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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 52  |  Issue : 4  |  Page : 117-124

Impact of Corona Virus Disease-2019 on occupational therapy practice in India: An online national survey


Department of Occupational Therapy, University of Texas Medical Branch, Galveston, TX; Department of External and Regulatory Affairs,NBCOT Inc., Gaithersburg, MD, USA

Date of Submission01-Jan-2021
Date of Acceptance12-Mar-2021
Date of Web Publication22-Apr-2021

Correspondence Address:
Karthik Mani
1572, Harvest Vine Ct, Friendswood, TX 77546
USA
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijoth.ijoth_1_21

Rights and Permissions
  Abstract 

Background: India imposed several consecutive lockdowns to control the spread of coronavirus disease-2019 (COVID-19) beginning March 2020. As a result, many establishments, including outpatient health-care settings and educational institutions, were closed. Consequentially, many health-care professionals experienced disruption in their work lives and faced financial crisis. Objectives: The objective was to assess the impact of COVID-19 on the occupational therapy (OT) community in India. Study Design: This is a cross-sectional study. A ten-item electronic survey was developed based on the research question to gather data. Methods: An online survey form was e-mailed to 760 OTs in India identified through convenience sampling. The survey link, generated through SurveyMonkey, was also shared on four WhatsApp Messenger groups (TNAIOTA Official Group, OTist Group, Clinic OT, and IPOTPDG1) with many Indian OTs (snowball sampling). In addition, the survey link was shared through Facebook Messenger to around 200 OTs in India. Data were collected from May 24, 2020 to June 21, 2020. Results: The number of responses received was 99. Eighty-seven respondents reported experiencing disruption in work, of which 37 reported 81%–100% income loss. The income loss was high among private practitioners and low among academicians. Respondents utilized telehealth to overcome the disruption. Conclusions: COVID-19 has severely impacted the work lives of OTs in India and caused financial strain. This study provides preliminary data and some suggestions for the professional organizations and leaders to consider when advocating for the profession. Further in-depth exploration is recommended.

Keywords: Occupational Therapists, Preliminary Data, Private Practice, Surveys and Questionnaires, Telerehabilitation


How to cite this article:
Mani K. Impact of Corona Virus Disease-2019 on occupational therapy practice in India: An online national survey. Indian J Occup Ther 2020;52:117-24

How to cite this URL:
Mani K. Impact of Corona Virus Disease-2019 on occupational therapy practice in India: An online national survey. Indian J Occup Ther [serial online] 2020 [cited 2021 May 18];52:117-24. Available from: http://www.ijotonweb.org/text.asp?2020/52/4/117/314215


  Introduction Top


Since its emergence in Wuhan, China, the coronavirus disease 2019 (COVID-19) pandemic has continued to wreak havoc on human beings, across the globe. It created enormous disruptions in the health-care practice as many countries closed outpatient health-care establishments and delayed elective medical and diagnostic procedures.[1],[2],[3],[4] Several studies conducted in the United States revealed that private practices faced the most economic brunt.[2],[5]

Occupational therapists (OTs) in India practice in a variety of settings, including a notable majority in outpatient and school settings.[6] The operations in most of the settings where OTs practice were modified or suspended secondary to lockdown and other measures taken by the Indian government in response to COVID-19.[4] Hence, understandably, OTs in India may have faced substantial disruption in their work lives and related income.

To help the OT community effectively understand and handle unprecedented and uncertain situations like COVID-19, this survey aims to generate data on how the OT practice is impacted by COVID-19.


  Methods Top


This study was conducted adhering to the principles of the Declaration of Helsinki guidelines.[7] The guidelines were reviewed before the survey being sent to the participants. The participants consented to participate in this study by reviewing the information provided in the survey before accessing the survey items. In addition, the survey invitation that was sent to and shared with participants clearly identified that participation in the survey was “entirely voluntary and the responses will be kept anonymous.”

Sample

The study's targeted population was OTs practitioners in India. The participants of this study were identified through convenience and snowball sampling. The author found 760 e-mail addresses belonging to OT practitioners in India through e-mail archives. The possibility of two or more e-mail addresses belonging to the same practitioner cannot be ruled out. Further, the survey invitation was also shared on four different WhatsApp groups of Indian OT practitioners and with randomly selected practitioners through Facebook Messenger to achieve national representation. The practitioners who received the invitation through Facebook Messenger were found from the author's Facebook friends/networks.

Instrumentation

The survey tool [Appendix A] was developed based on the literature review and survey writing guidelines.[3],[8],[9],[10] The survey tool consisted of ten items. The first few items gathered information on participants' demographics (gender, state, practice setting, and sector of work). Subsequent items explored whether COVID-19 disrupted respondents' practice, the effects of disruption, how respondents overcame the disruption, financial impact of disruption, and respondents' views on what the OT community shall do to overcome a situation like COVID-19. The final open-ended item asked participants to express any other related thoughts.

Seven experienced OT practitioners in India and abroad reviewed and commented on the survey tool. The following changes were made to the original survey tool based on their comments. First, percentage symbol was added to the response options of item 8. Second, item 4 was changed from multiple choice to multiselect item to accommodate respondents who work in more than one practice setting (e.g., academia and outpatient clinic). Third, the phrase “practice setting” was changed to “setting” as academia may not fit under “practice setting.” Fourth, the text limit of the “other” options was updated to 100 characters to allow lengthy responses. Fifth, clarifiers were added in parenthesis to response options “private practice” and “outpatient clinic” of item 4, so that respondents who own outpatient clinics and working in outpatient clinics do not select the same response option. Finally, the timeline in item 8 was changed from April to May, as the survey was launched only during the last week of May.

Procedure

The survey was conducted through SurveyMonkey™.[11] In May 2020, all identified participants were sent an e-mail invitation to participate in the survey. The survey link was also shared through social media channels (Facebook Messenger and WhatsApp groups) with June 21, 2020 as the response deadline. Two reminder e-mails were sent to participants during the open survey period.[10] The reminder e-mail message with the link was also posted on the WhatsApp groups. However, those who received the survey invitation through Facebook Messenger did not receive any reminders. It is important to note that the survey invitation was sent through Facebook Messenger over several weeks and hence, the recipients may not have had the same survey response period as other recipients. At the end of the survey response period, all data were exported and tabulated for statistical analysis.

Data Analysis

Chi-Square analyses were used to determine the association between disruption in practice and demographic variables. The association was deemed significant if the P < 0.05. All analyses were conducted using Microsoft Excel 2016. No test of association was performed when the frequency values were very low. The states identified by the respondents were grouped into zones based on the administrative zonal classification system identified in the State Reorganization Act of 1956.[12] Data are reported as percentages and aggregate numbers to protect the identity of respondents. The responses to the open-ended item were analyzed for themes.


  Results Top


By the response deadline, 99 responses (46 through e-mail and 53 through web link) were received. [Table 1] provides the demographics of the respondents. No responses were received from 15 states and six union territories.
Table 1: Respondents’ Demographics (n=99)

Click here to view


Eighty-seven respondents reported disruption in their employment or practice. The disruption spanned across practice settings. Respondents who identified their practice setting as nongovernmental organization, rehabilitation center, private practice, or outpatient clinic reported complete (100%) disruption. Except one respondent, all who worked in school/special school settings reported disruption. Respondents from academic settings and hospitals reported moderate disruption (n = 13 [72%] and n = 13 [59%], respectively).

The disruption forced respondents to temporarily close their business/practice (n = 55 [55.55%]), work for reduced hours (n = 24 [24.24%]), work in a voluntary or alternative role within the same organization (n = 12 [12.12%]), restrict the visits made to patient homes (n = 21 [21.21%]), and go on unpaid leave (n = 15 [15.15%]). One respondent (1.01%) reported that he/she went on paid leave during the disruption. No respondent reported resigning the job due to childcare/domestic responsibilities secondary to the pandemic. Eleven respondents (11.11%) selected the other options and their responses indicated assuming administrative roles, telecommuting to work, and inability to work due to travel restrictions.

[Figure 1] shows the strategies used by the respondents to overcome the disruption caused by COVID-19 in their practice. More than half of the respondents (n = 57 [58%]) reported utilizing telehealth to overcome the disruption. [Figure 2] presents the financial impact faced by the respondents between March 2020 and May 2020 due to the disruption of their business/practice secondary to the pandemic. Although the percentage of income loss varied between zero and 100, a notable number of respondents (n = 37 [39%]) reported heavy impact (81%–100% income loss). [Figure 3] identifies the views of the respondents on how OTs can overcome a situation like COVID-19, if any, in the future.
Figure 1: Strategies utilized by respondents to overcome work disruption

Click here to view
Figure 2: Percentage of income loss (March–May 2020) reported by respondents

Click here to view
Figure 3: Strategies to Overcome Situations like COVID-19

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No significant association was found between work disruption and gender (χ2 = 0.01; P = 0.91; odds ratio [OR] = 0.93; 95% confidence interval [CI] = 0.28, 3.12). Because of low frequency values, no test of association was performed for other demographic variables.

Eighty respondents (81%) responded to the final open-ended item. The following themes emerged from the analysis of their responses: (i) embrace telerehabilitation, (ii) identify alternative source for revenue generation, (iii) plan safe return to practice, (iv) advocate for government support and guidance, (iv) identify and follow other successful models, (v) stay positive-improve knowledge, and (vi) seek government jobs. These themes will be elaborated in the next section.


  Discussion Top


The results of this study reveal that COVID-19 has significantly impacted the OT practice in many parts of India, especially during the initial months of lockdown. This aligns with the finding reported in other parts of the world. The American Occupational Therapy Association reported that 56% of its survey respondents in April 2020 reported disruption in work.[8] In the United Kingdom, 97.6% of participants in the survey conducted by the Royal College of Occupational Therapists (RCOT) reported that the pandemic impacted their roles, responsibilities, and duties.[9]

Impact of COVID-19 and Related Lockdowns on Occupational Therapy Practice

COVID-19-related restrictions forced OT practitioners in India to temporarily close their practice, limit their service delivery channels, reduce their working hours, and lose their monthly income. The following sections discuss the disruption by zone, sector, and practice setting and the financial impact of the disruption.

Zone Versus Disruption

Due to nationwide lockdown, as expected, there was no significant difference in work disruption between administrative zones. However, respondents belong to South India reported relatively less disruption when compared to their counterparts in North India. All respondents (n = 17 [100%]) who belonged to North India reported work disruption, whereas only 51 (85%) of respondents from South India reported similar disruption. This observation aligns with the findings of the study conducted by the Indian School of Business.[13] In the Western Zone, 17 (89%) respondents reported work disruption.

Sector Versus Disruption

Eleven (58%) respondents working in the government sector reported work disruption, while nine (n = 90%) respondents in the nonprofit sector and 67 (n = 96%) respondents working in the private sector reported work disruption. This is expected as the government required health-care manpower to handle the COVID-19 crisis.

Setting Versus Disruption

Based on respondents' responses and comments, it appears that the disruption was severe in private, outpatient, home-based, and school-based practices when compared to the hospital-based practice. This could be due to the lockdown measures implemented by the government (closure of establishments, closure of schools, and restrictions in transportation).

Furthermore, the disruption was relatively less in academic settings. As schools may have resources and technology infrastructure, understandably, those who work in academic settings may have resumed their work through telecommunication platforms, and hence reported less disruption.

Financial Impact of the Disruption

Song et al. reported that COVID-19 has affected the health-care practice in profound ways, though there was some heterogeneity across practice areas.[5] The current findings align with this view. Although there was notable financial impact, it varied across practice areas. Most of the respondents who identified their practice setting as either “private practice” or “outpatient practice” reported 81%–100% income loss. The literature identifies that private health-care practitioners across the globe faced crippling financial losses due to COVID-19.[4],[14] The financial strain in private/outpatient settings was further complicated by the canceled appointments and increased expenditure associated with the purchase of the personal protective equipment.[15] Many respondents who reported 61%–80% income loss identified their practice setting as school-based practice or rehabilitation center. In addition, several of them also identified private practice as an additional practice setting. Except one respondent, all respondents who identified one of their practice areas as academia reported 0%–20% income loss. This shows that the academic community fared better during the pandemic with the help of technology.

It is essential to note here that several studies and reports predicted India's economy to be negatively impacted by COVID-19, and consequentially, affect consumer spending.[16],[17],[18] As most of the OT services are reimbursed out of pocket in India, one may assume that the impact on consumer spending may have influenced OTs income, especially those who are in private practice and home-based practice, in the months after the data collection for this study.

Strategies to Overcome Disruption

This section discusses the strategies used and/or proposed by the respondents to overcome the disruption caused by the pandemic. These strategies may also serve as a useful reference for the Indian OT community to handle a similar situation, if any, in the future.

Embrace Telerehabilitation

Many respondents reported engaging in telerehabilitation to overcome the disruption. They also suggested the Indian OT community to advocate for and educate stakeholders on telehealth. In addition, the comments (“In India we need to develop telehealth…”, “better to stay safe and promote tele-therapy”, “work more on telerehabilitation and develop resources”, etc.) of almost half of the respondents who responded to the final open-ended item revealed support for telehealth. As telehealth has offered a viable platform to continue services while minimizing the virus transmission, it assisted the OT community across the globe to survive the pandemic as practitioners. Several professional organizations, related to OT, in India and other countries, have advised their membership/licensees to embrace telehealth in response to the pandemic.[19],[20],[21],[22] In addition, conversations have also started in several parts of the world on sustaining telehealth as a viable service delivery model post-COVID-19.[23],[24] The pandemic, despite its overall impact, has increased stakeholders' readiness for telehealth services.[24] Utilizing this opportunity, OTs in India must embrace telehealth as an alternate mode of service delivery to expand access to OT services in the post-COVID world.

Identify Alternative Source for Revenue Generation

Many respondents (n = 65) suggested OT practitioners explore alternative revenue generation avenues utilizing the OT knowledge and skills. A few respondents advised OTs to identify alternative source of income to effectively handle situations like COVID-19. Some of their comments include: “be prepared beforehand for such situations and work in other sector as an alternative,” “have parallel talents other than OT for revenue generation…,” and “find other sources of income.”

Plan Safe Return to Practice

Several respondents suggested the OT community to safely return to practice by following precautions. They commented “Preparedness to start work slowly with precaution…,” “Go with change with precautions... change is the only way to progress,” and “make sure to follow the safety protocols.” As health-care practitioners, OTs have moral and ethical responsibilities to ensure the safety of their clients regardless of the pandemic. Hence, it is critical that they follow all safety protocols to ensure client safety. They shall make use of the resources that have been made available by the professional organizations to safely return to practice.[22],[25]

Advocate for Government Support and Guidance

A few respondents suggested that OTs should seek for government's support in the form of infrastructure, funding, and sanitization. One respondent commented, “government should have funds reserved to incorporate tele-rehab services on big scale, especially for conditions who need one on one basis intervention on daily basis[sic].” Another respondent stated “proper support from the govt authorities in terms of financial support and to help our clinics to maintain clean and hygienic by providing sanitation works free of cost.” The government agencies in India may also publish useful information (telehealth infrastructure and guidelines, insurance coverage, infection control, ethical implications, etc.) for health-care practitioners on their website.[26]

Identify and Follow Successful Models

As technology has enhanced the access and availability of data, OT practitioners in India may identify how health-care professionals in India and abroad are handling the crisis and adopt a similar model. Expressing a similar view, one respondent commented “Read and increase the knowledge and c what Worlds OT friends r doing in this situation[sic].”

Stay Positive-Improve Knowledge

One respondent assured OTs in India by stating “it's a matter of time. Focus on the work and everything will be normal…” Many respondents also suggested OTs to spend time on updating their professional knowledge, especially related to telehealth, by completing online professional development courses, attending webinars, sharing resources, etc. This view concurs with their counterparts in the United Kingdom who responded to the RCOT survey. A notable percentage of RCOT survey respondents perceived expanded practice and learning opportunities due to COVID-19.[9]

Seek Government Jobs

Several participants suggested OTs in India to advocate for and seek more government jobs as they may provide more stability and less disruption. One respondent suggested “fight for government job … to overcome situations.” Another respondent commented “No. of jobs in increase in government sector…[sic].” These comments highlight the respondents' belief of government jobs being more stable and secure. Regardless of the current situation, OTs in India have been advocating for government positions for decades and they should continue their efforts to enhance service accessibility and help the profession achieve its due place in the nation's health-care system.

Implications for the Profession in India

  • Professional leaders in the field of OT shall make use of the information and insights generated through this study to effectively advocate for the profession and support OTs in India
  • Professional organizations related to OT shall publish frequently asked questions on their website clarifying OT's role during a pandemic, how practitioners can continue to deliver services, etc.[26]
  • Professional organizations in India may create task forces to identify new practice opportunities for OTs in India
  • The OT community (therapists, educators, researchers, and professional advocates) in India shall work on developing resources to support telehealth practice in the Indian context
  • OTs in India shall publish booklets on how to manage the disruptions in occupational performance caused by situations like COVID-19, in the Indian context, highlighting the role and value of OT[27]
  • Falvey et al. suggested physical therapists to highlight the value of their service in reducing hospital readmissions and meeting the postdischarge needs of survivors of COVID. On a similar note, OTs may educate stakeholders on their role during the hospitalization and postdischarge[28]
  • Professional organizations representing OTs may work with government agencies to support the government's efforts to handle the pandemic. It is important to note here that the All India Occupational Therapists Association supported the COVID Warrior Program initiative by the Government of India and recruited hundreds of OT volunteers[29]
  • Professionals may brainstorm strategies to protect vulnerable practice areas (private practice, outpatient practice, etc.) against unprecedented situations like COVID-19
  • OTs in India shall collaborate with their global counterparts sharing and seeking resources
  • OTs shall educate stakeholders on occupational justice implications related to lockdowns
  • OTs, along with other stakeholders, shall advocate for technology infrastructure, technology access to rural areas, and cybersecurity to support telehealth practice




Limitations

Low number of responses and lack of responses from many states and UTs limit the generalizability of the data. Furthermore, the sampling method (only four WhatsApp groups) used in the study adds to the limitations in terms of generalizability. Not all survey recipients had equal time to respond to the survey.

Recommendations

Other modes of survey administration can be explored to gain more responses, which may validate and assist with the generalization of the findings. A qualitative study can be performed by inviting and interviewing representatives from multiple stakeholder groups (practitioners from various settings, referral sources, professional organizations, service recipients, etc.) to understand the impact of COVID-19 on OT practice in an in-depth and comprehensive manner.


  Conclusions Top


The COVID-19 pandemic and related lockdowns disrupted the OT practice in India with a noticeable financial impact. The disruption was severe in the private sector. Many practitioners embraced telehealth to overcome the disruption and to ensure continuity of their services. Further, in-depth exploration through qualitative studies is recommended.

Acknowledgment

The author expresses his sincere gratitude to all participants and those who reviewed the survey tool for face validity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


  Annexure A Top


Dear Occupational Therapist,

Thank you for participating in this survey. The primary goal of this survey is to provide occupational therapy leaders and advocates in India with reliable data and information about how COVID-19 has impacted the profession, with the express objective of using the data to generate insights and best practices for navigating the unprecedented world.

Your participation in this survey is strictly voluntary and completing this survey indicates your consent to participate in this study. Please do not provide your name or contact details anywhere on this survey.

Please DO NOT complete this survey if:

  1. You practice OT outside India
  2. You live in India, but work in another field




Should you have any queries or comments regarding this survey, you are welcome to contact Dr. Karthik Mani via [email protected]

Glossary:

COVID-19 – Coronavirus disease 2019

  1. Gender


    • Male
    • Female


  2. Please identify the state/union territory in which you currently work

    (Drop down menu of states and union territories of India)


  3. In what sector do you currently work?


    • Private
    • Government
    • Nonprofit


  4. Please identify the setting(s) in which you currently work (Check all that apply)


    • Academia (college/university)
    • Hospital
    • Nongovernmental organization (NGO, trust, community-based practice, etc.)
    • Rehabilitation center
    • School/special school (preschool, school, and special school)
    • Private practice (own clinic and home visits)
    • Outpatient clinic (working in an outpatient setting)
    • Other (please specify)


  5. Did COVID-19 disrupt your employment/business/practice?


    • Yes
    • No


  6. Due to the disruptions caused by COVID-19 (check all that apply):


    • I temporarily closed my clinic/private practice/business
    • I worked for reduced hours (part-time)
    • I worked/volunteered in a different role at my organization
    • I restricted the house visits
    • I was asked to go on paid leave
    • I was asked to go on unpaid leave
    • I resigned my job due to childcare/domestic responsibilities
    • Other (please specify)


  7. How did you overcome the disruptions caused by COVID-19 to your work/employment/practice? (Check all that apply)


    • Providing services via telerehabilitation (video calling, chat, etc.)
    • Working in a nonclinical/non-OT job
    • Working remotely (work from home)
    • Other (please specify)


  8. Percentage of income loss due to COVID-19 from March to May 2020


    • 0%–20%
    • 21%–40%
    • 41%–60%
    • 61%–80%
    • 81%–100%


  9. To overcome a situation like COVID-19, OT practitioners may (check all that apply):


    • Establish employment contracts with provisions for unforeseen circumstances such as COVID-19
    • Advocate for and educate stakeholders on telehealth
    • Explore alternate avenues for revenue generation utilizing OT knowledge and skills (adjunct teaching, delivering webinars, offering online courses, etc.)
    • Explore available insurance options for outpatient clinics/private practice
    • Other (please specify)


  10. What suggestions you have for the OT community in India to overcome a similar situation, if any, in the future?


(Text box)



 
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    Figures

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