1 Background

Occupational therapy is a discipline that merges social science and health. It centres around being able to partake in the everyday tasks that people do, from getting dressed, to driving, going to work, cooking, socialising and sleeping [1]. Restrictions in being able to partake in these tasks can be caused by disabilities and innate factors, or from restrictions in the environment and resources. Occupational therapists work with individuals across the lifespan and have traditionally worked with people with mental and physical disabilities [1]. The role of occupational therapy has now been expanded in working with populations without disabilities but who are at a risk for them if they are unable to engage in occupations that are necessary for health [2]. This new literature has been rooted in occupational science. Occupational science is a broad and multi-disciplinary field that originates from multiple contexts and looks at the study of occupations across the lifespan, the right to engage in occupations and injustices that may arise when not being able to do so. The role of occupational therapy in supporting marginalised populations is thus a growing but important topic [2].

Specifically, occupational therapy has a significant role to play in addressing the needs of forcibly displaced individuals (FDIs) in low- to middle-income countries (LMIC) through health promotion, and prevention of disease and disability services. However, the literature lacks a comprehensive overview of the role of occupational therapy in relation to FDIs. Furthermore, there is limited knowledge about the occupational therapy services provided to FDIs in LMICs and their resulting impact. This knowledge gap is problematic because it leads to a lack of awareness about the potential contributions of occupational therapy [3]. Consequently, small independent organisations are left to provide occupational therapy services to FDIs with limited global support and funding [4]. Previous research primarily focused on specific aspects of occupational therapy or on identifying instances of occupational injustices experienced by FDIs [5, 6]. This article is based on a scoping review that aimed to offer a broader synthesis and greater recognition of how occupational therapy has benefited FDIs in LMICs in terms of promoting health and preventing disease and disability. This article further explores how occupational therapy has successfully fulfilled its role in delivering health promotion and prevention of disease and disability services for FDIs in LMICs.

2 Conceptual framework for the challenges FDIs face

Forcibly displaced individuals have been compelled to leave their homes under distressing circumstances. The category of FDIs, namely refugees, asylum seekers, and IDP, is determined by legal status and whether they have crossed the borders of their country of citizenship. IDP often experience multiple barriers to accessing healthcare and other services because they have not crossed the borders of their country of citizenship, leaving IDP with limited international protection or specific service providers [7, 8]. Without an approved refugee status classification, individuals are referred to as asylum seekers [9, 10]. Many individuals can go for long periods without being classified as refugees and as a result, these individuals do not experience the full protection of the law to which they would be otherwise entitled [9]. However, while refugees’ rights are stipulated legally, there is a discrepancy between stipulation and implementation [11]. Despite their legal differences and subsequent slight differences in experiences, all individuals of forced displacement can experience a variety of challenges, including medical, systemic, and contextual issues.

A recent literature review revealed that FDIs have unique medical and social needs that require additional support in accessing healthcare policies [12]. Medical conditions commonly associated with forced displacement include developmental delay, behavioural problems, post-traumatic stress disorder, missed immunisations, and inadequate management of chronic conditions [13,14,15,16]. Furthermore, injuries such as burns, spinal cord injuries, traumatic brain injuries, amputations, malnutrition, and infectious diseases are prevalent among FDIs [13,14,15,16]. Hence, the changes in body functions and structures experienced by FDIs negatively influence their health. Moreover, mental health challenges, such as depression, often arise due to factors such as unemployment, social isolation, and discrimination, further compounding the health concerns faced by FDIs [17, 18]. These diagnoses impact individuals’ daily functioning and ability to engage in occupations.

In addition to medical challenges, systemic barriers also pose significant hurdles [12]. These barriers include language and cultural differences, xenophobia, stigma and administrative complexities [11, 19,20,21,22,23]. For example, not being able to communicate within the host community makes it difficult to receive support, receive an education, read medication labels, and know where to access services [24, 25]. These structural barriers prevent FDIs from accessing necessary healthcare and other essential general services required for daily occupations.

Moreover, FDIs’ routines and roles are disrupted, directly affecting the activities in which they can engage [26]. For example, as a result of forced migration, many FDIs are unable to fulfil the roles they were originally engaged in, such as the role of a worker [27]. Routines and roles can also be affected by a lack of essential resources often affecting LMICs such as poor road infrastructure, power cuts and a deficiency in clean water which can make engaging in daily life difficult for FDIs. Occupational therapists consider the environmental barriers and affords when designing interventions [28]. As a result of service inaccessibility and disruptions to routines and roles, FDIs are highly susceptible to experiencing occupational injustices.

3 Conceptual framework for occupational therapy and occupational injustices

Occupational therapy is grounded in the core belief that engagement in meaningful occupations can significantly enhance one’s health and wellbeing [17, 29, 30]. The philosophy of occupational therapy rests on the idea that humans are inherently driven to engage in occupations, which, in turn, brings about a sense of purpose, personal growth, and a feeling of connection with others [31]. Thus, the selection of studies has been limited to occupational therapy literature as occupational therapists purposefully use occupations for health. The positive impact of engaging in occupations on health and wellbeing is closely linked to the concept of occupational justice. Conversely, occupational injustice represents a distressing experience where individuals are either denied the opportunity to pursue meaningful activities, excluded from them, or forced into activities they did not choose [32]. Such occupational injustices can lead to additional health complications [26]. Certain pre-requisites are needed to engage in occupations, and as with the social determinants of health if these are missing and participation cannot occur, it can lead to ill health and poor health outcomes [33]. Both occupational justice, and health promotion and prevention of disease and disability services share the goal of creating opportunities for individuals to engage in meaningful daily tasks, roles, and activities. Moreover, both occupational justice, and health promotion and prevention of disease and disability services empower individuals by giving them more control over their lives [29, 34]. Subsequently, individuals can make better health-related decisions and effectively exercise their choices regarding occupational participation [34]. It is clear from the preceding paragraphs that FDIs face many occupational injustices, and thus, require occupational therapy services to ensure that occupational participation can still take place as engagement in occupations is vital for health and well-being.

4 Conceptual framework for situating FDIs within LMICs

By the end of 2023, the United Nations High Commissioner for Refugees estimated that there will be approximately 86.9 million FDIs globally [35]. Moreover, the current conflicts in Ukraine, Palestine and the Democratic Republic of the Congo, contribute to the increasing numbers of FDIs, further necessitating an understanding of the role of occupational therapy in relation to FDIs as these conflicts pose a growing global health concern. Notably, a significant portion of FDIs typically originate from and resettle in LMICs. While existing studies examined the provision of occupational therapy services to FDIs, these studies did not adequately consider the specific context of LMICs nor the unique needs and occupational injustices faced by FDIs in the Global South, which may significantly differ from experiences in the Global North [36]. The literature suggests that it is crucial to investigate specific subpopulations of FDIs as each group has distinct socio-political backgrounds, diverse life experiences, and unique cultural aspects [37,38,39,40]. Therefore, the aim of this review was to map out the existing literature regarding occupational therapy services for FDIs in LMICs with a focus on identifying contextually relevant interventions for health promotion and prevention of disease and disability. As there is such a need to focus on LMICs the search string yielding the selection of studies will only focus on those studies situated within LMICs and not HICs.

5 Methodology

A scoping review was conducted to comprehensively synthesise the available evidence on the occupational therapy services to FDIs to better understand the role of occupational therapists in LMICs. This review followed The Preferred Reporting Items for Systematic Reviews and Meta-analyses extension for Scoping Reviews (PRISMA ScR; Fig. 1) [41]. The respective university’s Human Research Ethics Committee granted an ethical waiver in 2022 for this review. Furthermore, this review adopted the five-stage methodological framework described by Arksey and O’Malley [42]. Arksey and O’Malley describe an iterative, reflexive process that allows for as much literature to be covered, in a comprehensive way, as possible [42]. The aim of using this approach is to determine the extent, range and nature of research activity; to determine the value of undertaking a full systematic review, and to summarise and disseminate research findings [42]. The Arksey and O’Malley steps for a scoping review include: identifying the research question; identifying relevant sources; highlighting the study selection; explaining how the data was charted; and collating, discussing and reporting the results. The Arksey and O’Malley structure for the methodology has also been used in the writing of this article and these steps will be expanded upon below [42].

Fig. 1
figure 1

PRISMA ScR diagram showing the identification, selection, and inclusion of sources

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5.1 Identifying the research question

The following research question guided the review: To what extent are occupational therapy services for health promotion and prevention of disease and disability available for FDIs in LMICs? While it is useful in using knowledge from multiple contexts to set the background and purpose of the study, the interventions found in this scoping review were based off certain criteria that filled a specific research gap; this being only interventions set within LMIC by occupational therapists.

5.2 Identifying relevant studies

The search string was centred on the four main concepts in the research question, namely FDIs, LMIC, occupational therapy, and health promotion and prevention of disease and disability. The following search string was used consistently for each database: (“occupational therapy” OR “OT” OR “occupational therapist” OR “rehab”) AND (“refugees” OR “refugee camps” OR “asylum seekers” OR “internally displaced” OR “forcibly displaced people”) AND (“health promotion” OR “health prevention” OR “CBR” OR “community-based-rehabilitation” OR “prevention of disease and disability” OR “health promotive programs” OR “health preventative programmes” OR “health education”). The databases searched included PubMed, OTseeker, The Wits library database, EBSCO, Taylor & Francis, and SAGE Journals. The search included results up until February 2022. Online databases were selected based for their ability to provide focused and comprehensive results, their relevance to our topic, and their accessibility. The search strategy involved not only searching the electronic databases for sources but also reviewing the reference lists of the selected sources. Sources were assessed for inclusion through a screening process by first examining them by title and then by abstract. The full texts of the sources that met the inclusion criteria or those requiring further examination were retrieved. Two independent reviewers completed the screening process to reduce bias in source selection and information extraction.

5.3 Study selection

Articles were eligible if they described services by occupational therapists for FDIs within LMICs in English. This did not include health promotion and prevention of disease and disability services that were not specific to occupational therapy. Furthermore, articles that included occupational therapy services that were not focused on health promotion and prevention of disease and disability were not considered. No restrictions were made regarding the date of publication, nor the age and gender of participants.

5.4 Charting the data

An iterative standardised data charting form was used to extract necessary data separately, but consistently, for each article. The form was developed based on the suggestions by Arksey and O’Malley [42]. Information charted included the study site, the year in which the study was conducted, the FDI group on which the study focused, and the key findings as they related to the study.

5.5 Collating, summarising, and reporting the results

The results of the charted data were presented in tables to numerically collate the data. The results also summarise the data per source. Structuring the results in this way showed similarities and differences between the sources. The discussion presents the data according to the different aspects of health promotion and the prevention of disease and disability, respectively. In order for the results to be accurate, the interventions for health promotion and prevention of disease and disability needed to be directly related to the definition, or part of the definition, of health promotion and prevention of disease and disability. Therefore, the data was broken down and organised into categories, and the categories were used to maintain alignment with the research question [43]. For the purpose of this study health promotion was defined as “The process of enabling people to increase control over, and to improve, their health. To reach a state of complete physical, mental, and social wellbeing, an individual or group must be able to identify and realise aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life. Health is a positive concept emphasising social and personal resources, as well as physical capacities.” [44], p. 1. Similarly, for the purpose of this study, prevention of disease and disability was defined on the different levels of care: “Primary prevention aims to promote health and wellbeing and prevent disease before it occurs; secondary prevention aims to prevent the progression of disease through early intervention; and tertiary prevention includes management to slow down the progression of the disease” [45]. Using the above definitions and a classification system that was concrete and objective, ensured consistency among reviewers. Moreover, the selected definitions created a structure for the discussion and reporting of results.

6 Results

6.1 Search results

The results of the database searches are reported in Fig. 1. Figure 1 shows that from 469 studies identified in databases and 32 references screened, only 75 were assessed for eligibility. The excluded records include sources that used the use of occupations but not occupational therapists; those that were based in high-income countries (HICs); health promotion and prevention of disease and disability services not specific to FDIs; and services offered to FDIs that are too broad and not aligned to this research topic. Six sources met all the inclusion criteria and were included in this review.

The six sources that met the inclusion criteria are summarised in Table 1 together with their interventions. In Table 1, play is described in four sources as a health promotion and a prevention of disease and disability strategy [46,47,48]. Three sources also described interventions that use health education as a health promotion strategy. Income-generating activities are used in two sources for health promotion [46, 49].

Table 1 Characteristics of the included sources with a description of the specific intervention (n = 6)
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7 Discussion

7.1 Overview of sources

Occupational therapists play a crucial role in health promotion and preventing disease and disability among the FDI population, especially in preventing future developmental delays and psychological trauma in FDI children. Occupational therapists can also tackle the social determinants of health by addressing factors within the environment causing ill-health, such as addressing FDIs’ anxiety in finding employment. Occupational therapists have additionally been crucial in establishing healthy behaviours, instilling coping skills, and hosting health education talks. Finally, occupational therapists have been essential in preventing the impairments from disabilities from progressing, such as in neurological conditions, and enabling those with a disability to still live a full and wholesome life by being able to participate in activities they enjoy.

Most of the included sources described interventions conducted in Jordan. This is not surprising given that Jordan hosts one of the largest refugee camps in the world, the Zaatari camp [35]. It is however noteworthy that only one of the six sources included in our review was situated in Africa, despite the continent hosting approximately 30 million FDIs [35]. The results from this scoping review indicate that the majority (68%) of research in this field has been produced within the last decade. This trend underscores the growing global concern for the health of FDIs, as demonstrated by the increasing body of recent research [52]. Furthermore, it is not surprising that most of the described interventions in the sources were targeted at refugees. This aligns with the international and legal protections afforded to refugees compared to asylum seekers and internally displaced persons, resulting in refugees often receiving more comprehensive services [9]. Notably, all four sources that mention refugees were based in refugee camps, which suggests that delivering services in such camp settings is relatively more prevalent, a trend also supported by existing literature [53].

7.2 Role of occupational therapy within health promotion for FDIs in LMICs

Occupational therapists play a crucial role in promoting the health of FDIs through engagement in meaningful activities in alignment with the core philosophy of occupational therapy [29]. This role includes using various occupations to enable individuals to improve their health and have improved control over their lives to achieve health and wellbeing outcomes. Play can be used to achieve health outcomes, such as achieving developmental milestones and preventing trauma in FDI children [26]. Moreover, the results of this scoping review revealed that facilitating participation in work is also shown to be essential in fulfilling basic human needs, ensuring survival, and promoting long-term wellbeing [31, 46, 54]. Furthermore, encouraging engagement in contextually relevant occupations, such as farming, household management, participation in sports groups, and attending school, fosters a sense of belonging and self-worth [29, 49]. The absence of meaningful activities for FDIs can lead to feelings of frustration and isolation that ultimately affect their overall health and wellbeing, thus necessitating the use of occupations as a health promotion strategy.

Another aspect of health promotion that occupational therapists have a role in is improving the personal and social resources of FDIs, which can occur through health education. Health education is important as it can empower individuals to make their own decisions and rely less on health professionals, making interventions more sustainable to ensure continuity of care [55,56,57,58]. Additionally, health promotion strategies for FDIs include running skills groups. These skills groups can vary from giving teenage mothers the skills needed to cope with pregnancy to helping FDIs practice skills needed to engage in the daily occupations they did prior to displacement but that might be difficult to continue due to newfound disabilities, such as a spinal cord injury or traumatic brain injury [59]. Literature shows that some FDIs can lose the ability to plan and execute tasks because of the change in environments and difficulty adapting to the new environment, making skills groups an essential component of health promotion [59]. Additionally, by building on social resources through addressing environmental factors caused by limited financial resources, occupational therapists can enable health promotion among the FDI population [11, 15, 22, 60]. For example, advocating for a safe space for children to play will lead to more opportunities for occupational engagement and justice and ultimately health and wellbeing [29].

When individuals are forcibly displaced, they often experience role loss and encounter challenges engaging in meaningful occupations [46]. To help FDIs adapt to their changed environments it is crucial to re-establish roles and routines. In this review, several interventions addressed this need by re-establishing worker roles and encouraging entrepreneurship and capacity building through activities such as carpentry and goat rearing [46, 49]. The re-establishment of economic activities is significant for health as the loss of the worker role is associated with increased stress, anxiety, and alcohol dependency [46]. Furthermore, the findings from this scoping review indicated that creating social opportunities has played a vital role in helping FDIs cope with their circumstances by re-establishing habits of community participation [46, 49]. These social activities included farming, football, dance and drama groups, and traditional weaving groups [46, 49]. FDIs experience multiple systemic and contextual barriers that can lead to feelings of isolation, and re-introducing occupations related to economic participation and community engagement can mitigate the adverse effects of role loss on the health and wellbeing of FDIs. Notably, occupations such as goat rearing and weaving were mentioned as these are traditionally associated with LMICs, and may not typically be the focus of interventions in HICs.

7.3 Role of occupational therapy in relation to the prevention of disease and disability for FDIs in LMICs

In this review, occupational therapists used strategies to prevent future mental illness in FDI children and thus have a role to play in primary prevention strategies. Playgroups were used to indirectly facilitate healthy coping and to prevent mental health issues that would later affect children’s ability to partake in everyday tasks [46,47,48,49]. The sources found in this scoping review show that primary prevention interventions look particularly at children, as early experiences, such as forced migration, can affect individuals’ health and capacity for later participation in work and the social life of a community [61, 62]. Promoting play can thus prevent developmental delays, trauma, and social isolation [62]. Literature confirms that FDI children are susceptible to developmental delays, among other conditions, and that a special focus must be placed on children as they are particularly vulnerable [13]. In adults, primary prevention interventions for FDIs included alcohol prevention programmes for at risk population groups to prevent alcohol-related health and social challenges [46].

Secondary prevention strategies for FDIs, as found in this scoping review, encouraged occupational therapists to directly tackle the physical structures and mental skills needed to engage in occupations, for example, stretching children with musculoskeletal problems often caused by a neurological injury [50]. Secondary prevention was additionally achieved through preventing mental health deterioration by creating opportunities for refugees with mental health concerns to engage in healthy occupations such as sports [49]. Factors causing mental health care users stress and depression, such as unemployment, should also be addressed [29, 31, 54]. Ultimately, addressing factors affecting health in the community, leads to improved health outcomes [16, 60, 63].

None of the sources mentioned tertiary prevention strategies. Rather, the sources targeted early intervention to prevent disease and disability from worsening at an early stage in the course of the disease [46,47,48,49,50]. This was interpreted as primary and secondary prevention services being more effective and impactful than tertiary intervention where disease and disability are at an advanced stage. Research consistently shows that there are considerable long-term implications for FDIs if they do not receive early interventions [39, 62].

7.4 Factors that affect occupational therapy services for FDIs in LMICs

Barriers that limit the extent of occupational therapy services for health promotion and prevention of disease and disability were also identified, including a lack of occupational therapists for the large FDI population owing to limited funding [50, 51]. Due to limited funding there is a shortage of occupational therapists compared to the high numbers of FDIs. While this trend is mostly true for all healthcare workers within the FDI sphere, rehabilitation services in general receive less funding due to a lack of research into the role of rehabilitation services within LMIC for FDIs [50]. Furthermore, structural barriers such as language, stigma, legislation, and a lack of infrastructure affect the number of occupational therapy services accessible to the FDI population [50, 51]. For example, the stigma against people with disabilities in LMICs discourages them from seeking treatment, ultimately impacting the occupational therapy services that can be delivered [50]. Lastly, the embedded hierarchy among healthcare professionals prevents occupational therapists from being more involved in programmes for FDI health promotion and prevention of disease and disability [51].

Interventions used by occupational therapists for health promotion and prevention of disease and disability for FDIs in LMICs with their proposed health outcomes are summarised in Table 2. It is evident from the six sources included in this review that engaging in occupations leads to improved mental, physical and emotional health and there is a need to ensure marginalised populations are able to access occupations that are important to them.

Table 2 Occupational therapy health promotion and prevention of disease and disability services provided to FDIs in LMICs and their health and well-being benefits
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8 Limitations

Although the research in the review only included sources that were conducted in LMICs, the researchers from these sources were from HICs, which is concerning as they may lack contextual understanding of the countries in which they are performing their research. Furthermore, this indicates a disparity in collaborative research between HICs and LMICs as it shows poor capacity building and recognition for LMIC researchers [64]. This allows authors from HICs to receive the academic, social, and financial benefits while researchers from LMICs remain under-represented even though the topics may be more pertinent to them [64].

Furthermore, hand-searches through journals, liaising with stakeholders for additional sources, and non-English articles were not considered. Thus, certain sources could have been undetected. Moreover, while other disciplines have a role to play in the health and well-being of FDIs this was not the focus of this study and it must be acknowledged that this study is limited to occupational therapy led interventions only.

9 Conclusion and recommendations

This scoping review contributes to the understanding of occupational therapy interventions addressing the health and wellbeing of FDIs and highlights the unique role that occupational therapists have in meeting the needs of FDIs. Occupational therapy interventions for health promotion and prevention of disease and disability are highlighted in Table 2 to provide a broader understanding of how occupations lead to positive health outcomes for FDIs.

Recommendations for future research include establishing congruency between the needs of FDIs and the occupational therapy services provided, which will be useful to ensure client-centred service delivery. Further research into the expressed needs of FDIs will enable meaningful occupational therapy interventions. Moreover, further studies could look at the role of health promotion and prevention of disease and disability with the FDI population from the perspective of other disciplines. Recommendations for practice include addressing occupational injustices using a multisectoral approach and including occupational therapy services to address both medical and social challenges. Furthermore, it is advocated that occupational therapy services should be included in health promotion and prevention of disease and disability policies and guidelines for FDIs. As there are currently small global organisations that deliver occupational therapy services to FDIs, it is recommended that links between these organisations are established to standardise services and ensure all areas within LMICs are being covered equitably. Partnering global existing organisations through a direct management link can help create a more centralised body for occupational therapy services for FDIs with a larger global force so the most benefit can be derived from occupational therapy services for FDIs in LMICs.