Abstract

Within the context of the COVID-19 pandemic, telehealth was seen to be a viable and alternative solution to provide occupational therapy services in the Philippines. This phenomenological study aimed to describe the lived experiences of Filipino parents and carers in receiving occupational therapy through telehealth for their children with disabilities. We interviewed 10 participants who were considered primary carers of a Filipino child with disabilities undergoing telehealth during the COVID-19 pandemic situation. An interpretative phenomenological analysis involving double hermeneutics was employed to analyze the interviews that yielded four themes: “dimensions of telehealth in occupational therapy”, “reinforcing family-centered occupational therapy”, “emphasizing an occupational therapist’s advocacy role”, and “telehealth in occupational therapy–today and tomorrow”. Our findings suggest that in order for telehealth to be a sustainable service, it should be seen not merely as an alternative in the occupational therapy service delivery process. Although telehealth remains to be an evolving concept and practice within health services, telehealth must be practiced within the principles of family-centered care approaches, interprofessional collaboration, and health accessibility and equitability. This study hopes to facilitate intersections between service providers and service users to cultivate a shared goal of bringing together experiences that will inform a more contextualized occupational therapy and telehealth practice at the tail-end of the pandemic. In conclusion, telehealth in occupational therapy shall not be an alternative, but an integrative tool that occupational therapists can maximize to transform occupational therapy access and equity.

Keywords:
Health Teleservices; Health Teams; Interdisciplinary; Rehabilitation; Occupational Therapy

Resumo

No contexto da pandemia da COVID-19, a telessaúde foi considerada uma solução viável e alternativa para a prestação de serviços de terapia ocupacional nas Filipinas. Este estudo fenomenológico teve como objetivo descrever as experiências vividas por pais e cuidadores filipinos ao receberem terapia ocupacional por meio da telessaúde para seus filhos com deficiência. Entrevistamos 10 participantes que eram considerados cuidadores primários de uma criança filipina com deficiência submetida à telessaúde durante a situação de pandemia da COVID-19. Uma análise fenomenológica interpretativa envolvendo dupla hermenêutica foi empregada para analisar as entrevistas, resultando em quatro temas: “dimensões da telessaúde na terapia ocupacional”, “reforçando a terapia ocupacional centrada na família”, “enfatizando o papel de militância do terapeuta ocupacional” e “telessaúde na terapia ocupacional – hoje e amanhã”. As nossas descobertas sugerem que, para que a telessaúde seja um serviço sustentável, deve ser vista não apenas como uma alternativa no processo de prestação de serviços de terapia ocupacional. Embora a telessaúde continue a ser um conceito e uma prática em evolução nos serviços de saúde, deve ser praticada dentro dos princípios de abordagens de cuidados centrados na família, colaboração interprofissional e acessibilidade e equidade em saúde. Este estudo espera facilitar interseções entre prestadores e usuários de serviços para cultivar um objetivo comum de reunir experiências que informarão uma terapia ocupacional e uma prática de telessaúde mais contextualizadas no final da pandemia. Concluindo, a telessaúde na terapia ocupacional não deve ser uma alternativa, mas sim uma ferramenta integrativa que os terapeutas ocupacionais podem maximizar para transformar o acesso e a equidade à terapia ocupacional.

Palavras-chave:
Serviço de Telessaúde; Prática Interdisciplinar; Reabilitação; Terapia Ocupacional

Introduction

Occupational therapists in the Philippines abruptly transitioned to deliver occupational therapy (OT) services using telehealth in response to the quarantine restrictions and stringent social distancing protocols implemented by the government to mitigate the spread of the novel coronavirus (Philippine Academy of Occupational Therapists, 2020Philippine Academy of Occupational Therapists – PAOT. (2020). Guidelines on the use of telehealth as an alternative form of occupational therapy service provision. Retrieved in 2023, August 7, from https://wfot.org/assets/resources/PAOT-Guidelines-on-the-Utilization-of-Telehealth.pdf
https://wfot.org/assets/resources/PAOT-G... ). From the 13th of March 2020 (Office of the President of the Philippines, 2020Office of the President of the Philippines (2020, March 13). Memorandum from the Executive Secretary on stringent social distancing measures and further guidelines for the management of the coronavirus disease 2019 (COVID-19) situation. Retrieved in 2023, August 7, from https://www.officialgazette.gov.ph/2020/03/13/memorandum-from-the-executive-secretary-on-stringent-social-distancing-measures-and-further-guidelines-for-the-management-of-the-coronavirus-disease-2019-covid-19-situation/
https://www.officialgazette.gov.ph/2020/... ), a community quarantine was imposed in the country where the movement of people is restricted to the access of basic necessities and essential health services. The government’s response to the pandemic is described as one of the longest and strictest. It relied on strict health protocols such as wearing of masks and social distancing implemented by the police and the military (Hapal, 2021Hapal, K. (2021). The Philippines’ COVID-19 response: securitising the pandemic and disciplining the pasaway. Journal of Current Southeast Asian Affairs, 40(2), 224-244.) delaying its response in strengthening the health system by increasing the hospital bed capacity for COVID-19 patients and having more human resources for health. Occupational therapists were prompted to transition their face-to-face sessions to be delivered remotely via telehealth. In light of this service delivery transition, the Philippine Academy of Occupational Therapists (PAOT) released interim guidelines on the utilization of telehealth with emphasis on professional standards, ethical considerations, and monitoring, and emphasized telehealth as an alternative form of service provision during a public health emergency (Philippine Academy of Occupational Therapists, 2020Philippine Academy of Occupational Therapists – PAOT. (2020). Guidelines on the use of telehealth as an alternative form of occupational therapy service provision. Retrieved in 2023, August 7, from https://wfot.org/assets/resources/PAOT-Guidelines-on-the-Utilization-of-Telehealth.pdf
https://wfot.org/assets/resources/PAOT-G... ). It was only until the 14th of November 2021 that the strict quarantine restrictions were lifted allowing more occupational therapy facilities to operate onsite services (Inter-agency Task Force, 2021Inter-agency Task Force, Management of Emerging Infectious Diseases. (2021). Guidelines on the implementation of alert levels system for Covid-19 response in pilot areas. Retrieved in 2023, August 7, from https://mirror.officialgazette.gov.ph/downloads/2021/10oct/20211104-IATF-Guidelines-RRD.pdf
https://mirror.officialgazette.gov.ph/do... ).

Telehealth in occupational therapy refers to the use of information and communication technologies to deliver health-related services, including evaluation, intervention, monitoring supervision, and consultation among therapists, clients, and other healthcare providers (World Federation of Occupational Therapists, 2014). There are low-tech strategies, such as phone calls, electronic mails, and text messages; mid-tech strategies, including videoconferencing and use of commercially available applications; and high-tech strategies, such as those that can cater to personalized and specialized intervention (Camden & Silva, 2021Camden, C., & Silva, M. (2021). Pediatric Telehealth: opportunities created by the COVID-19 and suggestions to sustain its use to support families of children with disabilities. Physical & Occupational Therapy in Pediatrics, 41(1), 1-17.). According to Doarn et al. (2008)Doarn, C. R., Yellowlees, P., Jeffries, D. A., Lordan, D., Davis, S., Hammack, G., McClosky-Armstrong, T., & Kvedar, J. (2008). Societal drivers in the applications of telehealth. Telemedicine Journal and e-Health, 14(9), 998-1002., telehealth is no longer an idea or a pilot project, rather it is considered a key societal driver that would transform health care delivery by being a solution to the aging population, unhealthy lifestyles, climate change, shortage of human resources for health, economic disparities, diversity, and inclusion among others.

In a case study conducted by Sy et al. (2020)Sy, M. P., Pineda, R. C., Yao, D. P., Guevara, C. A., Delos Reyes, R. C., & Castro, I. M. (2020). Shared voices of Filipino occupational therapists during the COVID-19 pandemic: reflections from an online forum. World Federation of Occupational Therapists Bulletin, 76(1), 60-64., occupational therapists expressed in an online forum that their use of telehealth is framed by the occupational therapy process where clients are evaluated based on their current needs, environments, contexts, and personal perceptions in using telehealth. Participants also mentioned that some of their clients expressed preference to direct therapy services versus telehealth. As telehealth allows for the intervention within a client’s natural environment, parents and carers actively participate in the therapy process done in the home context. Occupational therapy services delivered via telehealth for children with disabilities have been found to support families in their everyday routines (Little et al., 2018Little, L. M., Pope, E., Wallisch, A., & Dunn, W. (2018). Occupation-based coaching by means of telehealth for families of young children with autism spectrum disorder. The American Journal of Occupational Therapy, 72(2), 7202205020.). Wallisch et al. (2019)Wallisch, A., Little, L., Pope, E., & Dunn, W. (2019). Parent perspectives of an occupational therapy telehealth intervention. International Journal of Telerehabilitation, 11(1), 15-22. also identified similar findings on the perspectives of parents of children with Autism who received occupation-based coaching via telehealth. An evidence-based practice review conducted by Zylstra (2013)Zylstra, S. E. (2013). Evidence for the use of telehealth in pediatric occupational therapy. Journal of Occupational Therapy, Schools & Early Intervention, 6(4), 326-355. showed high levels of satisfaction when receiving occupational therapy services delivered through telehealth among children with disabilities.

However, practicing telehealth is not without barriers, as Cason (2012)Cason, J. (2012). Telehealth opportunities in occupational therapy through the Affordable Care Act. The American Journal of Occupational Therapy, 66(2), 131-136. noted security issues, privacy issues, concerns about the quality of services provided, and the current lack of evidence to support the effectiveness of telehealth. Moreover, parents also experienced fears of having to cope on their own and losing progress, feeling overwhelmed with the responsibility, difficulties in implementing the program, stress and anxiety from the child engaging in video, and isolation from other people as activities are being done online. The loss of structure and routine that parents of children with autism experienced during the COVID-19 pandemic has also contributed to their stress and concerns when utilizing telehealth (White et al., 2021White, S. W., Stoppelbein, L., Scott, H., & Spain, D. (2021). It took a pandemic: perspectives on impact, stress, and telehealth from caregivers of people with autism. Research in Developmental Disabilities, 113, 1-8.).

In the context of the Philippines, Delos Reyes (2021)Delos Reyes, R. (2021). Beliefs of Filipino caregivers on occupational therapy through telehealth. Annals of Physiotherapy & Occupational Therapy, 4(1), 1-4. https://doi.org/10.23880/aphot-16000187?
https://doi.org/10.23880/aphot-16000187?... identified that Filipino parents and carers from a rural locality who did not avail telehealth services considered telehealth as their last option due to internet connection problems, power interruptions in their area, anticipated challenges in engaging the child in therapy, and belief that in-person therapy is more effective. The perspective that telehealth may not be as effective in achieving outcomes as compared to face-to-face intervention has been present even before the pandemic (Edirippulige et al., 2016Edirippulige, S., Reyno, J., Armfield, N. R., Bambling, M., Lloyd, O., & McNevin, E. (2016). Availability, spatial accessibility, utilisation and the role of telehealth for multi-disciplinary paediatric cerebral palsy services in Queensland. Journal of Telemedicine and Telecare, 22(7), 391-396.). In times like this, Filipino occupational therapists must work together as a group to heed the call for sustainable actions towards making occupational therapy services not only available but accessible to the public (Sy et al., 2020Sy, M. P., Pineda, R. C., Yao, D. P., Guevara, C. A., Delos Reyes, R. C., & Castro, I. M. (2020). Shared voices of Filipino occupational therapists during the COVID-19 pandemic: reflections from an online forum. World Federation of Occupational Therapists Bulletin, 76(1), 60-64.).

This study aimed to understand the experiences of Filipino parents and carers in receiving occupational therapy delivered via telehealth for their children with disabilities during COVID-19 pandemic. Specifically, we intend to describe how occupational therapy via telehealth is delivered and to explore the meanings of the lived experiences of parents and carers towards telehealth.

Methods

Study design

A qualitative research design underpinned by phenomenological procedures involving double hermeneutics (Smith et al., 2009Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: theory, method and research. London: SAGE.) was used to understand the experiences of Filipino parents and carers about the phenomenon of receiving occupational therapy services delivered via telehealth during the COVID-19 pandemic. This study particularly followed an interpretative phenomenological analysis, a ‘participant-oriented’ analytical approach in treating qualitative data sets, with emphasis on showing respect and sensitivity to the ‘lived experiences’ of the research participants (Smith et al., 2009Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: theory, method and research. London: SAGE.). The study was granted ethical approval by the University of the Philippines Manila Research Ethics Board (UPMREB 2021-0360-01).

Purposive sampling was implemented. Potential participants were recruited through a poster posted on the social accounts of the National Teacher Training Center for the Health Professions (NTTCHP) and the PAOT. The poster contained a link to a Google Form that asked for participant’s eligibility. For eligible participants, an informed consent form would be shown for agreement in the same link. From those who agreed to participate, ten (10) participants were eligible (seeTable 1 for their demographic profile), which fits the sample size recommended for phenomenological studies (Creswell, 2014Creswell, J. W. (2014). Research design: qualitative, quantitative and mixed methods approaches (4th ed.). California: Sage.).

The study included parents and carers who are: Filipino citizens currently residing in the Philippines; have children that are currently receiving or have received occupational therapy services delivered via synchronous telehealth for no less than 4 months in therapy centers (e.g., private, hospital, community-based) in the Philippines; communicates primarily in Filipino based in Tagalog or in English; and, can participate in online audio or video interview voluntarily. Parents and carers of children with disabilities who received asynchronous telehealth alone such as that of home program instructions and e-mail communications were excluded from the study. Also, clients who had been serviced by the affiliated therapy centers of the researchers were also excluded. One participant (Participant 4) was excluded after the interview because the interview revealed that she did not meet the inclusion criteria for the duration of occupational therapy services received via telehealth.

Data were collected through semi-structured, in-depth interviews conducted online. Two (2) researchers were present to conduct video calls through a video conferencing platform (Zoom). An interview protocol (see Table 2) was used to guide the interview process. The 11 questions in the interview protocol were adapted from the open-ended interview questions used in previous studies (Wallisch et al., 2019Wallisch, A., Little, L., Pope, E., & Dunn, W. (2019). Parent perspectives of an occupational therapy telehealth intervention. International Journal of Telerehabilitation, 11(1), 15-22.; Foster et al., 2013Foster, L., Dunn, W., & Lawson, L. M. (2013). Coaching mothers of children with autism: a qualitative study for occupational therapy practice. Physical & Occupational Therapy in Pediatrics, 33(2), 253-263.).

The questions were adapted to be more specific on occupational therapy delivered via telehealth while retaining the essential keywords that will elicit answers to meet the objectives of the study such as quality, challenges, helpful components, and changes in doing. The interviews lasted for 30-60 minutes. All interviews were audio recorded and transcribed verbatim by an external encoder. After the interview of the tenth participant, data adequacy was achieved and there were no repeat interviews.

Analysis of findings

The data sets collected were processed through inductive thematic analysis involving double hermeneutics. It followed the six-step guideline based on the Interpretative Phenomenological Analysis proposed by Smith et al. (2009)Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: theory, method and research. London: SAGE.. The researchers read and reread the transcripts. Each transcript was assigned to two researchers for open coding based on content and meaning using software such as ATLAS.ti 9 (Friese, 2021Friese, S. (2021). ATLAS.ti 9 user manual. Berlin: ATLAS.ti. Scientific Software Development GmbH.), Microsoft Excel ®, and Miro Collaboration Platform. In accordance with the approach, we employed double hermeneutics where the researchers had to interpret the interpretations drawn from the in-depth interviews. The researchers conducted meetings to compare and agree on codes that were used and to discuss emerging themes based on the codes and categories formed. The iterative process of interpreting codes to decide on the categories and forming themes based on the categories was performed throughout the analyses.

Research team and reflexivity

The team of authors is composed of Filipino occupational therapists who come from different backgrounds and professional experiences. The first three authors are either working as full-time or part-time clinicians in the pediatric setting. The first author is a master’s student (health professions education) while the second author is a clinic manager. The third author is a doctoral student (health professions education) and faculty member of an undergraduate occupational therapy program. The last author is an academic and researcher who has been working on projects related to interprofessional practice and occupational justice. All authors have experienced using telehealth in providing occupational therapy services. Despite their differences, this team cultivated a shared goal throughout the research process, which is to create evidence-based information to meet community needs, particularly therapy services in the face of an emergency situation. All data were transcribed, encoded, and analyzed considering varied points-of-view in interpreting study findings. Participants have no knowledge of the interviewers prior to study commencement.

Strategies outlined by Elo et al. (2014)Elo, S., Kääriäinen, M., Kanste, O., Pölkki, T., Utriainen, K., & Kyngäs, H. (2014). Qualitative content analysis: a focus on trustworthiness. SAGE Open, 4(1), 2158244014522633. were employed to ensure rigor and trustworthiness in this qualitative study. To establish credibility, all participants were given the opportunity to clarify their responses and to ask questions throughout the interview process. Credibility was also increased when the researchers, during regular meetings, would acknowledge their personal and professional biases in interpreting the interviews and analyzing the data gathered (reflexivity). Transferability can also be possible since the research method could readily be employed in other research undertakings. For example, recruiting participants through social media, collecting interview data using videoconferencing applications, and employing the steps in Smith’s interpretative phenomenological analysis after some training. Dependability and conformability were also employed because in every step of the research, a consultation and confirmation among authors occurred prior to moving to the next step. To ensure authenticity, participants from diverse socio-economic and educational backgrounds and who have children with different ages and functional abilities were included. Thus, the interviews reflected a broad range of lived experiences and realities that provided us a deeper understanding of the phenomenon under study.

Findings

Four themes were determined after data analysis: dimensions of telehealth in occupational therapy (Theme 1), reinforcing family-centered occupational therapy (Theme 2), emphasizing an occupational therapist’s advocacy role (Theme 3), and telehealth in occupational therapy–today and tomorrow (Theme 4). Each theme is characterized by the lived experiences of parents and carers in engaging in the process of telehealth with their children. Table 3 outlines the themes and subthemes formed after the interpretative phenomenological analysis.

Theme 1: Dimensions of telehealth occupational therapy

The dimensions of occupational therapy telehealth include processes, considerations, benefits, and challenges. The processes are characterized by the intentional use of activity grading and adaptations, participating in information exchange, and measuring outcomes. Telehealth considerations include time and safety. Its benefits primarily relate to accessibility. Lastly, the following challenges must also be factored in and resolved such as connectivity issues and managing available resources. The participants herein are referred to as carers who availed occupational therapy services via telehealth.

Subtheme 1.1: Adaptation, information sharing, and targeting outcomes through telehealth

The carers described a process that they underwent with their therapists to help them, and their children navigate the transition from in-person therapy services to teletherapy sessions. They recounted having trial sessions, which were free-of-charge, where the therapist would orient the family about their roles, responsibilities, and what could be expected during the occupational therapy sessions. During the trial session, therapists explored resources that were available at home (i.e., making a simple inventory), tried certain tools and equipment when available, and piloted virtual interaction with the child. Participant 2 shared,

Exchange of information between the therapists and carers played a key role in the conduct of telehealth sessions. This was evident before, during, and after the sessions. Prior to the session, therapists sent out emails providing carers with detailed information about the plan for the occupational therapy session. This included therapy session objectives, activities (e.g., tabletop, movement-based, self-care, social groups, arts and crafts), and a list of materials that need to be prepared. During the session, therapists provide on-going feedback to the carers regarding how to work with the child’s challenging behaviors, to adapt tasks, and to provide appropriate assistance. The feedback process extended beyond the telehealth sessions since carers continued to seek guidance especially when working with the child outside occupational therapy sessions. The carers found these specific, immediate, and tailor-fit feedback more helpful especially in contrast to receiving generic feedback. Every after a completed telehealth session, therapists provided the attending carers with a summary of what transpired during the session including a description of the child’s performance in relation to the goal. Because many carers observed and experienced firsthand their children’s behaviors and how these were managed during the session, the information provided post-session equipped them with knowledge about what they can do in anticipation of the next session and as follow up at home. Participant 9 revealed:

Subtheme 1.2: Considerations of time and safety

Carers in the study identified several factors that weighed in on their telehealth experience, specifically regarding time, safety, and convenience. To them, telehealth sessions provided more flexibility in scheduling occupational therapy sessions. For the carers who reside far from therapy clinics, telehealth afforded them less time to prepare, travel, and reduce the likelihood of a child being fatigued from travelling. Telehealth also afforded them to adjust their schedules based on their availability. During a power interruption or poor internet connectivity, sessions were rescheduled more conveniently. This same flexibility, however, was also disadvantageous because some children had to adjust to unexpected and abrupt changes, which could lead to frustrations and tantrums.

At the time of the study, when the threat of the virus was still prevalent and quarantine guidelines were shifting every two weeks, carers viewed telehealth as a safer way to receive occupational therapy services. Participant 2 shared,

Subtheme 1.3: Benefits of telehealth

The carers expressed their satisfaction over the improvements that they have observed with their children as a result of the telehealth sessions. These improvements included attention to tasks and completion of activities, which were translated into their participation in online school. Participant 1 shared,

The provision of worksheets and activities during telehealth, as well as the introduction of online applications and web sources, paved the way for the expansion of carers’ repertoire of activities that are transferable at home. To them, these consequently supplemented their children’s learning and development beyond telehealth sessions as Participant 5 concurred that she had been following instructions from the therapist on creating a visual schedule to guide her child on daily routines.

Outcomes of telehealth extended beyond improvements in children’s occupational performance as carers perceived telehealth sessions as an opportunity to bond with their children. The virtual transaction also offered carers a deeper understanding of their child’s condition and better appreciation of the importance of consistency and family involvement in the therapy process.

Subtheme 1.4: Challenges encountered when receiving telehealth

The carers expressed the need to manage challenges in terms of social and physical resources including internet connectivity. Since telehealth requires internet, the carers thought that it is a must to have a stable connection entailing upgrading bandwidth, hence more expenses on top of the telehealth fees. Participant 3 shared,

Moreover, carers acknowledged the demand from them in terms of exerting physical effort in assisting their children to participate in the telehealth sessions as well as the emotional investment in coping with situational changes and disruptions. During telehealth, most of the carers in this study mentioned that they felt compelled to constantly be with their child, actively ask questions and give feedback to the therapist, and openly receive coaching from therapists. Some carers revealed that there were occurrences when they contacted the therapist beyond work hours. Limited interaction with other children outside their family was also identified as a challenge and this experience would be elaborated in the other themes. Participant 5 narrated,

Theme 2: Reinforcing family-centered occupational therapy

Using telehealth reinforces family-centered occupational therapy practice. Its use in occupational therapy practice has become a conduit in improving family dynamics between the child, the family members, and the occupational therapist. As a result, the telehealth process foregrounds the involvement of carers and family members, acknowledging their varied roles as a teacher and a learner, throughout the occupational therapy process. Carers can be parents, relatives, or guardians of the child with disability in the Philippine setting. Regardless of their relationship to the child, telehealth emphasized their roles as supporters of the therapy process during and beyond the occupational therapy sessions. Participant 6 narrated,

Subtheme 2.1: Highlighting parent and carer’s role as teachers and learners

Carers began to recognise their two-fold role—a teacher and a learner. As a teacher, telehealth afforded the carers an opportunity to act as a teacher by co-teaching their children with the therapist on how to develop certain skills and how to assist them with participation difficulties. As a learner, the carers took on an ‘insider’ lens about the occupational therapy process, albeit via telehealth, wherein they were able to get to be more involved in the decision-making process and the professional reasoning of the therapist. Participant 2 shared,

Subtheme 2.2: Emphasizing parent and carer’s involvement as learners

With their experiences in telehealth, parents and carers had a better understanding of their child’s skills and how they can be best managed using the specific strategies recommended by the therapist. Telehealth emphasized their involvement as learners. Participant 7 explained,

The participants admitted that they were willing to be coached by the therapist to help them be a co-teacher at home towards achieving occupational therapy outcomes. The telehealth experience also equipped them with skills in working with their children on a day-to-day basis, especially when compared to their experience with onsite therapy sessions.

Theme 3: Emphasizing an occupational therapist’s advocacy role

Occupational therapists doing telehealth have foregrounded their role in advocating for the profession and the people they serve. Advocacy in this context included two things: interprofessional collaboration between the child, family members, therapists, and other carers in the team, and the promotion of the occupational therapy profession to the public.

Subtheme 3.1: Collaboration

Participants expressed that telehealth allowed them to communicate more frequently and openly with their therapists, facilitating not only a stronger therapist-client relationship but interprofessional collaboration. Interprofessional collaboration entailed open communication, shared planning and decision-making for and with the child among the occupational therapist, carers, and other members of the child’s team. Some participants also expressed that it was easier for them to transition from onsite therapy to telehealth when they worked with the same occupational therapist. Participant 5 narrated,

Subtheme 3.2: Occupational therapists as support to primary carers

Since telehealth, from the side of the client, happened at home, it was inevitable to avoid involving other family members interacting with the child including grandparents, siblings, cousins, aunts, or uncles. These family members were also coached as necessary. Participant 6 shared about their family’s involvement in telehealth:

The collaboration was evident in telehealth because some participants expressed how they were able to share the decision with the therapist. Participant 10 then explained,

Subtheme 3.3: Valuing the role of occupational therapists

Expressions of appreciation towards the work of occupational therapists were highlighted by the participants. Particularly, they recognize the hard work, effort, and dedication in ensuring the continuity of care despite the pandemic situation. Participant 9 expressed:

Theme 4: Telehealth in occupational therapy--today and tomorrow

Telehealth has just been maximized in occupational therapy practice during the pandemic. Some carers decided to avail telehealth services to continue the therapy process at the comforts of their home without fear of getting infected by COVID-19.

Subtheme 4.1: Comparing onsite therapy and telehealth

It was evident that carers could not help but compare their experiences from onsite therapy and telehealth. For instance, carers emphasized that there are limitations in telehealth in terms of actual interaction with other children, compromising their social participation and communication abilities. The carers also appreciated the support they received from fellow carers during onsite sessions since they got to converse and share their experiences face-to-face inside the therapy facility. While the participants perceived that it would never be the same again, Participant 9 wanted to encourage other parents:

Subtheme 4.2: Occupational therapy continues in the pandemic

There were a lot of lessons learned from the pandemic and the telehealth experience. With the pandemic effects waning, and while things are slowly getting back to what it was, carers remain conscious of selecting the most fit service delivery model for them and their child. All the participants thought that telehealth in occupational therapy practice will continue even after the pandemic. A participant even mentioned that she was considering a blended approach where they could afford availing both telehealth and onsite therapy sessions based on their convenience and priorities. This way, they could be more proactive in co-designing the occupational therapy plan and intervention with occupational therapists. Participant 3 mentioned,

Discussion

This study attempted to describe the lived experiences of Filipino parents and carers upon receiving occupational therapy through telehealth for their children with disabilities during the liminal period of the pandemic and introduction to the use of telehealth within therapy services. Employing phenomenological methods, which included in-depth interviews online and thematic analyses of lived experiences, our findings revealed four themes. These themes captured the contextualized dimensions of telehealth as used in Philippine occupational therapy practice, the centrality of the family underpinned by Filipino virtues, the reinforcement of occupational therapists’ role in professional advocacy, and the ideation of telehealth’s potentialities as an instrumental aspect of health and social care. We draw our discussion from our findings, specifically about the emerging role of telehealth in occupational therapy, family involvement as a benefit of telehealth, collaboration as a concept and practice to sustain telehealth utility, appreciation of occupational therapists, and study merits and limitations.

Telehealth: an alternative or a strategic tool in occupational therapy?

As most occupational therapists are considered novice in the practice of telehealth in the Philippines, the PAOT has created a set of guidelines (Philippine Academy of Occupational Therapists, 2020Philippine Academy of Occupational Therapists – PAOT. (2020). Guidelines on the use of telehealth as an alternative form of occupational therapy service provision. Retrieved in 2023, August 7, from https://wfot.org/assets/resources/PAOT-Guidelines-on-the-Utilization-of-Telehealth.pdf
https://wfot.org/assets/resources/PAOT-G... ) to ensure that the quality of services provided in telehealth is the same as occupational therapy services delivered in-person, complying with all jurisdictional, institutional, and professional regulations (World Federation of Occupational Therapists, 2021World Federation of Occupational Therapists – WFOT. (2021). Position statement occupational therapy and telehealth. Retrieved in 2023, August 7, from https://wfot.org/checkout/25960/26409
https://wfot.org/checkout/25960/26409... ). Recently, a summary of reported strategies for promoting successful telehealth occupational therapy sessions is available with the following overarching phases: 1) staff trainings on telehealth occupational therapy; 2) resources for families and staff; 3) interventions and in-session strategies; and 4) parent education and coaching (Angell et al., 2023Angell, A. M., Carreon, E. D., Akrofi, J. N. S., Franklin, M. D., Taylor, E. E., Miller, J., Crowley, C., & Maher, S. O. (2023). Challenges and facilitators to telehealth occupational therapy for autistic children during COVID-19. OTJR (Thorofare, N.J.), 43(3), 513-522. http://dx.doi.org/10.1177/15394492221142597.
http://dx.doi.org/10.1177/15394492221142... ).

In the local context, there had been no standard process recommended for providing telehealth in occupational therapy practice. Based on participants’ experiences, several steps in the telehealth process were commonly identified although they have been receiving telehealth from different therapy centers. The interviews uncovered that telehealth was only introduced to them by their attending occupational therapist, who facilitated a ‘trial session’. The trial session aims to screen if the child with disabilities would benefit from telehealth, considering feasibility and practicality. The succeeding sessions were dedicated to training the primary carers online, either by the therapy facility as a group or by the occupational therapist on a one-on-one basis. Within these telehealth sessions, the therapist and the primary carer mainly determined the therapy schedule, prepared materials and tools, and discussed considerations for future sessions. Moreover, while providing occupational therapy services, Filipino occupational therapists, at that time, were encouraged to attend training that is specific on telehealth provision provided by local and international professional organizations to augment their lack of training in telehealth (Sy et al., 2020Sy, M. P., Pineda, R. C., Yao, D. P., Guevara, C. A., Delos Reyes, R. C., & Castro, I. M. (2020). Shared voices of Filipino occupational therapists during the COVID-19 pandemic: reflections from an online forum. World Federation of Occupational Therapists Bulletin, 76(1), 60-64.). Although the steps were not exactly akin to Angell’s et al. (2023)Angell, A. M., Carreon, E. D., Akrofi, J. N. S., Franklin, M. D., Taylor, E. E., Miller, J., Crowley, C., & Maher, S. O. (2023). Challenges and facilitators to telehealth occupational therapy for autistic children during COVID-19. OTJR (Thorofare, N.J.), 43(3), 513-522. http://dx.doi.org/10.1177/15394492221142597.
http://dx.doi.org/10.1177/15394492221142... list of telehealth strategies, it is evident that telehealth procedures are still evolving and changing the occupational therapy practice landscape to date. We, however, need to reflect and act upon the issue about how telehealth, as a tool, can be maximized in resource-constrained countries juxtaposing varying contexts and dimensions including family values, a health system that is not oriented towards primary care and has a low recognition of occupational therapy as a profession.

Family involvement: a benefit from telehealth

Another consideration in the evolution of telehealth practice in the Philippines is family involvement. Filipinos are known for their family-oriented culture where family members as a whole are considered in deciding on important life matters, including health-related decisions. Typically, any health care professional working with a Filipino family would be considered a ‘family member’, at least throughout the duration of patient-care. Moreover, a group of Filipino parents were found to share the experience of disability as a collective, which is reflected in the title of the study written by Lasco et al. (2022)Lasco, G., Nuevo, C. E. L., Nolasco, M. L. P., Famaloan, F. R. A. N., Bundoc, J. R., Capili, D. I. S., & Bermejo, R. (2022). “It’s as if I’m the one suffering”: narratives of parents of children with disability in the Philippines. Acta Medica Philippina, 56(7), 30-42., “It’s as if I’m the one suffering”. According to Lasco et al. (2022), aLasco, G., Nuevo, C. E. L., Nolasco, M. L. P., Famaloan, F. R. A. N., Bundoc, J. R., Capili, D. I. S., & Bermejo, R. (2022). “It’s as if I’m the one suffering”: narratives of parents of children with disability in the Philippines. Acta Medica Philippina, 56(7), 30-42. family-centered care approach must be incorporated in policies in relation to people with disabilities, entailing not only assistance in medical care but sustainable support to the parents to activate their economic and therapeutic roles. Another way to reduce the burden of the Filipino family living with and affected by disability is the consideration of family member’s quality of life and well-being in relation to the occupational therapy plan and implementation (Gomez & Gomez, 2013Gomez, I. N. B., & Gomez, M. G. (2013). Quality of life of parents of Filipino children with special needs. Education Quarterly, 71(2), 42-58.).

It is also impossible for occupational therapists working with children with disabilities not to work closely with carers. Using telehealth, with its remote and no-touch nature, could be particularly contentious in terms of developing trust between service providers and their patients (Brennan et al., 2013Brennan, N., Barnes, R., Calnan, M., Corrigan, O., Dieppe, P., & Entwistle, V. (2013). Trust in the health-care provider-patient relationship: a systematic mapping review of the evidence base. International Journal for Quality in Health Care, 25(6), 682-688.). Telehealth is not received positively by everyone. A local interview study of Filipino carers perceived telehealth as challenging and a last resort for service delivery (Delos Reyes, 2021Delos Reyes, R. (2021). Beliefs of Filipino caregivers on occupational therapy through telehealth. Annals of Physiotherapy & Occupational Therapy, 4(1), 1-4. https://doi.org/10.23880/aphot-16000187?
https://doi.org/10.23880/aphot-16000187?... ) coupled with the numerous challenges outlined by the systematic review on telerehabilitation in the Philippines by Leochico et al. (2020)Leochico, C. F. D., Espiritu, A. I., Ignacio, S. D., & Mojica, J. A. P. (2020). Challenges to the emergence of telerehabilitation in a developing country: a systematic review. Frontiers in Neurology, 11(1007), 1-14.. Despite that, intentional parent coaching via telehealth as well as hybrid arrangements in providing telehealth remain a sustainable support for families with children with disabilities (Pijarnvanit & Sriphetcharawut, 2023Pijarnvanit, P., & Sriphetcharawut, S. (2023). The effects of telehealth parent coaching on occupational performance and executive function of children with attention-deficit/hyperactivity disorders, and parent self-efficacy: a preliminary study. Occupational Therapy in Health Care. In press.; Wittmeier et al., 2022Wittmeier, K. D. M., Hammond, E., Tymko, K., Burnham, K., Janssen, T., Pablo, A. J., Russell, K., Pierce, S., Costello, C., & Protudjer, J. L. P. (2022). “Another Tool in Your Toolkit”: pediatric occupational and physical therapists’ perspectives of initiating telehealth during the COVID-19 pandemic. Physical & Occupational Therapy in Pediatrics, 42(5), 465-481.; Eguia & Capio, 2022Eguia, K. F., & Capio, C. M. (2022). Teletherapy for children with developmental disorders during the COVID-19 pandemic in the Philippines: A mixed-methods evaluation from the perspectives of parents and therapists. Child: Care, Health and Development, 48(6), 963-969.).

Collaboration: the antidote for sustaining telehealth

Interprofessional collaboration among different health care professionals with the shared goal of benefiting patients is considered best practice in telehealth practice (Ransdell et al., 2021Ransdell, L. B., Greenberg, M. E., Isaki, E., Lee, A., Bettger, J. P., Hung, G., Gelatt, A., Lindstrom-Mette, A., & Cason, J. (2021). Best practices for building interprofessional telehealth: report of a conference. International Journal of Telerehabilitation, 13(2), 1-16.). While it is important to acknowledge the numerous barriers of telehealth or telerehabilitation in resource-constrained countries like the Philippines (Leochico et al., 2020Leochico, C. F. D., Espiritu, A. I., Ignacio, S. D., & Mojica, J. A. P. (2020). Challenges to the emergence of telerehabilitation in a developing country: a systematic review. Frontiers in Neurology, 11(1007), 1-14.), the use of interprofessional collaboration as an approach in telehealth is considered viable and sustainable especially in rural and underserved areas (Johnson & Mahan, 2020Johnson, K. F., & Mahan, L. B. (2020). Interprofessional collaboration and telehealth: useful strategies for family counselors in rural and underserved areas. The Family Journal (Alexandria, Va.), 28(3), 215-224.). In order to do that, health care professionals must work closely with patients and their families (Johnson & Mahan, 2020Johnson, K. F., & Mahan, L. B. (2020). Interprofessional collaboration and telehealth: useful strategies for family counselors in rural and underserved areas. The Family Journal (Alexandria, Va.), 28(3), 215-224.), upskill competencies in digital literacy and technology use through formal courses and trainings (Sy et al., 2020Sy, M. P., Pineda, R. C., Yao, D. P., Guevara, C. A., Delos Reyes, R. C., & Castro, I. M. (2020). Shared voices of Filipino occupational therapists during the COVID-19 pandemic: reflections from an online forum. World Federation of Occupational Therapists Bulletin, 76(1), 60-64.; Macariola et al., 2021Macariola, A. D., Santarin, T. M. C., Villaflor, F. J. M., Villaluna, L. M. G., Yonzon, R. S. L., Fermin, J. L., Kee, S. L., AlDahoul, N., Karim, H. A., & Tan, M. J. T. (2021). Breaking barriers amid the pandemic: the status of telehealth in southeast Asia and its potential as a mode of healthcare delivery in the Philippines. Frontiers in Pharmacology, 12(754011), 1-6.; Ransdell et al., 2021Ransdell, L. B., Greenberg, M. E., Isaki, E., Lee, A., Bettger, J. P., Hung, G., Gelatt, A., Lindstrom-Mette, A., & Cason, J. (2021). Best practices for building interprofessional telehealth: report of a conference. International Journal of Telerehabilitation, 13(2), 1-16.), and establish partnerships with families, organizations, local governments, and professional associations to co-design practice guidelines of telehealth (Smith et al., 2023Smith, S. L., Aytur, S. A., & Humphreys, B. P. (2023). Effects of telehealth parent coaching in supporting family participation, cohesion, and adaptability. OTJR (Thorofare, N.J.), 43(1), 24-34. http://dx.doi.org/10.1177/15394492221083664.
https://doi.org/ttp://dx.doi.org/10.1177... ; Leochico et al., 2020Leochico, C. F. D., Espiritu, A. I., Ignacio, S. D., & Mojica, J. A. P. (2020). Challenges to the emergence of telerehabilitation in a developing country: a systematic review. Frontiers in Neurology, 11(1007), 1-14.).

Collaboration in health care can be overtly observed in two ways. On the one hand, there is collaboration between the patient and the service provider; on the other hand, there is collaboration between and among service providers. Both collaborative interactions aim to improve the quality of health care provided and received, underpinned by mutual trust. Mutual trust is defined as the shared feelings experienced or felt (Crits-Christoph et al., 2019Crits-Christoph, P., Rieger, A., Gaines, A., & Gibbons, M. B. C. (2019). Trust and respect in the patient-clinician relationship: preliminary development of a new scale. BMC Psychology, 7(91), 1-8.) and shared actions done by patient and therapist towards each other to foster a therapeutic relationship, and to improve service satisfaction and health outcomes. According to Lee et al. (2019)Lee, C., Tseng, S., & Tsai, F. (2019). Doctor-patient mutual trust, telemedicine quality, and satisfaction: the role of knowledge management. Journal Of Social And Administrative Sciences, 6(4), 176-187., mutual trust entails good communication methods between doctors and patients, reliance on each other, and improved work efficiency, especially in using telehealth. A systematic mapping review on trust between healthcare provider and patient by Brennan et al. (2013)Brennan, N., Barnes, R., Calnan, M., Corrigan, O., Dieppe, P., & Entwistle, V. (2013). Trust in the health-care provider-patient relationship: a systematic mapping review of the evidence base. International Journal for Quality in Health Care, 25(6), 682-688. revealed that while health care providers, including occupational therapists, trust their patients to seek consult in a timely manner, they also serve as “socially licensed adjudicators” or advocates for patients especially in lobbying their rights to care, benefits, and other concerns.

Telehealth remains to be perceived as a ‘viable alternative’ to face-to-face consultation and therapy locally (Leochico et al., 2020Leochico, C. F. D., Espiritu, A. I., Ignacio, S. D., & Mojica, J. A. P. (2020). Challenges to the emergence of telerehabilitation in a developing country: a systematic review. Frontiers in Neurology, 11(1007), 1-14.). Benefits of telehealth include foregrounding the essence of family-centered care, better understanding of the family towards the child’s condition, and accessibility in the middle of emergency situations; whereas challenges of telehealth include an increased demand for time and energy from both ends (service user and service provider), poor internet connectivity in the Philippines, decreased well-being of both therapists and parents among others (Angell et al., 2023Angell, A. M., Carreon, E. D., Akrofi, J. N. S., Franklin, M. D., Taylor, E. E., Miller, J., Crowley, C., & Maher, S. O. (2023). Challenges and facilitators to telehealth occupational therapy for autistic children during COVID-19. OTJR (Thorofare, N.J.), 43(3), 513-522. http://dx.doi.org/10.1177/15394492221142597.
http://dx.doi.org/10.1177/15394492221142... ; Eguia & Capio, 2022Eguia, K. F., & Capio, C. M. (2022). Teletherapy for children with developmental disorders during the COVID-19 pandemic in the Philippines: A mixed-methods evaluation from the perspectives of parents and therapists. Child: Care, Health and Development, 48(6), 963-969.; Delos Reyes, 2021Delos Reyes, R. (2021). Beliefs of Filipino caregivers on occupational therapy through telehealth. Annals of Physiotherapy & Occupational Therapy, 4(1), 1-4. https://doi.org/10.23880/aphot-16000187?
https://doi.org/10.23880/aphot-16000187?... ; Leochico et al., 2020Leochico, C. F. D., Espiritu, A. I., Ignacio, S. D., & Mojica, J. A. P. (2020). Challenges to the emergence of telerehabilitation in a developing country: a systematic review. Frontiers in Neurology, 11(1007), 1-14.). Considering all these factors, plus the forthcoming implementation of the Universal Health Care law in the Philippines, a future-thinking perspective sees telehealth not merely as an optional or alternative way of receiving occupational therapy services, but rather telehealth should be an integrative part of the occupational therapy service delivery model in the Philippines (Chiu et al., 2023Chiu, I. M., Sy, M. P., Oruga, M. D., & Bonito, S. R. (2023). Children with special needs and their access to rehabilitation services in the Philippines: A Q methodology study on perceived barriers by family members. Public Health Challenges, 2(2), e79.). Drawing from an occupational justice perspective, access to telehealth services is determined by social and justice determinants of health. While it would be ideal that telehealth services are made available in both urban and rural geographical areas, solutions oriented towards the system and (infra)structures should be undertaken. For instance, a screening tool could be developed to identify if a service user needs an in-person session or telehealth. Likewise, service users from rural areas could be given hybridized therapy schedules for 6 or 12 months, where both in-person and telehealth sessions are made available, in order to budget available resources. For those who live far away from the nearest therapy facility with employed occupational therapists, state-funded community health centers (primary health care) could be provided with accessible tablets with internet connection so that travel time and resources are kept to a minimum. These suggestions, however, will be possible when interprofessional and inter-agency (i.e., private-public partnership) collaboration are embraced and implemented both by practitioners and those in power.

A genuine appreciation for occupational therapists

While it is difficult to pinpoint how telehealth directly promotes occupational therapy as a profession, studies have shown that the use of telehealth in providing occupational therapy services has improved patient satisfaction due to its convenience, lesser cost, and improved access to care (Proffitt et al., 2021Proffitt, R., Cason, J., Little, L., & Pickett, K. A. (2021). Stimulating research to advance evidence-based applications of telehealth in occupational therapy. OTJR (Thorofare, N.J.), 41(3), 153-162.). Our study findings revealed that carers have appreciated the hard work and efforts of occupational therapists using telehealth. Their telehealth experiences have also allowed them to dispel misconceptions and myths about occupational therapy such as what Langbein (2019)Langbein, R. (2019). A Student’s Guide to Dispelling Common Misconceptions about OT. Retrieved in 2023, August 7, from https://www.aota.org/publications/student-articles/school-tips/misconceptions
https://www.aota.org/publications/studen... outlined in the American Occupational Therapy Association website: occupational therapy is the same as physical therapy, occupational therapy only works with the upper body (and hands), occupational therapy help people get jobs, and occupational therapists just work with kids who are diagnosed with autism among others. Without generalizing, the experiences of our participants have concurred with the findings of the online forum held by a group of Filipino occupational therapists at the beginning of the COVID-19 pandemic lockdowns (Sy et al., 2020Sy, M. P., Pineda, R. C., Yao, D. P., Guevara, C. A., Delos Reyes, R. C., & Castro, I. M. (2020). Shared voices of Filipino occupational therapists during the COVID-19 pandemic: reflections from an online forum. World Federation of Occupational Therapists Bulletin, 76(1), 60-64.). In this online forum, some occupational therapists who participated explicitly mentioned that telehealth gave them the opportunity to highlight the therapeutic use of occupations over merely techniques (Sy et al., 2020Sy, M. P., Pineda, R. C., Yao, D. P., Guevara, C. A., Delos Reyes, R. C., & Castro, I. M. (2020). Shared voices of Filipino occupational therapists during the COVID-19 pandemic: reflections from an online forum. World Federation of Occupational Therapists Bulletin, 76(1), 60-64.). Evidently, intentional collaboration is needed to advance our shared goal in providing a continuity of occupational therapy services in liminal times. Through our study, we can surmise that intraprofessional collaboration (shared practice in collaboration between individuals within the same professional group) is vital in achieving interprofessional collaboration especially in the context of telehealth practice.

Moving forward, telehealth is perceived to be a development in the practice landscape of not only occupational therapists but health care professionals caring for children with disabilities (Wittmeier et al., 2022Wittmeier, K. D. M., Hammond, E., Tymko, K., Burnham, K., Janssen, T., Pablo, A. J., Russell, K., Pierce, S., Costello, C., & Protudjer, J. L. P. (2022). “Another Tool in Your Toolkit”: pediatric occupational and physical therapists’ perspectives of initiating telehealth during the COVID-19 pandemic. Physical & Occupational Therapy in Pediatrics, 42(5), 465-481.). Before developing any practice model or clinical guidelines, it is important for therapists to take one step back and reflect on what we have learned in providing telehealth in the middle of the COVID-19 pandemic. Aside from relying on evidence to inform our practice, we believe that reflections from both clinicians and carers should also inform us in our next steps. In the future, we propose to view telehealth as: an integrative tool for occupational therapy practice; a reinforcement of family-centered care approach; a propeller of health access and equity; and, a facilitator of intra- and inter-professional collaboration.

Study strengths and limitations

This study has its merits and limitations. The lived experiences captured in our findings provided evidence on the utility and viability of telehealth as tool in making health care services more accessible. We also want to highlight that the methods were employed by a research team constituting occupational therapists who are engaged in clinical, education, research, and policy practices and immersed in the culture, which afforded them to produce context-focused data results and subsequent interpretations. However, the study was limited to parents and carers of children who received occupational therapy via telehealth for at least 4 months. This excluded those who received the services through government hospitals where there are set protocols regarding the duration of therapy (typically 8 sessions in a span of 2 months), considering the long waitlist and high number of referrals. While a small sample size is not necessarily the issue, the lived experiences could have been more diverse if we were able to recruit some more participants from different islands and provinces and those from lower socio-economic strata. Hence, a follow-up study to interview participants from different areas outside the main cities could provide new insights on the utility and viability of telehealth.

Conclusion

This phenomenological study described the lived experiences of Filipino carers who received occupational therapy via telehealth in the middle of the COVID-19 pandemic. The lived experiences of parents and carers are considered instrumental in informing the evolving practice of telehealth in occupational therapy in the Philippines. Our findings highlight the process of working as a team—composed of child, child’s family, therapists, and other professionals—with a shared goal of addressing community needs and achieving accessible and equitable occupational therapy services. We believe that this study did not only emphasize telehealth as an integrative part of the OT process, but as a critical development for the occupational therapy profession in the context of the forthcoming implementation of the Universal Health Care Law. Our findings intend to support the creation of telehealth guidelines in the local landscape of rehabilitation services. To support the guidelines development, follow up studies must be conducted focusing on generating empirical data about telehealth utility and generating more qualitative data about telehealth experiences of Filipinos coming from geographically isolated and disadvantaged areas.

References

Edited by

Section editor

Publication Dates

History