social participation was a separate category in the survey. Contrary to our expectation, social participation by itself did not significantly impact health during the lockdowns. Social participation is a concept used to describe “activities that involve social interaction with others, including family, friends, peers, and community members, and that support social interdependence” (American Occupational Therapy Association, 2020). It is the key type of activity most significantly impacted by social distancing policies. Social participation has known effects on health, and interventions were recommended to help people maintain social contacts during similar pandemics (Sikali, 2020), as positive social contacts are associated with psychological and physical health (Baumeister & Leary, 1995), and loneliness has been linked to suicidal behavior in the general population (Stickley & Koyanagi, 2016). The fact that changes in social participation did not significantly impact lockdown health status was therefore a surprising outcome.

Pre-COVID-19 versus lockdown physical activity [for example exercise, jogging, hiking, running, or walking outside] changes did not show a strong association with changes in health status during lockdowns. Physical activity was classified separately from play and recreation, although many play and recreational activities are physical activities. This was done to help detect any effect of physical activity by itself, but contrary to what other studies found (for example, Chi et al., 2021; Killgore et al., 2020), there was no significant association between change in physical activity and change in health status during lockdowns.

As the type of activity associated with income generation, work was expected to be among the activities that would significantly impact health during lockdowns. Pre-COVID-19 versus lockdown changes in work performance contributed 4.8% of variance between pre-COVID-19 and lockdown health status. It was not a surprising outcome, as unemployment has been attributed to psychological distress in a study involving a much larger sample size (Matthews et al., 2021), and psychological resilience, which was significantly impacted by work, influences mental health (Killgore et al., 2020) and coping skills (Vinkers et al., 2020). Work also provides financial resources for necessities of daily living, including costs associated with play and recreation among other essential daily activities. Therefore, work likely impacted health directly, but it may also have indirectly impacted health by limiting participation in other important activities due to lack of financial resources.

Changes in the performance of personal hygiene activities (e.g., taking showers or baths, brushing teeth, grooming, and dressing), called activities of daily living (ADL), significantly contributed to health during lockdowns, accounting for 3.2% variance between pre-COVID-19 and lockdown health status. The impact of participation in ADLs on health is consistent with outcomes of a systematic review that found that poor participation in ADLs, due to the COVID-19 disease, resulted in negative health-related quality of life (De Oliveira Almeida et al., 2023). The interruption of routines produced significant variations in the performance of personal hygiene activities, which are commonly performed in patterns that punctuate other daily activities. Lockdowns interrupted essential routines that make the performance of these activities automatic or regular.

Lastly, healthy eating accounted for 2.8% variance between pre-COVID-19 and lockdown health status. Eating is an essential everyday activity that supplies nutrients to the bodies, but in the survey, this activity was framed positively as ‘healthy eating’, not just ‘eating’. Eating healthy is distinguished in Health People 2030 as an important activity for meeting health goals set by the U.S. Department of Health and Human Services (2024). But eating as an activity can also be detrimental to health if the food consumed is not the right amount or variety. Unhealthy eating has been a contributor to conditions like obesity, cardiovascular disease, hypertension, stroke, type 2 diabetes, metabolic syndrome and some cancers (Gropper, 2023). Healthy eating, on the other hand, can treat or help manage some chronic health conditions (Di Renzo et al., 2019; Slawson, Fitzgerald & Morgan, 2013). It is therefore not surprising that healthy eating correlated positively and significantly with lockdown health status.

Study Limitations

The primary limitation of this study was that it relied on participants’ recollection of their occupational performance and health status before COVID-19, which may not have been perfectly accurate in light of their altered circumstances during lockdown. Furthermore, the study relied heavily on the AOTA list of occupations and ignores numerous other activities that people do, which could have significant health effects in positive or negative ways. For example, consideration of so-called ‘dark occupations’ may have revealed whether participation in such activities increased during COVID-19 lockdowns and whether they were predictive of health. Furthermore, the study relies on a relatively small and homogeneous sample, consisting predominantly of white American females. Further exploration of the relationship between health and participation in various occupations is warranted. Future studies are recommended to include a wider range of occupations, as well as larger and more diverse samples, including different socioeconomic, cultural, age and political factors.

Conclusion

This study revealed that occupational disruptions from COVID-19 restrictions impacted health differently depending on the type of activity considered. The five types of activity which impacted health the most were rest and sleep, play and recreational activities, work, personal hygiene, and healthy eating. Further research is needed to better reveal the effects of specific activities on health, particularly during pandemics or comparable occurrences that disrupt performance of everyday activity.

Supplemental Information