Beliefs of Filipino Caregivers on Occupational Therapy through Telehealth

Telehealth as a Service Delivery Model

Telehealth refers to the use of communication technologies for the delivery of healthcare services remotely [1]. It was expanded in response to limited healthcare and mental healthcare facilities in underserved and rural populations [2]. Additionally, it contributes to achieving universal health coverage by improving access of patients to quality, cost-effective, health services wherever they may be. It is particularly valuable for those in remote areas, vulnerable groups and ageing populations [3]. The mode of this service consists of both synchronous and asynchronous sessions wherein the patient and provider interact on real time or on their own time respectively [4, 5]. Moreover, this system has also been fortunate in minimizing the number of hospital readmissions due to predictable situations.

Generally, telehealth systems are commended for reducing time and travel costs, as well as for the convenience of the clients as stated by Bull, et al. [2]. However, there are also disadvantages in using telehealth: issues of privacy and security included the potential hacking or leaking of private health information, a lack of face-face-contact, which may be necessary for treatment or diagnoses, not feeling connected to the healthcare provider, and not knowing how to use the device properly, misreading of information, or having usability issues [2].

Perceptions of Caregivers about Telehealth

In a research conducted by Almathami, et al. [6] a number of patients preferred the traditional face-to-face delivery of service over telehealth. According to them, the resistance of caregivers with regards to telehealth mainly stems from lack of technology or the systems to be used. In contrast, according to the study conducted by Johnston, et al. [7], caregivers without telehealth experience are often open to the idea of using this as a service model. She also points out that they recognize its ability to create opportunities for families and individuals with disabilities. However, there are still uncertainties regarding the use of telehealth. This perception is due to a lack of awareness regarding telehealth and lack of information on its effectiveness compared to in-person care. For the general opinion of Cason, et al. [8], there are several factors that may influence refusal to avail telehealth. Based on her statement, one factor is that a caregiver may question their child’s safety. Additionally, she stated that some clients may not be suitable for telehealth, citing inability to access the required technology as an example. This is also supported by a study conducted by Salomone, et al. [9], wherein she stated that clients who are less likely to avail telehealth are also parents who are not technology-driven. Conversely, the perspectives of some parents and practitioners about telehealth are more on its advantages, wherein it will be more efficient for their child and patients according to a study by Iacono, et al. [10]. Additionally, they stated that delays in national infrastructure to support efficient and low cost internet connectivity add to its disadvantages.

Philippine Context on Telehealth

As mentioned by the Philippine Academy of Occupational Therapists (PAOT) [11] in their guidelines amidst the pandemic, occupational therapists should explore other means of service delivery, which include but is not limited to telehealth. Moreover, the same standards of practice observed in the traditional mode of service delivery are also to be followed in these alternative means. Furthermore, the therapist should make sure that the overall benefit from the alternative form of service provision outweighs the risks.

Nonetheless, this study focused on determining the beliefs of caregivers in Batangas City who have not chosen to avail occupational therapy through telehealth during the pandemic.

Ethical Considerations

Upon the approval of the Department of Occupational Therapy under the College of Allied Medical Sciences, University of Batangas, the study commenced. Ethical considerations were made wherein an informed consent was taken from each participant before each interview. Confidentiality and the right to withdraw at any point of the study were emphasized.

Participant Recruitment

The participants involved in this study are caregivers of those children with special needs attending in-person therapy in a private therapy center in Batangas City. The researchers used a purposive sampling method which is very useful in situations at which point the researchers need to reach a targeted sample quickly, and where sampling for proportionality is not the main concern [12]. The criteria for inclusion of subjects consisted of caregivers whose child is availing in-person occupational therapy in a private center in Batangas but did not avail of telehealth services during the various levels of community quarantines. Participants excluded are caregivers who availed telehealth in Batangas during the quarantine.

Data Gathering Procedure

Data collection was undertaken through a series of steps. A set of guide questions were formulated based on a literature review. It was agreed upon by all authors of the study. After the collection of informed consent, the guide questions were coordinated to the participants of the study through various methods such as phone calls, SMS, online chat, and so on. Follow-ups were provided to clarify some information. The data collected were transcribed properly and verified by each author. Thematic analysis was done afterwards, which according to Maguire, et al. [13], is the process of pointing out patterns or themes within qualitative data. Through this, the researchers familiarized themselves with the data and generated initial codes. Afterwards, emergent themes were identified, reviewed, and defined. And lastly, the themes were used [14].

Telehealth as Challenging

All participants considered telehealth as challenging. Participant 1 stated that her child may get unfocused in telehealth and that there is less interaction with the therapist in telehealth. Participant 2 stated, “...the child’s actual behavior cannot just easily be seen from the gadget’s screen.” Additionally, it was stated that the attention of the student is not totally focused on the task via telehealth as compared to actual and face to face activity. Participant 3 stated, “...because it’s not suitable for us. We have a poor internet connection here in [location] and also we experience power interruption most of the time.” The participant also stated that there can be miscommunication between the therapist and the child during the telehealth or session. Participant 4 stated “...he [the child] will not participate in front of the computer. He fidgets and doesn’t want to sit for long periods.” It was also stated that considering the new normal situation, special child adaptation is quite difficult especially in performing tasks that need physical assistance and guidance. Hence, the participant believes that face to face therapy is more effective. And lastly, a participant noted, “It is costly. Adaptation to computer-based classes depends on the performance and behavior of the child. There is limited gross motor or physical activities.” In a statement reported by the Department of Information and Communication Technology (DICT) in 2017 [15], the average mobile internet speed in the Philippines was 8.5 Mbps. Additionally, in 2019, the Philippines was below the global average of 26.12 Mbps, ranking 103rd out of 139 surveyed countries according to the Speedtest Global Index [16] . These articles support the internet concerns of some caregivers who did not avail telehealth. Aside from internet problems, caregivers view telehealth as challenging due to their children’s attention. According to Critchley, et al. [17] children have a hard time paying attention since they sometimes find it hard to filter out distractions. Additionally, majority of the caregiver’s children were diagnosed with ASD, which are found to have a weaker orienting attention compared to typically developing children according to a study conducted by Keehn, Lincoln, Müller, & Townsend [18]. Telehealth as the Last Option All participants considered telehealth as the last option. They said that how they see themselves availing telehealth for their children. Participant 1 stated she will avail telehealth when her child is older and when she is too busy to go to the therapy center for in-person services. Participant 2 stated, “When during this pandemic we will need telehealth and my son is not yet allowed to go out or if telehealth will be mandatory by the government.” Participant 3 stated, “...when he is starting to show behaviors that need help.” And lastly, Participant 4 stated “If the pandemic continues and there is no other option.” Furthermore, the participants showed interest in availing telehealth in the near future when the necessity arises.

According to the Interim Guidelines on the Practice of Occupational Therapy amidst the Coronavirus Disease (COVID-19) Situation in the Philippines released by the Philippine Academy of Occupational Therapists (PAOT) [19], in-person services may continue depending on the policy directives of the authorities. Last July, the city of Batangas was placed under Modified General Community Quarantine (MGCQ), wherein measures were relaxed, allowing businesses such as therapy centers to open [20, 21]. This has allowed caregivers who did not avail telehealth to go back to in-person therapy.