Enlightening Stakeholders on the COVID-19 Pandemic Impacts and Preparation for Minimizing Future Pandemics’ Negative Effects on Occupational Therapists

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Introduction
Te 2019 coronavirus disease (COVID-19) emerged in Wuhan, China, in December 2019 as a novel, highly infectious disease that became a worldwide pandemic that has impacted all aspects of human functioning [1,2].Te COVID-19 pandemic has been described as more devastating and pervasive across almost all nations and has the potential to lead to psychological problems, posttraumatic stress symptoms, and economic burdens [3] with adverse impacts on job performance and job satisfaction [4].Te COVID-19 pandemic has had a terrible impact on the occupations of millions of individuals all over the world.
According to the World Federation of Occupational Terapists [5], there are multiple changes and consequences to how people carry out their occupations during times of pandemics, including access to resources for activities of daily living (ADLs), mobility, communication, social interaction, and overall well-being.In this regard, occupational therapy, as part of the multidisciplinary team on the front lines of the crisis, shows itself as a critical specialization in mitigating the efects of symptoms, hospitalization, and social isolation [6] by adopting patient-centered methods and care throughout the acute phase of the disease and aftercare [7].
In early March 2020, when the World Health Organization (WHO) classifed COVID-19 as a pandemic, most countries closed nonessential workplaces, restricted social spaces, and instituted measures to limit or cancel outof-home leisure activities [8,9].Te majority of employees had to work from home, in addition to home-schooling their children [10].Global reports indicate worsened unemployment and economic situations, with associated worries and anxieties for clients and their dependents.Tese constraints and economic challenges have the potential to result in distress on mental health problems among adults and their families, insomnia among employees, and obesity [3,11,12], and subsequently, negative outcomes on job performances and productivity [13].Occupational therapy has been signifcant in coping with social emergency circumstances throughout history, starting after World War I, when thousands of individuals had physical and/or mental disabilities [14].
Considering the worldwide spread of COVID-19, the government of Ghana instituted measures aimed at mitigating its socioeconomic and health impacts by declaring diferent levels of community quarantine throughout the country, all of which have signifcant consequences on the lives, health, and well-being of the Ghanaian people [15], among others.For occupational therapists in Ghana, as is also the case in many parts of the world, the COVID-19 pandemic and its ramifcations had a signifcant impact on how people participate in their occupations or their daily activities as individual entities and in their families and communities.Central to occupational therapy practice, is the task of ensuring that clients can perform and participate in meaningful activities in the environment where they are in [16].In Ghana, the growing number of COVID-19 cases and the associated health and psychosocial-economic challenges adversely impacted the work and functions of occupational therapists and worsened the plight of individuals with disabilities due to the prevailing attitudinal, institutional, and environmental barriers.
A global survey, during the peak of the pandemic, on the impact of COVID-19 on occupational therapy found a ranging impact of the pandemic on the profession, including a lack of preparedness, restrictions in service areas, new demands during redevelopment, frequently changing work conditions, use of new technology and limitations in resources, reduced morale, and concerns for their safety [17].Individuals recovering from COVID-19 illness, including older adults, and those with multiple chronic diseases or organ failures are candidates for occupational therapy rehabilitation interventions [18,19].Generally, individuals receiving clinical and occupational therapy interventions are confronted with long-term physical, cognitive, and emotional complications [20,21] and often require short-and long-term rehabilitation [22,23].Given the need for occupational therapy interventions and rehabilitation services for individuals with these medical conditions, in addition to those who were afected by the COVID-19 pandemic, research is needed in resource constraints countries, such as Ghana, to understand the impact of the COVID-19 pandemic on the provision of occupational therapy services for the growing client base.
Accordingly, the current study seeks to provide information on how, if any, the COVID-19 pandemic impacted occupational therapy services in Ghana.While the recorded COVID-19 case numbers may currently appear fnite in the country, the pandemic's impact persists through newly adapted treatment modalities and increasing infection control measures.Te fndings of the current study could be a useful resource to drive the restructuring and design of well-tailored interventions and support systems for the profession's clients, families, and communities for the present and future.

Study Design.
Tis study employed a descriptive qualitative design.Descriptive qualitative design involves an indepth exploration and description of participants' experiences, emphasizing rich, nonnumerical data collection to provide a comprehensive understanding of the impact of the pandemic on occupational therapy practice in Ghana [24].Tis allowed an accurate account of participants' experiences that most occupational therapists would agree are accurate [25].Tis approach employed semistructured interviews to collect data from seven (7) occupational therapists in the Greater Accra Region of Ghana.

Participants and Study
Sites.Seven (7) participants participated in this study, even though initially, we anticipated a minimum of 12 participants.According to Baker et al. [26], a sample size of 7 is enough to explore the descriptive nature of the phenomenon.Te study population comprised all practicing occupational therapists in the aforementioned sites.As of 2023, 46 practitioners have graduated from the Department of Occupational Terapy of University of Ghana since the start of the program in 2012 and have been working in various practice settings across the country.
Participants were sampled from four practice settings.Tese included the Korle-Bu Teaching Hospital, 37 Military Hospital, Department of Occupational Terapy (University of Ghana), and Pantang Hospital.Te Korle-Bu Teaching Hospital has the highest number of practicing occupational therapists-who provide services to patients referred from all over Ghana as well as neighboring countries.Te occupational therapists at Pantang Hospital were the frst to be employed in the country and have worked for the longest period.Terapists at the Department of Occupational therapy (University of Ghana) are both faculty members and practitioners and have also worked for an extended period.Te 37 Military Hospital has a well-established occupational therapy department that serves the military, their families, and the general public.

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Health & Social Care in the Community 2.3.Recruitment.Purposive and convenience sampling methods were adopted to recruit participants into the study.Following the recommendation by Etikan et al. [27], the convenience sampling method allowed the collection of information from participants that was readily available and accessible, whereas purposive sampling was used to identify and select individuals who met the criteria for inclusion and who had specifc characteristics that contributed to achieving the study objectives.Seven (7) participants participated in this study, even though we initially, anticipated a minimum of 12 participants.Initially, 12 potential participants expressed interest in participating; however, after several attempts by the researcher, the potential participants never made time for the interview.Irrespective of this, Baker et al. [26] emphasized that a sample size of seven is enough to explore the descriptive nature of the phenomenon.Only participants who agreed to take part in the study were included.Before the interview, participants flled out a written informed consent form.Te ethical principles guiding the study and all eforts instituted to ensure the confdentiality of data, privacy, and anonymity were comprehensively explained to each participant and adhered to.

Data Collection.
After ethical clearance was obtained, an introductory letter was obtained from the Head of the Department of Occupational Terapy and presented to the heads of the selected practice settings for a permit to conduct the research.Individual practitioners were approached and invited into the study after the objectives of the study had been introduced to them.Individuals who agreed to participate were recruited.Written informed consent was sought and the interview was conducted at a time convenient to individual participants and at a place that guaranteed privacy.Te data for the study were collected through semistructured interviews, but based on participants' responses, follow-up questions were asked for more details of the information provided.Data were collected in January 2021 when the government of Ghana instituted strict measures to control of the spread of the COVID-19 virus.
Interviews were done with six participants face-to-face while observing the COVID-19 safety protocols and one participant over the phone due to the participant's busy schedule.Ethical principles such as confdentiality, the anonymity of data, and the right to withdraw from the study at any time without any penalty were explained to individual participants in detail and adhered to.All interviews were audio recorded with permission from individual participants and lasted 30-45 minutes.Participants were recruited and interviewed until data saturation was reached.Detailed feld notes of the research process and observations were also kept.Before the interviews, participants completed an initial demographic questionnaire answering some sociodemographic information.All COVID-19 protocols were observed.
2.6.Data Analysis.Te study systematically applied the principles of thematic analysis [28] to analyze the data.Firstly, the data were transcribed into text by the student researcher and a trained research assistant, independently, and compared subsequently for verifcation.Secondly, the transcripts and feld notes were read independently by the student researcher and study supervisor severally to acquaint themselves with the data.Next, coders compared and contrasted their fndings as research consensus in emerging themes from collected data.Participants' responses for each identifed theme were represented by verbatim quotes from the text.

Findings
Seven occupational therapists including four females and three males participated in face-to-face interviews to explore the impact of the pandemic on their practice of occupational therapy.Participants were aged 25-30 years (see Table 1 for more details).

Summary of the Analytical Temes.
Te analysis of the interview data revealed 9 major interrelated themes shedding light on the impact of the COVID-19 pandemic on the work of an occupational therapist and strategies to prepare for future pandemics.Te major themes are (1) impact of the COVID-19 on occupational therapy practice and practitioners; (2) aspects or domains of work signifcantly afected by the pandemic; (3) the existing strategies employed to handle the challenges; and (4) strategies to minimize these challenges in the future.

Impact of the COVID-19 Pandemic on Occupational
Terapy Practice and Practitioners.Tis theme specifes how occupational therapy was afected by the pandemic.Participants spoke about the change in hospital administrative policies, halt in reviews, and OT clinics.

Change in Hospital Administrative
Policies.Results indicated that hospital administrative policies that had been in existence had to be reviewed due to the COVID-19 protocol.Some of these changes in policies were made by the Human Resource Departments of the various hospitals, for example, reducing the number of clients and employing the shift system, while other revamps were done personally by the therapists, that is, a halt in reviews and OT clinics to ensure their safety and that of their clients.Often, clients are scheduled for reviews after their discharge to help monitor their progress to recovery.Some physical settings call this review, the OT clinic.Another impact of the pandemic on occupational therapy services was that these reviews and OT clinics had to be halted to ensure the safety of both the clients and the therapist.
". . .We had to break therapy because clients were scared for their safety" (P3) Another participant said: "Tere were patients that we instructed them to come at least once in a while, but when there was the Covid and lockdown and all we had to stop. .." (P4)

Aspects or Domains of Work Signifcantly
Afected by the Pandemic.Tis theme houses various aspects of participants' work afected by the pandemic.Te main themes that emerged were the lack of personal protective equipment (PPE) and reduced or halt in home services/private sessions (locums).

Lack of Personal Protective Equipment (PPEs).
In previous and present pandemic, PPEs play a major role in the prevention and control of transmission of infections and remain a vital item for all healthcare workers.Agonizingly, many participants recalled how limited the safety gears were and because of their safety they had to purchase these PPEs themselves.". ..some little scrubs that we wear . . .but it was not a full protective gear" (P2) ". ..We were not getting the PPEs, it was a challenge . . .so we were buying them ourselves" (P5) Another participant recalled how it would take a while before these needed safety gears would get to the practitioners from the higher-ups: ". . .we were not getting them readily, once in a while, and when they are brought, it would take weeks before you are given, so we were getting them ourselves" (P7)

Reduced or Halt in Home Services/Private Sessions (Locums).
Under this subtheme, participants recounted how they had to put a stop to the private home servicing (locums) using their discretion or because families had asked them to stop and how limited their stay was if they were allowed into clients' homes.
"It was very risky going to pick a car, you are moving from the hospital you are in touch with a lot of people, going to pick a car, going to their homes, . .., so I had to stop because my safety and my clients' were compromised. .." (P3) Another participant related that: ". ..families were telling us not to come to their house regularly because of the pandemic . . .when I am allowed there . . .just like 20 minutes, I would be done" (P5)

Te Existing Strategies Employed to Handle the Challenges.
Tis theme explored the strategies participants employed to minimize the challenges they faced during the pandemic.Most participants used technologies as a way of curbing the efects of the pandemic and continually staying in touch with their clients.

Te Use of Technology.
Many respondents related how they had to adopt a "new normal" and use technology to render services.As therapists were not in contact with clients for close to a year, participants had to devise new ways of rendering services to clients.Tey employed the use of technologies and software such as Gmail, and WhatsApp and condition-specifc ones like AutismApp.". ..I remember this client, I just wrote down what he had to do and sent it via WhatsApp and another via e-mail" (P5) "We also used specialized apps like this autism app called Te AutismApp" (P6) Traditionally, occupational therapy services are rendered face-to-face or in an in-person format, but given the pandemic, therapists had to render services using technologies-teletherapy such as Zoom, Skype, and FaceTime.

"We had to devise other means of therapy, like calling patients-calling them over the phone as a means of therapy as opposed to the usual in-person kind of therapy and for
the pediatric case we used Zoom, FaceTime or Skype, directing the kid on what to do" (P1)

Strategies to Minimize Tese Challenges in the Future.
Participants highlighted some strategies that needed to be put in place to minimize the impacts of the COVID-19 pandemic on occupational therapists in Ghana.Tey mentioned the need for education, help from the OTAG body, revision to the occupational therapist teaching and learning curriculum, and exploring other therapy means.

Te Need for Education.
Tis main theme describes how participants saw the need to educate therapists and client relations to ensure the smooth sailing of service rendering.A suggestion that arose to minimize the impact of the pandemic was the need to organize training seminars and conferences to educate therapists on proper ways of handling pandemic efects as well as to clearly outline the roles of the profession.

". . .a form of training or a conference something to sort of educate us on okay, if some sort of pandemic-viral pandemic happens, occupational therapists play these particular roles in this kind of this thing. So, you would be able to adjust your setting in a sort of way." (P1)
Participants related the need to include family members in the treatment process.Tey related how family members should be immediately educated on their family member's condition and indulge in activities in the home.Another suggestion to minimize the challenges of the pandemic was the need for family members to be educated to uproot the myths surrounding the pandemic to prevent therapists from home services.

"Educate client families immediately they come on the wards about their independence as to the activities they can do at home" (P4)
". ..more education should to be done. . .so that families would not tell me I should not come to their house and conduct home assessment or home services" (P5).

Support from the Occupational Terapy Association of Ghana (OTAG) Body.
Te OTAG is a collection of all licensed occupational therapists and occupational therapy students.Participants mentioned how their dues should be used to help them in this challenging time to provide a guideline on what to do.

"the OT community could come up with specifc printed guidelines on how to react when such pandemics happen
Health & Social Care in the Community and maybe Covid has come all of a sudden, put measures in place such that we know what protocols to take should something happen, it could be printed, and it could be distributed" (P1) Many interviewed participants agreed that OTAG should lend a helping hand in that feld in providing PPEs.
Tey stated: "Tey should help in providing us the PPEs and it should be often" (P4) "OTAG in its small way can help with the public education . . .and if they can help with the PPEs provision. .." (P5)

Te Need for a Revision to the Teaching and Learning
Curriculum.Te occupational therapy teaching curriculum teaches students the traditional way of providing services to clients, that is, meet client, assess, and provide therapy sessions to improve their independence in the society.Tis "straight-forward" approach proves naught when they encounter out-of-context situations such as the present pandemic.Owing to this, one participant stated the need for a change in our teaching curriculum to include teletherapy and the requisite skills needed to provide such services.
". ..as part of our teaching curriculum, we should add the whole concept of teletherapy. . .and teach students the unique skills they might need to work under that" (P6)

Te Need to Explore Alternate Terapy Means.
A few participants called on occupational therapists to explore other creative means to provide services to their clients and not be fxated on one-on-one or face-to-face therapy.
"We should not be fxated on the usual way of delivering therapy" (P6) "We should allow and encourage the use of other treatment alternatives the workers can adopt" (P7)

Discussion
Tis study explored the impacts of the COVID-19 pandemic on occupational therapy practice in Ghana.Face-to-face interviews were conducted with licensed occupational therapists to investigate the challenges they faced during the pandemic, their challenge management strategies in rendering quality services to service users, and recommendations for dealing with future pandemics.Te fndings have shown how both individuals receiving clinical and occupational therapy interventions and occupational therapists are confronted with long-term physical, cognitive, and emotional complications due to the impact of COVID-19 in Ghana, as evidenced elsewhere [20,21].Te decline in the number of clients of occupational therapists during COVID-19, found in the current study, was to observe the COVID-19 safety protocols of social distancing aimed to reduce the spread of the virus to protect clients and therapists themselves [29].
Furthermore, clients reduced the number of working hours and began the shift system for safety reasons.Occupational therapists were compelled to return home after attending to their designated clients for a day and would come to work on schedule.Subsequently, occupational therapists' clients related how they had to put a stop to their reviews and clinic visitation because they felt insecure due to nonadherence to COVID-19 protocols.Some occupational therapists also related how they did not feel safe to be closer to clients because they did not know of their COVID-19 status and there was a high chance that they could get infected if they ever got in contact with a COVID-19-positive client [30].Te implication of the occupational therapists' experiences warrants short-and longterm rehabilitation [22,23].Further, there should be calls for advocacy for occupational therapy interventions and rehabilitation services for individuals with medical conditions, including those who will be afected by a pandemic such as COVID-19 in the future.Considering this, the development of hospital administrative policies that facilitate the quick adaptation to pandemic incidences should be encouraged across the board.Tus, policies focused on safety protocols, client admissions, and work timetables should be fexible enough to withstand alterations in service delivery without compromising the welfare of therapists and clients.
Te fnding that occupational therapists began washing their hands after each therapy session support the evidence that people resort to multiple changes in carrying out their occupations during times of pandemics aimed to improve overall well-being [5].Occupational therapists, in the current study, lamented how despite how new and tedious this practice was to them, they had no choice but to still practice this.Tis commitment refects a conscientious efort to prioritize client safety and mitigate the spread of the virus within the healthcare settings [29].
Te necessity to halt occupational therapy home services during the pandemic was underscored by safety concerns and infections [31].Because concern for their safety was paramount for occupational therapits and their clients, effectives measures such as a reduction or a halt of home visits were put in place.Tese experiences from the occupational therapists indicated that the tumultuous efects of the COVID-19 pandemic had a signifcant impact on the quality of occupational therapy services in Ghana, potentially thwarting the occupational therapy process in caring for clients which includes referrals, evaluation of clients, interventions, and discharge of clients.
Te fnding that occupational therapists face several challenges in Ghana supports available evidence that occupational therapists in African contexts face challenges and responsibility, yet also tremendous opportunities and potential [32].In developing countries, the unavailability of personal protective equipment (PPEs) during the pandemic posed a critical challenge hindering efective infection control [33].Recounting the aspects or domains of work signifcantly afected during the pandemic, though PPEs are considered highly essential in pandemics [34], PPEs were not available at all times.In Ghana, PPEs were procured and 6 Health & Social Care in the Community delivered by the Ministry of Health to the various hospitals, but this takes several weeks to get to facilities for use.Due to this, occupational therapists had to get their safety gear despite their fnancial difculties to protect themselves from contracting the virus.Tese gears include gowns, N95 masks, gloves, and eye protection.Despite their willingness to buy these PPEs for themselves, because they were in high demand, it was quite difcult to readily get them.Tis compelled them to put a halt to home services at the request of family members or because of their safety implying that minimal government funding and support in Africa perpetuates the challenges for people accessing services and limits resources available for occupational therapists to implement efective interventions [35].
To overcome some of these challenges, occupational therapists used technology to facilitate their practice.Occupational therapists contacted clients on the phone to check up on them.For some other clients, participants sent a list of recommended activities to be done via WhatsApp or Gmail.For clients who had to have regular therapy sessions, it was done via Zoom, Skype, or FaceTime.Tis, though, presented challenges such as unstable network connectivity, high cost of Internet bundles, and the unwillingness of clients to partake in this new therapy session.Nonetheless, the relevance of integrating technology in the healthcare system is evident in the fndings as supported by evidence from Singapore that telehealth is efective in supporting young children and families through occupational therapy demonstrated during COVID-19 [36].Te relevance of telehealth as reported implies that technology can be used as an integral part of the work of an occupational therapist in Ghana.Technology can be seen as part of the cyber culture of occupational therapists' activities in Ghana.Terefore, policymakers should prioritize such initiatives (e.g., training and investing in infrastructure) to ensure the continuity of care during pandemics.Furthermore, some fnancial support mechanisms should be put in place for healthcare offcials, including occupational therapists, to help reduce the fnancial strain entailed with using technology and/or encountered during pandemics.
To prepare themselves for such unexpected events in the future, occupational therapists recommended exploring other alternate means to deliver therapy sessions to help clients.Tese alternate means were going to be useful in events of lockdowns during a halt in one-on-one therapy sessions.Many comments were received on the need to educate family members on their wards' condition, therapy treatments, and changes to be made in their homes to ensure clients' safety in the absence of the therapist.Some occupational therapists suggested that there was a need for COVID-19 training to equip them on what guidelines to follow in specifc cases.Tis could lessen their frustration.
Occupational therapists mentioned the need to revise the teaching curriculum to equip students studying occupational therapy to deal with future pandemics.Revising the teaching curriculum could better address the aftermath and efects of the epidemics, as well as arranging and attending educational seminars to prepare for future pandemics.Advocacy is emphasized as another signifcant responsibility in assisting occupational therapists and their clients to interact and contribute to their communities, such as lobbying governments to change policies to provide more accessible support.Furthermore, occupational therapists create awareness about the value of their profession due to low knowledge and comprehension of the occupational therapy function in Ghana.Occupational therapists in Ghana must argue for the importance of their position in the community and at schools.Tis recommendation is particularly important because it could be used as a medium to dispute certain misconceptions surrounding pandemics like COVID-19, promoting appropriate collaborations from clients.

Conclusion
It was concluded that the pandemic had varied efects on the practice of occupational therapists in Ghana such that some participants had to halt therapy sessions with some clients, and others lost their additional source of income.Occupational therapists in Ghana play a crucial role in promoting meaningful occupations and improving quality of life during and after the COVID-19 pandemic implying that they need to be supported with technological tools to discharge their duties well.Ghanaian occupational therapists should prioritize community-oriented approaches on their collective needs to ensure sustainable outcomes while providing quality care to their clients in the postpandemic era.Te fndings of this study also emphasize the relevance of adaptability, preparedness, and ongoing education in the occupational therapy feld to efectively address and mitigate the impact of future pandemics.
". . .when the families told me not to come, initially, I was happy because I was scared.I would also come to work, hurriedly do what I have to do, close early and go home" (P3) ". . .I was so scared of seeing clients because you cannot guarantee that the patient even wears a nose mask when coming because most 'average Ghanaians' sit in public transports and . . .you do not necessarily know whether or not they have done a Covid test and have tested negative.Tey could lie about their status so you are not guaranteed safety when seeing clients" (P1) ". ..they gave us some Task Relief incentives. . .but I came to beneft just a month because they reversed it" (P3) Another participant posited that: ". ..It afected my locums so I was not getting the extra money. .." (P5).

Table 1 :
Demographic information of participants.