Insertion and activities of occupational therapists in the field of social assistance: the panorama presented by the Social Services in Brazil (SUAS Census)

Abstract

Occupational therapy has historically been present in social assistance services that are part of the Unified Social Assistance System (SUAS), whose regulation was established in 2011 through Resolution No. 17 of the National Council of Social Assistance. This study aimed to identify the professional insertion of occupational therapists in SUAS, characterizing them according to sex, age group, employment status, function, workload, and location, and describing the main activities they develop. An exploratory, descriptive, and analytical study was conducted based on secondary data obtained from the official Federal Government database, the SUAS Census, covering the period between 2007 and 2022. The data were collected, organized, and examined to synthesize values of the same nature. The variables were described according to their content and frequencies. The results were organized into three themes: the characterization of occupational therapists, the scenario of insertion and exclusion, and work within SUAS. A decrease in the number of occupational therapists was identified, with lower decline in Day Centers and Homeless Population Centers and bigger decline in the Social Assistance Reference Centers (CRAS). The findings highlight their activities in essential services of social assistance units and their performance in management positions. Based on these results, this study seeks to contribute to guiding the assessment of participation in SUAS and to draw attention to the trend of decreasing numbers of professionals, with the intention of strengthening the category, encouraging work in the sector, and improving the assistance provided to users of the Social Assistance Policy.

Keywords:
Occupational Therapy; Social Work; Multidisciplinary Care Team; Professional Practice

Resumo

A terapia ocupacional esteve presente historicamente em serviços socioassistenciais que integram o Sistema Único de Assistência Social (SUAS), cuja regulamentação ocorreu em 2011, por meio da Resolução n.º 17 do Conselho Nacional de Assistência Social. Este estudo teve como objetivo identificar a inserção profissional de terapeutas ocupacionais no SUAS, caracterizando-as de acordo com sexo, faixa etária, vínculo empregatício, função, carga horária e localidade, além de descrever as principais atividades desenvolvidas. Para tanto, desenvolveu-se um estudo exploratório, descritivo e analítico, realizado a partir de dados secundários obtidos na base oficial do Governo Federal, o Censo SUAS, abrangendo o período entre 2007 e 2022. Os dados foram coletados, tabulados e analisados com vistas a sintetizar valores de mesma natureza. As variáveis foram descritas considerando seus conteúdos e frequências. Os resultados das análises foram organizados em três temáticas: a caracterização de terapeutas ocupacionais, o cenário de (des)inserção e o trabalho no SUAS. Evidencia-se a diminuição no quantitativo de terapeutas ocupacionais, com menor expressividade nos Centros Dia e Centros Pop e maior diminuição nos Centros de Referência de Assistência Social (CRAS). Destaca-se a atuação nos serviços essenciais das unidades socioassistenciais e o exercício da função de gestão por terapeutas ocupacionais. Com base nesses resultados, espera-se contribuir para subsidiar o dimensionamento da participação no SUAS e alertar para as tendências de retração no número de profissionais, de modo a de fortalecer a categoria, fomentar o trabalho no setor e qualificar a assistência prestada aos usuários da Política de Assistência Social.

Palavras-chave:
Terapia Ocupacional; Serviços de Assistência Social; Equipe Multiprofissional; Prática Profissional

Introduction

Social policies may be understood as responses to the expressions of the social question, produced within the correlations of force between capital and labor (Behring & Boschetti, 2011). For Iamamoto (2003, p. 27), the social question is the “set of expressions of the inequalities of mature capitalist society,” in which social production becomes more collective and labor broadly social, “while the appropriation of its fruits remains private, monopolized by a portion of society.” Consequences of the social question, such as the extreme concentration of wealth and the unrestrained growth of poverty, among others, have been the target of reparative actions within social policies, which seek to reduce the consequences generated by the capitalist system without, in fact, intending to break with the roots of inequality (Behring & Boschetti, 2011).

Within social assistance policy, the scope of intervention encompasses issues such as social unprotection, poverty, fragile relational bonds, unemployment, and gender inequality, among others (Santos et al., 2018). That is, social policies, including social assistance, are responsible for expanding opportunities within a structure intrinsically marked by inequities, and therefore have significant relevance for mediating access to social goods in the dialectic between superstructure and everyday life.

Social assistance policy was regulated later than the other two pillars of social security, health and social security insurance. Its structuring began within the parameters of the Brazilian Constitution with the approval of the first Organic Law of Social Assistance (LOAS) in 1993. Since then, marked by advances and setbacks, this policy has served as a pathway for expanding access to social rights for the Brazilian population (Vaitsman et al., 2009).

The government promulgated the National Social Assistance Policy (PNAS) in 2004 and the Basic Operational Norm of the Unified Social Assistance System (NOB/SUAS) in 2005. These documents established elements such as objectives, guidelines, principles, and management axes, allowing SUAS to organize the actions of Brazilian social assistance policy and constituting a milestone in the implementation of social rights. This perspective stands in opposition to the charitable and benevolent logics historically present, and still evident today, in social assistance actions (Brasil, 2004, 2005).

From the perspective of implementing social assistance services, programs, projects, and benefits, the PNAS document indicates that the protections guaranteed by the policy include Basic Social Protection and Special Social Protection of Medium and High Complexity (Brasil, 2004). Published in 2009 and updated in 2014, the National Typology of Social Assistance Services (TNSS) reiterates this organization by levels of social protection, establishing typologies intended to strengthen the supply of and access to social assistance rights (Brasil, 2009, 2014a).

The TNSS establishes a standardized matrix that defines the elements: service name and description, users, objectives, provisions, conditions and forms of access, unit, operating period, scope, network articulation, expected social impact, and regulations¹ (Brasil, 2014a). Table 1 summarizes the structure outlined in the TNSS.

Table 1
Summary of the National Typology of Social Assistance Services (TNSS).

Protection level	Unit	Service
Basic Social Protection	Social Assistance Reference Center] [Centers for children, adolescents, young people, and older people referenced to CRAS] /[User’s home].	1. [Comprehensive Family Care Service];
		2. [Coexistence and Bond Strengthening Service];
		3. [Basic Social Protection Home-based Service for Persons with Disabilities and Older People].
Special Social Protection – Medium Complexity	[Specialized Social Assistance Reference Center] / [Specific Unit Referenced to CREAS] / [User’s home] / [Day Center] / [Specialized Reference Center for the Homeless Population].	1. [Specialized Protection and Assistance Service for Families and Individuals];
		2. [Specialized Social Outreach Service];
		3. [Social Protection Service for Adolescents Fulfilling the Socioeducational Commitment of Assisted Freedom and Community Service];
		4. [Special Social Protection Service for Persons with Disabilities, Older People, and their Families];
		5. [Specialized Service for Homeless Persons].
Special Social Protection – Medium Complexity	[Shelter Unit]: For children and adolescents: [Small Group Home]; [Institutional Shelter]. For adults and their families: [Institutional Shelter]; [Transit Shelter]. For women experiencing violence: [Institutional Shelter]. For young people and adults with disabilities: [Inclusive Residences]. For older people: [Small Group Home]; [Institutional Shelter (Long-term Care Facility for Older People)]; [Supervised Independent Housing]; [Host Family Residence]; [Units Referenced to the Social Assistance Management Body].	6. [Institutional Shelter Service];
		7. [Supervised Independent Housing Service];
		8. [Host Family Foster Service];
		9. [Protection Service in Situations of Public Calamity and Emergencies].

Among the professionals who work in social assistance, occupational therapists have a historical presence in social assistance services (Almeida & Soares, 2023). The category obtained formal regulatory recognition in 2011 through Resolution no. 17 of the National Council of Social Assistance (Brasil, 2011a). The overview of the insertion of these professionals was presented in 2019 by Oliveira, Pinho, and Malfitano, who showed, based on SUAS Census data, that 1,323 occupational therapists were working in social assistance in 2016. Most were women, concentrated mainly in the Southeast region, and employed predominantly in Day Centers and Institutional Care Units (Oliveira et al., 2019). In 2024, according to the SUAS Census, 1,224 occupational therapists were working within SUAS (Brasil, 2024)².

Regarding the bibliographic production in the field, an integrative literature review published in 2024 by Bardi and Malfitano indicated that the number of articles has been increasing. Among the publications analyzed, most texts address services within medium complexity in SUAS, with emphasis on the Specialized Home Care Service (SEAD), the Specialized Assistance Service for Homeless Persons, and the services of Assisted Freedom and Community Service (PSC). Concerning target populations, socially vulnerable adults and young people predominated, with a strong emphasis on the homeless population (Bardi & Malfitano, 2024).

The growing number of publications highlights the potential contributions of occupational therapy in social assistance and reflects important challenges, such as the need to strengthen professional practices and to deepen understandings of issues related to the social field. This requires the creation of professional development processes that provide critical foundations and tools for work within the PNAS (Almeida et al., 2012; Bezerra & Basso, 2023; Bardi et al., 2023).

Inspired by Oliveira (2020) and by the challenges inherent to conducting occupational-therapeutic practice in social assistance, this study aimed to identify the professional insertion of occupational therapists in the social assistance units that compose SUAS and to characterize them according to sex, age group, employment status, function, weekly workload, and location (state and region). It also sought to describe the main activities developed by these professionals within the different social assistance services, based on the official records of the SUAS Census.

Method

This is an exploratory, descriptive, and analytical study conducted using secondary data obtained from the official Federal Government database, the SUAS Census, covering the period between 2007 and 2022.

The SUAS Census was created through Decree no. 7.334/2010 and constitutes one of the main tools for evaluating and monitoring the services, programs, and benefits offered by SUAS (Brasil, 2010). Data are collected through questionnaires and provide information on infrastructure, services, human resources, among other dimensions. The information analyzed in this study refers specifically to the human resources component. The questionnaires are completed annually by professionals working in the Social Assistance Reference Centers, Specialized Social Assistance Reference Centers, Homeless Population Centers, Day Centers, Institutional Care Units, Coexistence Centers, and by professionals in Municipal Management, State Management, and Municipal Social Assistance Councils (Brasil, 2008).

Since 2007, the data have been collected nationally and disseminated by the Ministry of Social Development and Social Assistance, Family, and Fight Against Hunger (under its current designation). Information on the category of occupational therapists began to appear explicitly in 2008. A review of the timeline for questionnaire completion and data availability in the SUAS Census shows that the Social Assistance Reference Centers were the first units to complete the questionnaire, with records available since 2007. The Specialized Social Assistance Reference Centers began completion in 2008. In 2011, the Homeless Population Centers also began to provide data. In 2012, the Institutional Care Units initiated completion, followed by the Coexistence Centers in 2014, and the last to provide data were the Day Centers, in 2015 (Brasil, 2023).

Since 2014, the questionnaires have linked services performed to professional categories. Thus, in the Social Assistance Reference Centers, Specialized Social Assistance Reference Centers, and Homeless Population Centers, it is possible to identify which professionals are assigned to social assistance services according to the following classifications: primary activity, secondary activity, and tertiary activity³. In the Day Centers, Coexistence Centers, and Institutional Care Units, this same classification does not exist; therefore, in this study, activities were analyzed based on the presence or absence of occupational therapists (Brasil, 2023). The classification differs because the format of data collection in the SUAS Census questionnaires is not the same across units.

These distinctions regarding the years in which each type of unit began completing the questionnaires are directly related to the availability of data for each of them. Consequently, there is heterogeneity in the information when analyzing the historical series from its beginning. Moreover, the questionnaires have been refined over time, and as a result, data have been added, further detailed, or removed from the form.

Procedures

The first stage of the study consisted of a preliminary analysis of the information available in the SUAS Census, particularly regarding human resources. Missing information relevant to the study’s objective was identified in the historical series (from the beginning of data availability in the SUAS Census, in 2007, up to its 2022 publication). In response, a formal request for the missing data related to occupational therapists was submitted through the Electronic Citizen Information System (E-Sic) portal in September 2022. E-Sic is one of the instruments that mediate the relationship between society and the State, created through the Access to Information Law (Brasil, 2012). The consultation through E-Sic made it possible to obtain information that was not available on the Federal Government websites, specifically concerning the human resources of social assistance units in the years covered by the historical series.

The variables selected referred to the Social Assistance Reference Centers, Specialized Social Assistance Reference Centers, Homeless Population Centers, Day Centers, Coexistence Centers, and Institutional Care Units⁴ between 2007 and 2022, with the following information obtained from the SUAS Census:

1. Data on occupational therapists according to sex, age group, unit, year, locality, employment relationship, weekly workload, and function;

2. Description of the primary, secondary, and tertiary activities of occupational therapists, as well as of the units with and without the presence of these professionals.

It should be noted that professional categories in the SUAS Census are identified by educational background and do not necessarily correspond to the function performed. For example, occupational therapists inserted in SUAS may perform the function of higher-level technician or another function for which they were hired.

Data analysis

An exploratory analysis of the secondary data was conducted initially. This analysis aimed to synthesize values of the same nature, allowing a global view of their variation and enabling the organization and description of the data.

Qualitative variables were described considering their content and frequencies (absolute and percentage), whereas quantitative variables were presented through summary measures⁵ such as mean, standard deviation, minimum, median, and maximum. For the analysis of quantitative data, the authors received support from a professional in the field of statistics, specifically for the application of regression tests and the use of the SAS 9.4 statistical software.

Changes in the percentages of occupational therapists from 2008 to 2022 were analyzed using a Joinpoint regression model (Kim et al., 2000), through the Joinpoint Regression Program (version 5.0.2). This statistical technique allows the identification of points of change (joinpoints) in time series and the estimation of trends (increase, stability, or decrease) in each identified segment.

Based on Poisson regression, the quantitative variables were calculated by counting elements, while the positions of the joinpoints and the regression coefficients were estimated. The ideal number of joinpoints was selected through a Monte Carlo permutation test, considering a maximum of two points and uncorrelated errors. To facilitate interpretation, the annual percent changes were estimated for each segment, along with their 95% confidence intervals.

Results and Discussion

The analyzed data enabled the delineation of an overview of the insertion of occupational therapists in SUAS, including the main activities they conduct—an aspect that, to the best of our knowledge, has not been addressed in previous publications. To present the results and the corresponding discussion, the content was organized into three themes: Characterization of occupational therapists working in SUAS; The scenario of professional (dis)insertion of occupational therapy in social assistance units; The work of occupational therapists in SUAS.

Characterization of occupational therapists working in SUAS

Regarding gender, women predominate in the occupational therapy profession and within social assistance services. On average across the period analyzed, women accounted for 95.3% in Specialized Social Assistance Reference Centers, 93% in Social Assistance Reference Centers, 92.36% in Homeless Population Centers, 92.36% in Day Centers, 91.39% in Institutional Care Units, and 91.06% in Coexistence Centers.

Concerning the most prevalent age group among occupational therapists, the interval between 30 and 40 years was identified as predominant. The corresponding annual averages were as follows: Social Assistance Reference Centers (46.02%), Specialized Social Assistance Reference Centers (46.49%), Homeless Population Centers (39.49%), Day Centers (45.49%), Institutional Care Units (42.91%), and Coexistence Centers (43.59%). Until 2019, the SUAS Census disclosed workers’ ages; beginning in 2020, however, information began to be provided in age groups, since, according to data protection legislation, age came to be considered sensitive information (Brasil, 2018).

Weekly working hours appeared in two main patterns over time: between 21 and 30 weekly hours in the Social Assistance Reference Centers (38.71%), Specialized Social Assistance Reference Centers (54.4%), and Homeless Population Centers (53.04%); and up to 20 weekly hours in the Coexistence Centers (52.72%), Day Centers (60.83%), and Institutional Care Units (52.32%). Information on the weekly workload of occupational therapists began to be recorded in 2009. The Federal Council of Physical Therapy and Occupational Therapy (COFFITO) established a maximum working week of 30 hours through Law no. 8.856 of March 1, 1994 (Brasil, 1994).

As for the employment status of occupational therapists, statutory public servants were most prevalent in the Social Assistance Reference Centers, Specialized Social Assistance Reference Centers, and Homeless Population Centers; workers hired under the Consolidated Labor Laws (CLT) in the Coexistence Centers and Day Centers; and employees of companies, cooperatives, or service-providing entities in the Institutional Care Units, as shown in Table 2.

Table 2
Professionals contracts in the social assistance services.

Employment status	Social Assistance Reference Center	Specialized Social Assistance Reference Center	Homeless Population Center	Day Center	Institutional Care Unit	Coexistence Center
	(CRAS)	(CREAS)	(Centro Pop)	(Centro Dia)	(Unidade de Acolhimento)	(Centro de Convivência)
Statutory public servant	33.34%	42.33%	52.38%	4.18%	11.04%	6.96%
Public employee under the Consolidated Labor Laws (CLT)	10.56%	11.38%	10.37%	10.71%	23.23%	8.31%
Private-sector employee under the Consolidated Labor Laws (CLT)	–	–	–	68.6%	–	44.66%
Temporary public servant	31.28%	11.67%	15.01%	3.25%	5.23%	4.26%
Outsourced worker	4.62%	13.67%	10.37%	3.87%	4.27%	11.16%
Other non-permanent employment	10.42%	4.8%	3.2%	8.16%	7.06%	14.35%
Commissioned position	6.68%	3.48%	2.4%	0.55%	0.9%	1.78%
Company/cooperative/service-providing entity	1.78%	12.63%	5.64%	–	43.84%	–
No employment relationship	–	–	–	–	1.47%	–
Volunteer	–	–	–	–	–	8.49%

• Source: SUAS Census, 2008–2022. Prepared by the authors.

An association emerges between employment arrangements in which service provision is managed directly by the State and the preservation of more stable working conditions, as evidenced in the Specialized Social Assistance Reference Centers, the Homeless Population Centers, and, with reservations, the Social Assistance Reference Centers. In the Social Assistance Reference Centers, statutory civil servants predominated; however, temporary civil servant status presented a very similar proportion and, when combined with the other employment statuses, the less stable arrangements prevailed.

In the Specialized Social Assistance Reference Centers, the impact of outsourcing became evident, demonstrated by the growth in the number of workers hired through companies, cooperatives, or service-providing entities. Although the more stable arrangements remained predominant, the total number of fragile statuses was very close to that of workers with stable contracts and guaranteed rights.

In the Homeless Population Centers, the most stable arrangements predominated.

The Day Centers presented the highest proportion of less stable arrangements, followed by the Coexistence Centers, with similar values. In both units, employees governed by private-sector CLT contracts constituted the majority.

In the Institutional Care Units, fragile employment statuses predominated, with emphasis on contracts established through companies, cooperatives, or service-providing entities, a pattern that showed a tendency to increase. The existence and proliferation of nongovernmental organizations in the execution of protective actions concentrate the proposals for partnerships between the State and civil society organizations. However, this model, supported by financial transfers that are often insufficient, tends to reproduce the precarization and flexibilization of working conditions. As a result, low wages and high turnover rates are recurrent, and under these provisional insertion arrangements many professionals, including occupational therapists, accept these positions as their first professional experience (Borba & Lopes, 2016).

In addition, Law no. 13.467, known as the Labor Reform, came into force in November 2017 and amended more than 100 articles of the CLT. Among the main changes, the law expanded flexible forms of hiring, such as intermittent work, autonomous work, hiring as a legal entity, outsourcing of core activities, and part-time work. Although the justification presented was the generation of employment, what has been observed socially is the replacement of protected employment relationships by precarized forms of work. Under a rhetorical discourse that refers to workers as collaborators or entrepreneurs, the current context resembles that of a century ago, marked by excessive working hours and lack of social protection. Moreover, the burden is individualized, since workers themselves must choose between ensuring employment and defending their rights (Fonseca, 2019).

Finally, the data presented highlight the consequences of different management arrangements for professional insertion. A broad network of service-providing units operates in social assistance, composed of “partner” nongovernmental entities, including assistance and philanthropic organizations, which constitute the so-called third sector. According to Montaño (2021), the third sector contributes to the dismantling of the State-based model of social intervention, producing responses guided by neoliberal logics.

With the expansion of neoliberal policies beginning in the 1990s, the number of outsourced services in Brazil increased, and various employment statuses became part of public policies. With the institutionalization of the social assistance policy, there was a movement away from the historical trend in labor relations, since the Unified Social Assistance System (SUAS) promoted the insertion of more stable arrangements, generating tension with the neoliberal order. At present, there are several forms of outsourcing, including concessions, public-private partnerships, cooperatives, nongovernmental organizations, civil society organizations for public interest, social organizations, and contracting of service-providing or labor-intermediating companies (Druck et al., 2018).

The scenario of professional (dis)insertion of occupational therapy in social assistance units

Regarding the functions performed by occupational therapists in social assistance services, the function most frequently observed is that of higher-education-level technician. The region with the highest concentration of professionals is the Southeast. The findings presented by Oliveira (2020) corroborate the data on gender, age group, working hours, region, and employment status, reinforcing the characteristics of occupational therapists who work in the sector.

A temporal examination of insertion shows that the category begins to appear gradually in the SUAS Census database starting in 2008 (Table 3). Using 2022 as a reference, the unit with the largest number of occupational therapists is the Day Center, the unit with the smallest number is the Homeless Population Center, and the location with the most pronounced decrease in professionals is the Social Assistance Reference Center.

Table 3
Number of professionals with a degree in occupational therapy by unit and year.

Year	Social Assistance Reference Center (CRAS)	Specialized Social Assistance Reference Center (CREAS)	Homeless Population Center (Centro Pop)	Day Center (Centro Dia)	Institutional Care Unit (Unidade de Acolhimento)	Coexistence Center (Centro de Convivência)
2008	98	54	-	-	-	-
2009	85	36	-	-	-	-
2010	117	41	-	-	-	-
2011	122	51	5	-	-	-
2012	127	53	4	-	-	230
2013	104	43	5	-	-	188
2014	115	38	13	-	-	260
2015	120	44	14	654	214	295
2016	127	56	16	605	218	301
2017	127	49	18	755	206	283
2018	142	50	12	920	212	350
2019	130	60	16	958	204	298
2020	122	56	14	1067	217	349
2021	92	64	14	1025	209	342
2022	87	49	9	922	171	351

• Source: Brasil, 2023. Prepared by the authors.

A careful examination shows a decrease in the number of professionals in Social Assistance Reference Centers, especially given their relevance for implementing social assistance rights, because they are the most widely distributed units in SUAS and therefore located closest to their users. These units are considered the access point for promoting social rights in the territory (Brasil, 2009). In addition, Social Assistance Reference Centers constitute the largest number of social assistance units in the country⁶ and exclusively offer several important services, such as the Comprehensive Family Care Service. Because of these attributes, these units can be regarded as a significant site of insertion for occupational therapists, given the possibilities for professional contributions to promote social protection through actions such as the facilitation of groups and workshops, individualized and territorial follow-ups, welcoming procedures, and network coordination (Oliveira, 2020).

Although Homeless Population Centers register the lowest absolute number of occupational therapists, they were the unit that, together with Day Centers, remained stable in number of these professionals over the years when compared to other professions, according to the Joinpoint regression analysis (Kim et al., 2000). This stability appears to reflect the prevalence of more stable employment arrangements and the fact that professional activities are performed primarily in the Specialized Service for People Experiencing Homelessness through direct public management by municipalities.

In Day Centers, which quantitatively have the highest insertion of occupational therapists, no decreasing trend was observed. This is attributed to the requirement that the profession be included in the minimum team when the unit provides services to 30 or more users per shift (Brasil, 2012).

However, the provision of social assistance services through the so-called third sector is a strong characteristic of Day Centers, and as Marinho and Euzébios Filho (2025) indicate, its effects in SUAS contribute to “justifying and legitimizing the dismantling of the social security model and the weakening of professional intervention” (p. 8). It is even possible for a single organization to be responsible for services across several levels of complexity in the system, as well as to hold agreements for the provision of services from other public policies, such as health and education (Basso et al., 2024).

Regarding the other social assistance units, specific recommendations indicate that the profession should be part of the reference team in the Basic Social Protection Home Care Service for People with Disabilities and Older People, linked to the Social Assistance Reference Centers, and in Institutional Care Units operating as Inclusive Residences (Brasil, 2014a; 2017).

Overall, the statistical regression analyses allowed the identification of the trends of the profession in each unit and revealed a movement of reduction in the insertion of occupational therapists in social assistance services. This finding contrasts with the results of Oliveira et al. (2019), which generally indicated an expansion of insertion. The difference is likely related to the broader temporal scope considered in the present study when compared with that analysis (2011 to 2016). Although the earlier period did not show linear growth, the trend was not maintained in recent years, and the decline in the number of professionals, particularly in 2022, became more evident.

This scenario of (dis)insertion may result from multiple factors, and the present data do not allow identification of the specific causes of the decline in the number of occupational therapists in the system. The weakening of public policies, especially social assistance policy, may be one of the hypotheses that influence this process (Bronzo & Araújo, 2024). The period from 2016 to 2022 was marked by a neoliberal government agenda that expressed interest in privatization and the dismantling of social policies. Furthermore, the COVID-19 pandemic, which began in 2020 and was particularly poorly managed in the national context, exacerbated multiple expressions of the social question, increasing poverty and social inequality and, consequently, intensifying the demand for social assistance services, especially for the most basic needs of the population, such as food security (Bronzo & Araújo, 2024). This process cannot be separated from the precarization of work, which was evident in the employment status patterns observed in the system.

Expanding the analysis to other professionals in the units, workers without higher education were the most prevalent. Even social workers and psychologists, who constitute the majority of the reference teams, were numerically fewer than workers without higher education⁷. Nationally, social workers represented the second most numerous category, except in Coexistence Centers, where they ranked fourth, and in Day Centers, where they ranked fifth. Psychologists, in the national overview, represented the third most numerous category; however, in Day Centers and Institutional Care Units, they ranked fourth, followed by Coexistence Centers, where they ranked fifth.

When occupational therapy is compared to other professional categories in decreasing order of prevalence, the following national pattern is observed: 12th place in Institutional Care Units; 11th in Coexistence Centers; 9th in Social Assistance Reference Centers and Homeless Population Centers; 8th in Specialized Social Assistance Reference Centers; and 7th in Day Centers. It is noteworthy that physical therapists ranked sixth in Day Centers, which is unexpected because this profession is not included in the NOB/RH/SUAS guidelines (Brasil, 2011b). It is essential that these guidelines be followed in daily social assistance practice (Pereira et al., 2017).

In this context, it is necessary to consider units with an intersectoral character, which combine activities aimed at social protection and are usually contracted to provide services across different public policies, most commonly social assistance, health, and education⁸ (Basso et al., 2024).

Day Centers and Institutional Care Units most frequently exhibit these characteristics. It is understood that, to some extent, intersectoral action within a single unit could strengthen interventions depending on work management and demand coordination, provided that the parameters, analyses, and social assistance objectives required by the field and by social assistance policy are not neglected.

Moreover, regarding units that combine actions from different sectors, it is important to consider that the structure of the SUAS Census data-entry system may not offer possibilities to distinguish the specific composition of teams. Concerning the involvement of units in completing the census, some fragilities can be identified. Only Specialized Social Assistance Reference Centers, Homeless Population Centers, and Coexistence Centers completed the SUAS Census questionnaires in all years. In other units, gaps appeared in certain years, although they are not statistically representative. Within the same argument, the number of cases of missing⁹ is recalled, revealing the absence of some information, preventing complete homogeneity of the dataset and, to some extent, indicating a limitation. Even so, the SUAS Census remains a relevant information source and constitutes the main tool for social assistance monitoring in municipalities and states.

With respect to the indirect provision of social assistance services, the presence of these workplaces has expanded. Many of them operate in continued engagement with poverty, preserving remnants of a logic of assistentialism rather than securing rights for the assisted population. Financial resources depend on funding from the State and from different public and private sectors. However, when service delivery is outsourced, these initiatives may fail to provide adequate pay and appropriate conditions for technical work in the field (Borba & Lopes, 2016).

The deterioration of working conditions and the precarization of employment arrangements that have occurred in the context of neoliberal capitalism affects all professional categories (Araújo & Morais, 2017). In occupational therapy within social assistance policy, however, a specific situation emerges: the insertion of the profession has declined, while the insertion of other professions has not shown a proportional reduction.

Other elements may also contribute to this scenario of professional disinsertion: the insufficient number of occupational therapists in Brazil; the distancing from the social assistance sector because of limited interest in salaries, which are generally lower than those offered in health-related services; and the lack of professional recognition. According to Basso (2025, p. 91), social assistance institutions, particularly those linked to the third sector, tend to offer positions with low weekly working hours and low wages, in addition to precarious employment arrangements established through service-provision contracts. This raises questions about the social value attributed to workers dedicated to social action, and about the recognition and prestige they receive in comparison with workers in other fields. At the same time, the current labor market has shown increased demand for positions in private pediatric clinics focused on children diagnosed with autism spectrum disorder (ASD) (Ricci et al., 2025). Given the availability of positions with higher pay, occupational therapists have opted for work in private clinics, a singular chapter in their professional history, which was marked by their involvement in charitable services and, later, in public policies.

However, working conditions in these clinics have also shown different forms of precariousness. Ricci et al. (2025) present a critical analysis of workers’ accounts, indicating fragile contracts, often resembling outsourced and intermittent arrangements, marked by limited rights and restricted social protection. These contracts are governed by neoliberal ideology, based on the paradigm of flexibility in labor rights, replaced by free negotiation between employers and workers (Dagnino, 2004).

Given the specific discussion about the scenario of professional (dis)insertion in SUAS, the trend toward a decline in the number of occupational therapists in social assistance units must be regarded as a warning for professionals, representative bodies, and policy managers. It is essential to strengthen efforts to secure opportunities for insertion by increasing visibility and recognition of the profession’s contributions to the promotion of social protection. This involves advocating for positions with more stable working arrangements, offering professional education that supports practice in social assistance, and reinforcing support for workers already inserted in SUAS. It is expected that making these data available will prompt strategies capable of fostering an effective mobilization of the profession, with the aim of reversing this trend.

In this context, and as part of the effort to strengthen the defense of broader employment opportunities, the next section examines the roles and practices of occupational therapists in this field.

The work of occupational therapists in SUAS

The analysis of activities performed by occupational therapists in SUAS is presented in two ways because of the nature of the data available in the Census. Information on Social Assistance Reference Centers, Specialized Social Assistance Reference Centers, and Homeless Population Centers allows services to be linked to the professional responsible for them. In Day Centers, Coexistence Centers, and Institutional Care Units, such detailed information is not provided. Consequently, for these units, the analysis focused on the actions conducted by the service, distinguishing between those with and without the presence of an occupational therapist.

The SUAS Census questionnaires associate responsibility for services with one of the professional categories listed by each unit during the mandatory annual data submission. Social Assistance Reference Centers, Specialized Social Assistance Reference Centers, and Homeless Population Centers classify activities as Primary, Secondary, or Tertiary Service/Activity. The Census uses the term “activities” to connect the service with the actions performed by professionals. For example, within Basic Social Protection, the following social assistance services may be offered: Family Comprehensive Care Service (PAIF), Coexistence and Bond Strengthening Service, and Basic Social Protection Home-Based Service for Older People and Persons with Disabilities. Accordingly, the term “activities” was maintained to respect Census terminology, while distinguishing between services and the actions conducted in each unit. In this study, the description was limited to the primary category linked to the occupational therapist.

In Social Assistance Reference Centers, the main service identified was the Coexistence and Bond Strengthening Service, between 2014 and 2020, at 23.8%, with a downward trend. It was followed by PAIF at 19.7%. Until 2020, PAIF showed a declining trend; however, it became the primary service linked to occupational therapists in 2021 and 2022. Administrative and management activities accounted for 6.39%, showing stability until 2020 and an upward trend thereafter.

According to Oliveira (2020), there is a consistent demand in these units for supporting and conducting groups and workshops. Although this is not a function exclusive to occupational therapists, they have demonstrated education and resources suitable for developing this type of activity.

In Specialized Social Assistance Reference Centers, the main service was the Specialized Care Service for Families and Individuals (PAEFI), at 26.72%, showing a downward trend. It was followed by social educational measures (Guided Community Service or Assisted Freedom), at 24.74%, which presented an increase until 2018 and a decrease thereafter. The Special Social Protection Service for Persons with Disabilities, Older People, and their Families accounted for 19.87%, with records starting in 2018 and growth over the past four years.

In Homeless Population Centers, the primary service was the Specialized Service for People Experiencing Homelessness, at 80.9%. This service showed prevalence until 2019, followed by a downward trend. Administrative (management) activities were noteworthy at 9.55%, with growth, especially between 2019 and 2020. The category “other” followed, at 4.33%.

Data also reveal the presence of occupational therapists in management functions. In Social Assistance Reference Centers, this function showed a growing trend; in Specialized Social Assistance Reference Centers, it was the most reported activity in 2022; and in Homeless Population Centers, it was the primary activity reported in all years. The SUAS Census began to include public administration/management as an option only in 2019. The increase of occupational therapists in management positions suggests recognition of their professional competence and indicates that the reduction in the number of therapists in some units may not be linked to a lack of qualification or insufficient recognition of their contributions.

The description of Coexistence Centers, Day Centers, and Institutional Care Units considered the presence and absence of occupational therapists, since, as noted, the available data do not specify which services are performed by this profession.

In Day Centers, more occupational therapists were found in units serving children and adolescents with disabilities and some degree of dependency and their families; adults with disabilities and some degree of dependency and their families, and older people with disabilities and their families. In units assisting older people with some degree of dependency (without disabilities) and their families, more units operated without an occupational therapist.

Some activities conducted within the Special Social Protection Service for Persons with Disabilities and Older People and their Families in Day Centers include: initial support and listening; social assessment; development of an individual and/or family follow-up plan; support for basic activities of daily living and self-care (hygiene, nutrition, rest); group and socialization workshops; individualized or group activities to support personal development and autonomy; collaboration in the application or referrals to other professionals (physical therapists, speech therapists, teachers, etc.); home visits; activities with the user’s family; and support and guidance for caregivers (Brasil, 2023).

There was a wide range of group-based activities conducted by occupational therapists in social assistance. This indicates that groups and workshops function as creative intervention opportunities aligned with the social vulnerabilities experienced by users and their families, structured according to the demands of social assistance and grounded in relational and everyday-life dimensions (Oliveira & Malfitano, 2021).When examining the actions conducted during the workshops¹⁰, the execution of these activities was, on average, more frequent in the units with an occupational therapist than in those without one. Even with the reduction of some actions in 2022, the trend still points to an increase.

As for the Day Centers and the populations assisted, it is important to note that the relationship between occupational therapy, social assistance, and persons with disabilities has historical roots that precede the current regulatory framework. This connection dates to the period in which nongovernmental organizations, formerly philanthropic entities, were responsible for delivering different public services, including services for persons with disabilities, older people, and children in situations of abandonment (Borba & Lopes, 2016). The cultural shift surrounding social assistance remains in progress and requires the construction of a new sociocultural understanding of rights, which also implies changes in professional practice in services directed toward persons with disabilities (Oliveira et al., 2019).

The provision of services shared with other sectors, such as health and education, in Day Centers raises questions about the practices currently implemented and the extent to which social assistance is prioritized in institutions that host these demands and multidisciplinary teams. Integrated and intersectoral actions offer significant value, but careful attention is necessary to prevent the work from approaching a medicalizing or biomedical logic (Oliveira et al., 2019). Many professionals working in a social assistance service may choose to respond to health-related demands, as they can produce faster and more concrete outcomes for the user within professional practice. Oliveira (2020) identified, for instance, professionals who, even when working in units linked to SUAS, did not see themself as part of the sector; and Basso (2025) discusses policy guidelines that do not reflect social assistance needs, particularly those of persons with disabilities and older people. Nonetheless, critically addressing the social dimension may require more time and complexity, since it demands a thoughtful examination of social realities and often results in long-term outcomes. Despite this, such an approach is necessary in the context in question.

Work in social assistance requires forms of care directed toward the social dimension of life, which makes knowledge from the humanities and social sciences indispensable. Contributions from the health field, while important, are often insufficient, or even inadequate, to respond to social needs (Malfitano, 2023).

In Institutional Care Units, the partnership with the third sector in service provision is also relevant, combined with the predominance of less stable employment conditions. Borba & Lopes (2016) contribute to this discussion by examining the possible roles of occupational therapists in nongovernmental organizations and noting that these entities frequently operate with reduced staffing structures. This results in an expansion of professional responsibilities beyond direct user support, requiring new skills and functions and increasingly exposing the political dimension embedded in technical work. Such units have historically employed occupational therapists, especially those directed toward children and adolescents (Fernandes et al., 2021), as well as older people (Freitas et al., 2022).

Although several types of care services exist in policy for the same population, service provision occurs in a heterogeneous manner, with an average of 95.13% of Institutional Care Units nationwide operating without occupational therapists. In recent literature, the contribution by Fernandes et al. (2021) is notable for its analysis of occupational therapy practice in an Institutional Care Service for Children and Adolescents in a municipality in the interior of the state of São Paulo. Freitas et al. (2022) also conducted a study aimed at understanding and describing the work of occupational therapists in a Long-Term Care Facility for Older People.

Regarding the populations assisted in Institutional Care Units, the units for children and adolescents recorded the highest prevalence of occupational therapists, with an average of 51.59%, followed by units exclusively for older people, with an average of 28.57%.

Among the main actions implemented by occupational therapists in the Institutional Care Units are¹¹: home visits conducted by the unit’s technical team to the user’s family; meetings with groups of users’ families; individualized psychosocial support; psychosocial support in groups; psychosocial support for the families of the persons assisted (family guidance); lectures and workshops; preparation of technical reports on cases under follow-up; case discussions with other professionals in the network; referrals for obtaining personal documents; outings with users; and recreational activities, among others.

When describing these actions, it becomes clear that many of them showed an increasing trend in units with and without occupational therapists. The average for 11 of the 16 actions analyzed was higher in units with occupational therapists than in those without these professionals. Although the SUAS Census database does not allow a more detailed characterization of what occupational therapists perform in these units, Borba and Lopes (2016) highlight functions that occupational therapists frequently undertake in non-governmental organizations, including coordination, intersectoral articulation, participation in events and forums, fundraising, project development and coordination, and team supervision, among others. Although some of these functions do not involve direct contact with users, they affect the quality of the work undertaken (Borba & Lopes, 2016).

In the Coexistence Centers, considering both the presence and absence of an occupational therapist and the populations assisted, units for children aged 0–6 years, young people aged 18–29 years, adults aged 30–59 years, and older people (60 years or over) recorded higher averages in units with an occupational therapist compared with units without the professional. Only the units for children and adolescents aged 7–14 years showed a lower average in those with an occupational therapist than in those without the category, although both types of units presented increasing trends.

The principal actions undertaken in Coexistence Centers include: home visits by the technical team to users’ families; family meetings; lectures; recreational activities; case discussions with other professionals from the social assistance network; activities involving community participation; activity planning; documentation and monitoring of information from the Coexistence and Strengthening of Bonds Service (SCFV); and workshops on cross-cutting themes (health, environment, culture, sport, and others). Among these actions, five of the 10 systematically undertaken in the Coexistence Centers recorded higher averages in units with an occupational therapist compared with those without the professional, and three showed very similar averages. In relation to the SCFV, the literature describes experiences focused on possibilities for work with children and young people (Borba et al., 2017; Minatel & Andrade, 2020) and with informal caregivers of persons with intellectual disabilities (Gomes et al., 2023).

Another item in the questionnaire concerns activities normally undertaken with SCFV users. A particular feature in the data is that these activities began to be recorded at least two years after the first data entries, in 2015. Nevertheless, among the 12 actions analyzed, eight showed higher averages in units with an occupational therapist than in those without the professional. These include musical activities (singing and playing instruments); handicrafts (costume jewelry making, fabric painting, embroidery, crochet); digital inclusion activities; actions involving food handling (cooking, preparation); gardening; school reinforcement; activities introducing users to the world of work; and activities involving daily life care, among others. Two additional activities showed very similar averages: arts and culture (painting, circus, dance, theater, paper crafts) and language-related activities (text production, storytelling, discussion circles).

Overall, occupational therapists have been part of the essential services in the various social assistance units. The category appears to respond to the technical demands of the services, with emphasis on group-based actions and, in particular, on work undertaken in Day Centers—an area strongly oriented toward persons with disabilities. Given the diversity of units and populations, professionals must analyze the social reality considering the consequences of the social question, particularly inequalities and their implications for multiple dimensions of everyday life. Thus, ways of understanding users’, groups’, and territories’ realities must be sensitive to identifying features related to social protection and unprotection, especially regarding the structure (or absence) of social support networks (Oliveira, 2020; Bardi et al., 2023).

Situations of vulnerability and violation of rights undermine the participation of individuals or groups in autonomously performing activities that are meaningful or relevant to their social environment. Experiences of suffering and the paralysis often associated with them become silenced by standardized and predefined responses from programs, services, and professional practice (Almeida & Soares, 2023). It is necessary, however, to break with these determinations, and occupational therapists have sought conceptual frameworks to contribute actively to this task, in partnership with other social professionals.

Final Considerations

This study aimed to identify the characteristics of the professional insertion of occupational therapists and the actions they implement in the different units of the Unified Social Assistance System (SUAS). The findings revealed a context of contraction in this insertion, with a decreasing trend in the Social Assistance Reference Centers. Although the data analyzed do not enable identification of the reasons for this reduction, the study highlighted some aspects that may be related to this process of professional (dis)insertion, such as the weakening of public policies, particularly social assistance, the insufficient number of professionals, and the expansion of better-paid work opportunities in private clinics. These data, therefore, underscore the relevance of further studies that explore the causes of this process and function as a warning for mobilizing efforts that involve different actors, including professionals, managers, and professional representative bodies.

Regarding the work of occupational therapists, the study showed that these professionals are part of the essential services in the units and are closely involved with the implementation of groups and workshops. In addition, given their predominant presence in Day Centers, the findings suggest recognition of occupational therapists’ role in work with persons with disabilities. The study also highlighted management functions performed by occupational therapists in SUAS.

In view of the scenarios revealed by the analyses, it is important to emphasize that the findings derive from information publicly provided by the SUAS Census, which does not necessarily portray an exhaustive picture of the workforce. It is relevant to mention that this Census, as a Federal Government database, depends on unit teams to submit responses to local Secretariats and Councils, which in turn complete the forms. During the study, missing data were identified, which may indicate fragilities in this source, in addition to the fact that it does not include data from all units in the country.

These limitations do not reduce the relevance of the SUAS Census as a research source and as the main instrument of social assistance surveillance. On the contrary, more frequent use of this database, together with the identification of gaps in completion or inconsistencies in specific variables, can support the improvement of social assistance surveillance resources for data collection and consolidation, thus outlining scenarios that contribute to understanding elements that are essential for professional and political action.

Finally, this study is important for the field of occupational therapy, because a deeper understanding of its reality enables the profession to design strategies to strengthen its role in social assistance policy. This descriptive and analytical mapping can inform continuing education initiatives, professional development, and knowledge production that support advocacy for an increased number of occupational therapists in social assistance.

Based on the argument that occupational therapy has methodologies and tools that can contribute directly to achieving social protection in Brazil, the expectation is that its role will be strengthened in social assistance services, so that it contributes to mediating processes aimed at reducing the staggering social inequality that characterizes the country, by fostering solidarity in the difficult everyday lives of people assisted by social assistance services.

• 1
  It is worth noting the distinction between the social assistance unit and the social assistance service, described in the TNSS document in the following terms: “NOME DO SERVIÇO [SERVICE IDENTIFICATION]: Terms used to designate the service in a way that highlights its main function and its users. […] DESCRIÇÃO [DESCRIPTION]: Content of the substantive provision of the service. UNIDADE [UNIT]: Facility recommended for the implementation of the social assistance service.” (Brasil, 2014a, p. 9).
• 2
  Value obtained from the total number of professionals with a degree in occupational therapy working in the following units: Social Assistance Reference Center (63), Specialized Social Assistance Reference Center (36), Homeless Population Center (12), Institutional Care Unit (278), Coexistence Center (151), and Day Center (684). Data available in the 2024 SUAS Census.
• 3
  In the SUAS Census questionnaire, respondents are asked to indicate the services and/or activities to which the professional, whether with secondary or higher education, is assigned, identifying the main service, the second most central service, and the third most central service performed. This question applies to the following units: Social Assistance Reference Centers, Specialized Social Assistance Reference Centers, and Homeless Population Centers.
• 4
  The Foster Family Care Service was not included in this study because of the nature of the work, since the activities are related to the management, supervision, organization, and articulation of the service with families, which does not characterize work within an institutional setting (Brasil, 2009). Data on the technical administration of municipal and state funds were also not included.
• 5
  The arithmetic mean is the sum of all elements in the series divided by the number of elements. The standard deviation indicates the degree of uniformity in a dataset: the closer the standard deviation is to zero, the more homogeneous the data. The minimum is the smallest value in the series. The median is determined by ordering the data in ascending or descending order and identifying the central value of the series. The maximum is the largest value in the series (Morato, 2019).
• 6
  According to data from the Censo SUAS.
• 7
  The category “without higher education” is one of the options available in the questionnaire, in the field designated to indicate the profession of higher-education workers.
• 8
  An example of an institution that brings together services from different policy areas is the Associação de Pais e Amigos dos Excepcionais (APAE). For instance, under the Education Policy, APAE may offer Specialized Educational Assistance – Multifunctional Resource Rooms, a Specialized Educational Assistance Center, and a Basic Education School in the Special Education modality, among others. Under the Health Policy, it may operate a health unit for habilitation and rehabilitation or a Specialized Rehabilitation Center I or II, or a clinical analysis laboratory and other services authorized by specific regulations. Under the Social Assistance Policy, similarly, it may operate a unit referenced to the system with different service, program, and project offerings according to the typification, other resolutions, and additional provisions in advisory services and/or protection and enforcement of rights (Brito, 2019, p. 37).
• 9
  Missing: refers to information that does not exist or is absent in the database. The tables with complete information, including the missing data, are available in the dissertation from which this study originates (Theodoro, 2024).
• 10
  All activities examined derive from the SUAS Census questionnaires completed by social assistance units. Unlike the Social Assistance Reference Centers, the Specialized Social Assistance Reference Centers, and the Homeless Population Centers, where the service is linked to the occupational therapist, the Day Center questionnaire lists the actions implemented.
• 11
  Terms used in the SUAS Census questionnaires.
• How to cite:
  Theodoro, A. M., Bardi, G., Malfitano, A. P. S., & Oliveira, M. L. (2025). Insertion and activities of occupational therapists in the field of social assistance: the panorama presented by the Social Services in Brazil (SUAS Census). Cadernos Brasileiros de Terapia Ocupacional, 34, e4077. https://doi.org/10.1590/2526-8910.cto414840772
• Data Availability
  The data supporting the results of this study are available from the corresponding author upon request.
• Funding Source
  This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - Brasil (CAPES) – Finance Code 001.

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Edited by

• Section editor
  Prof. Marta Carvalho de Almeida

Data availability

The data supporting the results of this study are available from the corresponding author upon request.

Publication Dates

• Publication in this collection
  09 Feb 2026
• Date of issue
  2026

History

• Received
  15 Mar 2025
• Reviewed
  15 July 2025
• Reviewed
  09 Sept 2025
• Accepted
  04 Nov 2025