Impact of COVID-19 Pandemic in Filipino Occupational Therapy Practice Across Regions

The Philippine Government has implemented community quarantine throughout the country to respond to the COVID-19 pandemic that has since profoundly affected the lives, health, and well-being of individuals, families, and communities. This has also created an impact on the practice of occupational therapy in the country as the pandemic presents occupational disruptions in the new normal. This paper summarizes the current conditions of the practice of occupational therapy in times of the unprecedented disaster highlighted by the COVID-19 crisis and the situation of practitioners and recipients of service across the regions of the country. Findings conclude that there are: (1) emerging delivery service patterns, (2) consequences of COVID-19 to therapists, and (3) insights moving forward.


INTRODUCTION
In light of the worldwide spread of the coronavirus disease (COVID-19), the Philippine government has aimed to mitigate its socioeconomic and health impacts by declaring different levels of community quarantine throughout the country, all of which have significant consequences on the lives, health, and well-being of Filipinos. 1, 2 The country's community quarantine measures, which are among the longest-lasting in the world, 3 consisted of social distancing, cessation of the operations of non-essential institutions and entities, restrictions of any form of travel, among others.
For occupational therapists in many parts of the world, this is an unprecedented time that evolves every day, and this may significantly affect how people participate in their occupations, or the activities that they do-as an individual, in families, and with communities-to occupy time and bring purpose and meaning to life. 4 This is important because the core of occupational therapy practice is the task of ensuring that everyone, from all walks of life with different levels of ability and independence, is able to perform and participate in meaningful activities in the environment where they are in.
In the Philippines, the wide-scale impact of the pandemic becomes even more complex for persons with disabilities because of prevailing attitudinal, institutional, and environmental barriers. This prompted the Philippine Academy of Occupational Therapists, Inc. (PAOT), as the professional organization of occupational therapists in the country, to release in May 2020 the Board Resolution 2020-003 (or the Interim Guidelines on the practice of Occupational Therapy amidst the Coronavirus Disease  situation in the Philippines) to provide guidance and recommendations to its members and recipients of service to ensure the safety of all while providing or receiving quality occupational therapy services. 5 In support of this, the chapters of the organization have been instrumental in disseminating information, upholding, enforcing, and monitoring practice standards and ethics, as well as serving as linkages to regions outside Metro Manila, especially during these difficult times. 6 This paper aims to synthesize all the information that has been gathered from the recognized and potential chapters across the country in an effort to understand the overall impact of the COVID-19 pandemic with regards to the occupational therapy practice in the Philippines.

PARTICIPANTS AND SETTING
Currently, there are four recognized chapters and three potential chapters (organized groups of occupational therapists in a region applying for official recognition from PAOT). In this paper, both recognized and potential chapters are considered as PAOT chapters. Information gathering was done during July 2020, four months after the implementation of community quarantine in different areas of the country. More than a third of the participants are practicing in pediatrics based on the data analyzed.

APPROACH
Upon the approval of the PAOT Board of Directors, the Committee on Chaptership tasked each PAOT chapter to assess its members on the impact of COVID19 through remote surveys and online discussions. Questions such as, but not limited to, "What are the impact of COVID-19 on their lives and service recipients?", "How was the experience of service delivery during the pandemic?" and "How do they see their future after the pandemic?" guided their surveys. It was ensured that all participants were asked for verbal or written consent before participating in each survey as it was assured that participation is voluntary and would not affect standing with PAOT. Each chapter was asked to submit reports with no strict format or template, which included summarized narratives of their surveys, anecdotes from some participants, and raw survey results. Because all findings are based only on the submissions of each chapter, the data analyzed may not necessarily indicate the prevailing situation across the entire nation and, as such, should be taken with caution.
In this paper, a secondary analysis was utilized to synthesize the overall impact of the COVID-19 pandemic with regards to the occupational therapy practice in the Philippines across regions. To wit, secondary analysis is a costeffective and useful method when there is already available data, such as summarized reports. 7 All these reports were compiled by the first author, and only the number of participants was clarified with each chapter. The compilation was the sole set of data analyzed through thematic analysis following the six-step process proposed by Caulfield: familiarization, coding, generating themes, reviewing themes, defining and naming themes, and writing up. 8 The first and last authors conducted independent coding and the generation of preliminary themes. All participated in the finalization of the themes to ensure rigor.  Table 2).

Emerging Service Delivery Patterns
Shift to Teletherapy. The ongoing worldwide crisis has made Filipino occupational therapists abruptly shift to teletherapy, an action made by necessity and not by choice. Teletherapy is a service model that has been utilized in other countries since the late 1990s but was an unpopular mode of service delivery in the Philippines even before the pandemic. For many Filipino occupational therapists, teletherapy has its appeal (subtheme 1.1) and drawbacks (subtheme 1.2) (see Table 3).

New Normal in the Clinical Setting.
For some participants who resumed face-to-face therapy sessions in clinics, hospitals, and other facilities, they also had to make adjustments with their practice delivery. Health sectors and companies had to look into the redesign and construction of facilities to encourage air circulation, training of healthcare workers on infection prevention and control, sourcing of personal protective equipment (PPE), and the optimal settings for care delivery and how it is reimbursed (e.g. online and mobile payments). 9 But even with these precautions, a majority of the participants expressed anxiety and uncertainty on the levels of safety at work, especially for those who have children or elderly parents at home and are also burdened with other responsibilities outside of direct patient care.
Another major source of worry for many participants is the risks associated with inperson therapy services. Although rehabilitation professionals are considered as essential healthcare workers or front-liners, 10 therapists who are working in private clinics are not compensated with hazard pay. In addition, there are still no definitive guidelines published by PAOT or any government agency for a safe return to private therapy centers, which left many clinic owners and managers scrambling to come up with their own protocols to support clinic-based practice. Adding to the confusion is the unclear standards for therapy centers to reopen, as local government units have implemented varying policies when it comes to health and safety protocols. This makes it difficult for clinic owners and managers to find and utilize a model to help comply with these standards.
Threats to Practice. Before the pandemic, there were some individuals that can be identified as pseudo-professionals, who have represented themselves as legitimate therapists without the necessary educational background and clinical training required to practice occupational therapy. Unfortunately, there have been more reports of pseudo-professionals surfacing in the provinces and rural areas during these times, where the public may not have access to information that can protect them from  fraudulent practices. They have become a more common choice for service recipients because they offer cheaper rates. However, they do not guarantee effective and evidence-based intervention and only pose an alarm to the health and safety of the public that they attempt to serve.

Consequences of COVID-19 to Therapists
Decreased Financial Security. The majority, if not all, participants shared that they were eventually forced to downsize their lifestyles and re-evaluate their financial priorities, or to go back to being dependent on their families because of lack of work. Most of the participants were consultants before the pandemic who were paid per therapy session, and many of them do not have the same financial benefits that employees enjoy, such as health insurance and fixed monthly income. This meant additional financial burden when it comes to COVID-19 testing and possible hospitalizations if they contract the virus, special transportation expenses (because cheaper public transportation is limited), and purchasing the needed PPE for work. 11 To augment their income, some participants have gone into other ventures, such as opening home-based and retail businesses, creating therapy and educational materials for sale, or even entering an unrelated industry altogether.

Rising Mental Health Concerns.
Because not much is known about the novel coronavirus causing COVID-19 and how it affects the body, it is common for everyone to experience increased levels of distress and anxiety 12,13 Occupational disruptions are inevitable, causing added anxiety, stress, and strain physically as well as mentally. 14 A number of participants have experienced, and are still experiencing, various degrees of emotional distress over the transition from in-person therapy to teletherapy. Aside from the exhaustion and screen fatigue, which is very common for health practitioners offering online services, 15,16 some have experienced difficulty in accepting or adjusting to the transition because they believed that the community restrictions, and the pandemic itself, were temporary. This, in itself, is also already a traumatizing event for service recipients as the transition to the new normal was not anticipated at all. 16 There are also concerns about the inevitably delayed career and life plans, which may cause what is called a career shock or loss in direction when it comes to a career. 14,18 Generally, disruption to an early career path have significant career consequences for the next several years. 17,18 Nevertheless, the sudden change in employment (including unemployment) coupled with the broader societal and political changes that are currently happening in the country have made the participants re-examine either their career trajectories or life aspirations.
Finally, while some participants praise the Philippine government's efforts to contain the COVID-19 outbreak, a number of participants have grown dissatisfied with the heavy-handed approach and contradicting statements from the country's leaders. News reports of systemic corruption in different government agencies, 19 the apparent lack of transparency from the health sector, 20 and the lack of active response other than to wait for a vaccine have culminated into a general sense of hopelessness for the coming months.

Activity Engagement as a Coping Mechanism.
Without a doubt, the direct and indirect psychological and social effects of the COVID-19 pandemic are pervasive and could have lasting effects on a person's mental health now and in the future. For some participants, this is a time for them to take a break and spend more time with their family due to the decreased workload and to explore new hobbies and interests. There are several participants who shared that they have turned to their faith -by participating in online religious services, among others -to cope with the trauma and distress brought about by the pandemic, which research has shown to be an important coping mechanism. 21 As occupational therapists, they are aware that even when confined and isolated, people still need to engage in a routine that includes being physically active, having fun, staying in contact with other people, and limiting media consumption in order to reduce stress and nourish emotional well-being. 20,21 Moving Forward

Challenges and Opportunities.
Being at the forefront of the profession in the country, PAOT has been called to act on the current situation by strengthening its stand on teletherapy and developing guidelines to enable standardization and assurance of safe and quality service delivery. Aside from this, participants have appealed to PAOT to promote teletherapy more as a valid and effective mode of service delivery in order to address the demand for accessible therapy services. Many participants have also expressed that continuing education opportunities be given online. However, some have suggested that more comprehensive workshops be given, rather than lectures, to facilitate skill-building; and to get experts from other regions to provide a more enriching and contextualized experience.
Furthermore, the rising mental health issues of practitioners should be addressed promptly since it can affect their service delivery and overall well-being. Creating a platform that can provide mental health response and support to members, and a concrete plan to solve the growing number of employment changes are two windows of opportunities that the organization can look into to alleviate the burdens that therapists are currently facing.
Finally, while one of PAOT's mandates is to serve its members and stakeholders, non-members and newly licensed occupational therapists should also be included in the discussions because the pandemic experience is universal and social connections are all the more important at this time. It has been suggested that PAOT revitalize its membership campaigns and to make membership to the organization more approachable and inclusive.

Professionals in the Future.
As the Philippines continues on its eight-month community quarantine, Filipino occupational therapists face a daunting task to rise above obstacles and explore unfamiliar and potential roles that do not only involve direct patient care. Because of the physical restrictions, the COVID-19 pandemic has opened up opportunities for practitioners to navigate the virtual environment, so some participants continue to view the situation as a challenge to learn something new, rediscover their strengths, and reflect on their passions. One participant shared that the true value of an occupational therapist-rooted in creative thinking and problem-solving-is being tested during a prolonged crisis such as this ongoing pandemic, and they are hopeful that a new breed of occupational therapists will emerge.

REFLECTIONS AND CONCLUSIONS
This paper explored the limited data from Filipino occupational therapists who are practicing in different regions of the country. Because of the pandemic, changes in care delivery appear to have significant effects on both the practitioners and the recipients of service-from its service delivery and the providers in varied aspects of their engagement in daily life to the future direction of the practice.
The first theme discusses teletherapy as the emerging mode of service delivery in lieu of traditional face-to-face therapy. Despite the guidelines released by PAOT, teletherapy has been received with hesitation and uncertainty. This suggests that there is still room for further development of this delivery model, through research and contextual analysis, to better suit the context of Philippine healthcare. Likewise, with the transition to the new normal, traditional therapy practice must also undergo adjustments in order to better fit the new environment. This introduces a challenge to adjust and improve already established aspects of the healthcare practice, such as the educational or training process, the licensure process, and the monitoring of care, just to name a few.
The second theme discusses the consequences of the pandemic on occupational therapy practice and its practitioners. While practitioners and the general populace alike are both similarly affected by the pandemic, practitioners have the added obligations to provide frontline services at the cost of their physical and mental health. Emphasis was placed by the participants on the mental health strain they have experienced due to the stress of adaptation to the new environment, as well as of overall job security. This prompts PAOT to create and prioritize plans that address these concerns to protect and care for its members and their recipients of care.
The third theme describes the windows of opportunities from the perspective of the participants that may guide the organization in responding to the changes brought about by the new normal. Occupational therapy is still a growing profession, and it continues to develop according to the needs of the populations that it serves while staying true to its foundation: to promote health and well-being through meaningful engagement for everyone from all walks of life.

Individual Author's Contributions
R.C.D.: conception of work, acquisition, analysis, and interpretation of work, drafting the work and revising critically, approval of the version to be submitted for publication, and accountable for most aspects of the work; K.C.T.: acquisition, analysis, and interpretation of work, drafting the work and revising critically, approval of the version to be submitted for publication, and accountable for most aspects of the work; W.S.: analysis, and interpretation of work, drafting the work and revising critically, approval of the version to be submitted for publication, and accountable for most aspects of the work.

Disclosure Statement
The first two authors are members of PAOT's Committee on Chaptership, while the last author is a regular member of PAOT. The views expressed in this paper do not reflect the general position or opinion of the organization.

Funding
No funding agency supported the completion of this paper.