Occupational health, integrative and complementary practices in primary care, and the Covid-19 pandemic

ABSTRACT OBJECTIVE: To identify the possible repercussions of the COVID-19 pandemic on the workers’ health, the care strategies used, and the provision of Integrative and Complementary Practices in health services in the context of COVID-19. METHOD: Descriptive study, with a qualitative approach, which used a focus group for data collection and content analysis according to Bardin. RESULTS: Eleven health professionals from the city of Registro (SP) participated and, based on the information analysis, four categories emerged: (1) Changes in work routine caused by the pandemic and the feelings they generate in health professionals; (2) Integrative and Complementary Practices as a self-care strategy in the pandemic; (3) Provision of Integrative and Complementary Practices during the pandemic; and (4) Occupational health as the focus and strategy motivator to resume the provision of Integrative and Complementary Practices in the municipality. CONCLUSION: This study allowed the identification of the impact of the pandemic, especially on workers’ mental health, which influenced the search for care strategies that included the Integrative and Complementary Practices. Professionals with this training began to offer the Integrative and Complementary Practices in the service to other workers, given the interruption of their provision to the population due to the COVID-19 pandemic.


PoPulation
Health services workers and managers from the Municipal Health Department (SMS) and of the Family Health Strategy teams (FHS).

Data collection
The focus group is widely used in public health research, aiming to obtain data from a group of individuals purposely selected (8) . To recruit focus group participants, a formal invitation was sent to the DS coordinators, and this request was also extended to all health workers, especially those who provide Integrative and Complementary Practices, as well as those who have training in some complementary therapy.
Data collection was carried out in two focus groups, using the platform Google Meet, on October 1 and 8, 2020. The groups, conducted by a moderator (ECP), had the participation of two observers (LZF and MCS) to ensure the continuity of the activity in case there were problems with the internet connection. The groups had an average duration of 50 minutes and were recorded. The direction of the debate was guided by the following questions: "How do you feel about the pandemic?", "How is your daily routine, your practice?", "How are you dealing with the changes?", "What are the complementary therapies provided in the services?" and "Is there a demand for complementary therapies in the services?".

Data analysis anD treatment
The focus group sessions were transcribed (ECP) and submitted to content analysis according to Bardin, going through the steps of (i) pre-analysis, (ii) exploration of the material, (iii) treatment of the results, and (iv) interpretation (9) . The identification of extracts and the elaboration of the categories were carried out in groups by all the authors. For the presentation of the results, the following codes were used for the participants: "P" for workers (profissional in Portuguese) or "G" for managers (gestores, in Portuguese); for services: "SMS", "FHS" or "DS"; and, for the focus group session: GF-S "1" or "2". The focus group was part of a project funded by CEREST-Registro, and supported by the Municipal Health Department of Registro (6) .

RESULTS
Eleven health workers participated in the focus groups, and the sessions were held in October 2020, with eight FHS professionals, two DS managers, and one SMS manager. Of these, ten were women and one, a man. As for education, nine participants had an undergraduate degree in Nursing, one participant had a degree in Physiotherapy, and one was a community health agent. Five participants had training in the following complementary therapies that make up the PNPIC: acupuncture, auriculotherapy, and flower therapy.
The group discussions provided an in-depth investigation of the provision of complementary therapies in Primary Care (PHC), exchange of experiences about workers' health and their work process in the current pandemic scenario, and discussion of strategies for the challenges presented. From these discussions, four categories were elaborated, and the main excerpts are presented below: category 1 -changes in the Work routine Due to the PanDemic anD feelings generateD in health Workers The COVID-19 pandemic has considerably transformed the professionals' work routine, requiring a new posture. Distancing from the family network, greater workload, difficulty in raising awareness among the population, and insertion of new protocols in the routine made the moment challenging and stressful, and led the workers to feel pressed, fearful, and insecure.
(...) it is something that we are tired of already and would like it to end soon. Like, the feeling is: 'it's over' and it isn't, you know, and we need to find more strength to hold on a little longer because it's not over yet, right? I think the most distressing thing, in my situation, is this issue of the family, of not having contact with them, anyway, that's it. (G1/DS GF-S1) Daily routine has been very disturbed. I don't know if I can use that word, much more agitated than we were used to, you know, with actions being integrated, like, in our daily lives, in a very crazy way and that, sometimes, we are not even prepared to that. (P1/FHS GF-S1) So, I think that, in the beginning, for everyone it was a mixture of feelings, right? It's fear, insecurity, so sometimes we don't know how to act in the face of something unknown, in the face of changes in protocol, in front of our family, in front of the team, and everyone expects a lot from you. (P2/FHS GF-S1) So, this moment, it's been a very challenging period, with a very important workload there, right, that we're trying to balance, right, between the demands that we already carried, you know, as our responsibility and, adding to this demand, this situation, right, the pandemic. (P3/FHS GF-S2) It's pretty stressful. Actually, it's day by day, and trying to get adapted to the conditions we're having at the moment. (P5/FHS GF-S2) category 2 -integrative anD comPlementary Practices as a self-care strategy in the PanDemic Self-care is essential for health maintenance and preservation and, in the context of the pandemic, its importance for the population as a whole became more present, which was no different for the participants of this research. Reiki, meditation, aromatherapy, and flower therapies were the practices mentioned as self-care strategies used. Based on the participants' reports, it was possible to identify different dynamics in the offer of complementary therapies during the pandemic: • interruption of the supply of complementary therapies to the population and search for strategies for its return; • interruption of the provision of complementary therapies to the population and its orientation to co-workers, especially auriculotherapy; • provision of complementary therapies, initially, directed to co-workers to, later, be offered to the general population; • introduction of complementary therapies with greater ease in the workers' routine of care; and • referral of cases to a reference professional. Here

DISCUSSION
Among the integrative and complementary practices that make up the PNPIC, the participants mentioned training in acupuncture, auriculotherapy, and flower therapy. The first two complementary therapies are part of the integral system of Traditional Chinese Medicine for health promotion and disease treatment. The first one uses the insertion of needles into acupuncture points; and the second places seeds or metallic spheres in points on the pinna. The third one, flower therapy, is a therapeutic practice that uses flower essences to balance and harmonize the individual (6) .
A project funded by the Brazilian Ministry of Health (MS), in partnership with the Brazilian Academic Consortium for Integrative Health (CABSIN) and the Regional Library of Medicine/ Pan American Health Organization/World Health Organization (BIREME/PAHO/WHO), sought to systematize, through maps, scientific evidence on Traditional, Complementary, and Integrative Medicines (TCIM) to support health workers, decision makers, and researchers in the construction of evidence-based health actions. These maps present an overview of the evidence in complementary therapies for specific health problems, including a map on acupuncture and a map on auriculotherapy, both of which are available on the site of the Virtual Health Library (VHL) in MTCI (https:// mtci.bvsalud.org/pt/mapas-de-evidencia-2/).
When analyzing the 30 years of SUS (5) , Integrative and Complementary Practices stands out as an important strategy in the redirection of the care model, as well as in the improvement of care integrality and the expansion of therapeutic options, in the face of a scenario of demographic-epidemiological transition. Specifically, complementary therapies from traditional knowledge are included in the field of primary care, encouraging category 4 -Worker's health in focus anD as a strategy for resuming the Provision of integrative anD comPlementary Practices in the municiPality In addition to modifying the work process at PHC, the COVID-19 pandemic shows the need to prioritize the workers' health. Participants understand that, at first, resuming or starting to care with complementary therapies for health workers would be the best option to reorganize its provision in the municipality.

I think it's cool. I think it's even a way for us to organize these services and then open them to the population, right? (...) In addition
to taking care of those who take care, right, because it's very complicated, sometimes we demand so much from our colleagues here, employees, but they are sometimes sicker than the population, you know. A way to value them too. (P1/FHS GF-S1) I think the team comes. It has to come first, because a team that feels welcomed, that feels that we professionals are paying attention to it, they can perform much better. (

...) Put it as something scheduled, do all that conversation that is necessary, you know, and do all that follow-up. I think it's a very good proposal and I'm going to implement it here. (P2/FHS GF-S1)
But I believe that we should, at this first moment, think about caring for the worker, about the team self-care, so that, later, when this is all very organized, structured, offer it to the population in its entire context. (G2/SMS GF-S1) I, in particular, think it would be great if it started with the health workers because we are the direct caregivers of the community in the use of available cultural and community resources, contributing to the production of changes in care and in the health services daily routine.
The pandemic produced new challenges for professionals, for example, dealing not only with the work routine directed to the new demands of the current context, but also with the emergence of feelings that can affect mental health. To minimize the negative effects of the pandemic, professionals use complementary therapies both for self-care and for the health care of co-workers. The reorganization of the provision of complementary therapies, aiming to improve the attention to the worker's health, can be a strategy to maintain and/or resume the provision of these practices in the municipality.
PHC is the gateway and the organizer of care in the complex health care network of SUS (10) . The professionals working there gain greater prominence in solving the health demands of the territories and are more exposed to risks. In addition to vulnerability to biological risks, such as contamination by the virus, the COVID-19 pandemic highlights the psychological suffering to which these professionals are exposed in the work environment. A review evaluated the relationship between factors linked to the workplace and the workers' mental health during the COVID-19 pandemic, revealing that these workers are more likely to have increased symptoms of depression, stress, anxiety, insomnia, among others (11) .
Participants in this study reported a heavy workload, distancing from the socio-affective network, unpleasant feelings and sensations in relation to changes in the work routine and the management of their own relationships. These issues are expected in the current context of a pandemic and directly reflect on the quality of life and self-care of these professionals. Therefore, the adoption of mental health care strategies for these workers is important and, thus, ensure their well-being to perform their duties (12) . Accurate updating of information about the disease, training in the use of personal protective equipment, monitoring of the team well-being, and mapping and dissemination of actions regarding the care available to workers should be measures to be incorporated in the recommendations to managers (12) .
This study showed that complementary therapies are adopted as a self-care strategy in the pandemic by workers who have training in one of the practices. Among the practices mentioned, meditation presents robust clinical evidence in mental health care. The mapping of possible evidence of complementary therapies in the context of COVID-19 shows that meditation techniques have "positive" and "potentially positive" effects for the management of post-traumatic stress, anxiety, depression, sleep disorders, work and psychological stress, among others. The studies included in the mapping and that investigated this practice highlight evidence with a confidence level of "moderate" to "high" (13,14) .
The participants' reports and the protection measures that were imposed in the municipality allowed the observation of a reduction in the supply of complementary therapies to the population of the municipality of Registro (SP) due to the needs of adaptation in assistance in the context of the pandemic. In this scenario, the provision of complementary therapies was directed to meeting the demand that arose from co-workers.
In 2020, there were initiatives to offer complementary therapies due to the pandemic, and the actions of the Nursing Care Network (https://redecuidarenfermagem.com.br/) and the Integrative and Complementary Practices Collaborative Network (https://www.ufrgs.br/levi/rede-colaborativa-PICS/#page-content) stood out in occupational health care. These collaborative projects received support from the Federal Nursing Council (CFE) and the National Health Council (CNS), respectively, and had the participation of professionals from different backgrounds, SUS workers and volunteer therapists, who offered several complementary therapies through individual or collective teleservices.
The provision of complementary therapies in PHC increased by 324% between 2017 and 2019, especially the practice of auriculotherapy, with an increase from 40,818 to 423,774 records (15) . This amount can be explained by the offer of training in this practice to PHC health professionals, which began in 2016. The agreement between the National Coordination of Integrative Practices and the Universidade Federal de Santa Catarina has already trained more than 10,000 higher education professionals (16) . This practice already has evidence-based clinical recommendations for the treatment of smoking, anxiety, insomnia, obesity and low back pain, which are prevalent conditions in PHC, and these protocols can be directed to the workers' health.
Studies indicate that the use of auriculotherapy in health professionals during the pandemic contributed to minimize pain; reduce symptoms of stress, depression and anxiety; promote the strengthening of bonds; and also improve the work environment (17,18) . This is one of the practices the participants of this study used in their co-workers health care. Auriculotherapy and other therapies, such as acupuncture, as well as practices related to the mind and body of Traditional Chinese Medicine, such as Tai Chi Chuan and Qi Gong, gather clinical evidence for pain conditions, treatment of several chronic and acute diseases, mental health and quality of life (19)(20)(21)(22) .
The WHO has designated 2021 as the International Year of Health Workers and Caregivers as a way of recognizing the dedication of healthcare professionals, responsible for the front line care of COVID-19. Thus, complementary therapies reveal themselves as a powerful health care strategy for these workers, as they address physical, emotional, social and also spiritual aspects of health care (23) .
The continuity of supply of complementary therapies during the pandemic at the initiative of some of the workers participating in the research demonstrates this care, but the recognition of managers and the proper registration is fundamental for the expansion of these practices at SUS. In addition, even though the PNPIC has existed for 15 years, the mobilization of institutional resources for its maintenance and expansion is increasingly necessary (24) .
The focus group, therefore, allowed an exchange of experiences and care practices in this complex moment of the pandemic, including complementary therapies. However, this exchange could have been enhanced if the group sessions had taken place in person. This, in fact, was the initial proposal of the project. It can be inferred, therefore, that the online format of the focus group was one of the limitations of this study, since some people quit and/or abandoned the sessions due to technological difficulties or lack of contact, which, in its turn, can reduce the idea of group belonging.

CONCLUSION
This study allowed the identification of the impact of the pandemic on workers' health, especially on mental health. This situation influenced the search for care strategies that included complementary therapies, as the professionals with adequate training began to offer these practices in the service to other workers, given the interruption of their provision to the population due to the COVID-19 pandemic.
Countless were -and continue to be -the challenges in the routine of health workers during the pandemic. In this study, complementary therapies were cited as a self-care strategy, and their provision to workers during the pandemic period revived the discussion about the importance of occupational health. The workers even indicated the following strategy for the resumption, at PHC, of complementary therapies, which were interrupted in the second half of 2020 due to the pandemic: first the practices should be offered to workers and, later, to the entire population.
This way, besides adapting services to ensure health and safety for workers during the pandemic, the construction of support networks and the systematization of the provision of complementary therapies to workers during the workday can help mental health care and health promotion.