Occupational Therapy in Cancer Survivorship—A Toolkit for Stimulating Rapid-Research on the Neglected Domain of “Participation” during COVID-19

COVID-19 has disrupted people’s occupational daily activities with detrimental impact on their daily living performances and quality of life. Occupational therapy contributes toward restoring health by remediating limitation in participation in meaningful occupation with lifestyle redesign interventions. However, the research gap on the area of “participation-limitation” for the field of Occupational Therapy in cancer survivorship during the COVID-19 is largely untapped and unknown. This commentary-review paper discussed the PEOOT (person-environment-occupation) grid as a conceptual toolkit for stimulating research in the domain of occupational participation—an essential aspect in the field of occupational therapy, for cancer survivors. It applies the expertise finding from a large Delphi study on research priority in the fields and integrating these into evidenced methodology, to provide a structure to guide the novice researchers towards rapid reviews, by selecting evidencebased methods to ensure contextually-relevant enquiry to identify the “occupational-participation issues”—i.e., an emerging social determinant of health, affecting the daily self-management of cancer survivors with or without comorbidities.

COVID-19 has created a big chasm of unknowns including research needs, with much uncertainties. Liang and collegues [25] gave a preliminary conclusion that cancer survivors (n = 18 out of 1590 Covid-19 cases) have higher risk of COVID-19 and with poorer prognosis. Zhou and collegues [26] attempt to highlight priority treatment for cancer patients during the pandemic. Two missing research aspects that needs greater work evidence in occupational therapy with cancer survivors are participation limitation and patient self-management [27] [28].
Occupational therapists need the research evidence to enable cancer survivors to engage in daily participation, and be effective in self-managing their daily occupational participation, through daily monitoring of their condition and make whatever cognitive, behavioural, and emotional changes needed to maintain a satisfactory quality of life. Patient self-management is the patient's ability to deal with everything that having a chronic condition, entails and it includes, managing the symptoms, treatment, emotional impact, physical and social consequences, and lifestyle changes, and there is evidence of effectiveness in woman with breast cancer [28]. Occupational participation is a key significant outcome in occupational therapy rehabilitation [27] [28] [29], and has been measured in breast and colorectal cancer survivors using the occupational participation questionnaire [12] [26]. Within these concepts, the Person-Environment-Occupation (PEO) model [30] described occupational performance (or occupational participation) as shaped by the interplay between 1) Person (i.e. role, self-concept, cultural background, personality, health, cognition, physical performance, and sensory capabilities), 2) environment (physical, cultural, institutional, social, and socioeconomic environment), and 3) occupation (i.e. groups of tasks individual participated in to meets self-maintenance, expression and fulfilment). As a model, PEO can be used as an assessment tool, in practice and in research, to understand and analyse problematic areas that affect clients' occupational performance [30] [31] [32].
Therefore, the neglected area participation-limitations are key domains in Occupational therapy, requiring more research to be stimulated and explore. However, rapid, timely research to inform interventions that supports the rising cancer survivors to better self-manage living with cancer effectively, are scare and efforts are complicated by low manpower rendering it as an area relatively untapped during the COVID-19 pandemic. Thus, this paper aims to stimulate a rapid-response for research priority in the neglected domain of participation issues, in Occupational therapy for cancer survivors during the COVID-19 pandemic.

Methodology
This review draws from the years of expertise' experience within the field of the cancer survivorship and occupational therapy (which are both relatively new in the healthcare of many developing countries). Using a flow process involving 3-sequential steps, rapid-review proceeding (Figure 1), novice researchers are guided to the overall process of planning, structuring and refining questions for research in the area. Health Two key occupational therapy documents were used for this paper: the Person-Environment-Occupation (PEO) Model [32] [33], and the recent findings from the World Federation of Occupational Therapists' (WFOT) on research priorities [34].
The three horizontal themes from the PEO model were utilised in the second step of conceptualising this research process for a conceptual toolkit to facilitate research in the area. The three themes of 1) Person-related, 2) Environment related and 3) Occupation-related context for therapy were used as the vertical theme in the grid, to generate a PEO.OT Grid. Using this Person-Environment-Occupation (PEO) model, it helps identify the occupational performance, shaped by the interaction between person, environment, and occupation [31] [32] [33].
Next, the second document (i.e. the WFOT document) with key significant research findings (derived from rigorous Delphi techniques with member organisations) on Occupational therapy research priority areas was used. Seven of the eight key priority areas were selected for inclusion into the PEO.OT Grid ( Table 1). The Occupational therapy professional issue was not selected as its too specific into profession-development issue. The remaining seven themes or Occupational therapy areas were: 1) Participation in everyday life 2) Occupational therapy and Non communicable diseases/Cancer 3) Effectiveness of interventions, 4) Evidence-based practice & Knowledge translation, 5) Healthy Aging, 6) Community development and populations, and 7) Technology and occupational therapy.

Results
The result of these cognitive deliberations using findings from research and established research methods, resulted in a PEO.OT Grid toolkit (Table 1) which served as a potential decision-aid tool to frame broad research questions, but focussed on issues related to Occupation therapy in cancer survivorship.

Question-Refinement Guides-for Qualitative, Quantitative and Policy Research
The novice and limited novice researchers can build up the broad questions using the evidence-based tool such as PICO (for quantitative clinical research topics) SPICE, PEO or SPIDER (for qualitative research topics), ECLIPSE or CLIP (for health management, policies). nants of Health called for governments to redirect health focus on social determinants, due to the increasing evidence of social contributions to health inequities [39]. This perspective is a timely call for the relevant health workers such as occupational therapists, to engage in integrated, contextually relevant and affordable care deliveries. The measures of impacted areas of occupational participation from the occupational therapy's perspective on the use of environments and contexts to facilitate health and well-being is timely during this pandemic of COVID-19 [40].  • Setting-where is the study set e.g., in a specific country, community, in a hospital, in a care home etc. • Perspective-from whose perspective is the study done e.g., the patients, the health professionals., the carers etc. • Sample-the group of people being looked at, because qualitative research is not to generalize, but to understand. • Phenomenon of Interest-reasons for behaviour and decisions, rather than an intervention.

Discussion
The PEO.OT grid (Table 1) as a conceptualised toolkit was formulated from this cognitive mapping process, with the aim to facilitate the novice therapists to structure their research question by focusing on the person-environment-occupation (PEO) constructs, within the intervention of occupational therapy (OT). This PEO-OT grid allows clinicians a directly focus into structuring for an area of cancer survivorship, to contributes to the needed data for expanding the occupational science knowledge-based. Once the research questions are formulated, refining using the established research methodology guide (see Table 2) to guide therapists towards an in-depth deliberation on the focussed topic from either a quantitative or qualitative approach. Table 2 will be useful to help redefine the specifics such as the population, setting, perspective, and evaluation to focus.
In general, this PEO.OT toolkit will help captures areas of occupational impacts or the ramifications of living with cancer during COVID-19, from an occupational perspective of an activity-based (occupation) living in the restricted pandemic environment, and to explore what are the associated outcomes associated with the physical, mental, social wellbeing of survivors. As the number of therapists are low in many developing countries, such toolkit can aid novice therapists/researchers in the field of cancer survivorship, to focus gathering the relevant evidence to inform their current intervention and future care from ano-ther pandemic. Using this PEO.OT grid, a guide on flow of research inquiry processes from planning, structuring to refining may help therapists to understand the experiences of cancer survivors living in the current pandemic.

Conclusion
In this era of prolonged COVID-19 pandemic, numerous impacts on health and also on daily-living participation are largely unknown. Participation limitation is an emerging social determinant of health, affecting the daily self-management of cancer survivors with or without comorbidities. This paper presents the application of the expertise finding from a large Delphi study (on research priority in the fields of Occupational therapy), into evidenced research methodology, to provide a conceptual-structure that guides the novice researchers towards rapid reviews, ensuring the results are contextually-relevant enquiries to identify the emerging "occupational-participation issue". A toolkit to facilitate novice researcher towards a rapid response to research can encourage the limited workforce and novice researchers in the field of occupational therapy to conduct the needed research, to inform practice, as well as for gathering evidence for policy and therapeutic care management. The PEO.OT grid is a potentially useful conceptualtoolkit to facilitate rapid decisions using evidence-based research methodology, to guide towards a contextually-relevant research topic on how the person (cancer survivors) and the COVID-19 environment, has impacted their daily living occupation (activities of daily living). These data are needed to inform occupational interventions to improve Quality of Life of cancer survivors. More research is needed on enabling patient self-management of the rising number of cancer survivors to improve effective living with cancer and its prolonged treatment but also, on aspects of recurrence prevention and health promotion.

Conflicts of Interest
The author declares no conflicts of interest regarding the publication of this paper.