Professional Training and Therapeutic Resources Needed for the Adoption of Telepractice in the Philippines

Survey Construction

The questionnaire was adopted from a study by Lam et al. (2020) and modified to suit the Philippine population (see online Supplemental Material 1). Unlike in Hong Kong, where there are school-based SLPs, the majority of SLPs in the Philippines work in speech clinics or therapy centers. Since SLPs working in clinics serve both children and adults, questions were revised to specify that the survey concerned school-age clients only. The final questionnaire contained 36 questions and covered five areas: (1) adoption of telepractice (12 questions), (2) concerns about the implementation and perceived effectiveness of telepractice (nine questions), (3) student candidacy (three questions), (4) continuous education (six questions), and (5) demographics (six questions). All respondents completed the survey in approximately 20 min. Ethical approval was granted by the Human Research Ethics Committee of the University of Hong Kong, and respondents completed online consent forms before the survey.

Survey Administration

The Philippine Association of Speech Pathologists (PASP) was emailed to disseminate the survey forms to its members. The research team also called and emailed speech clinics and therapy centers within Metro Manila to recruit local SLPs to participate. Verbal consent was obtained and a cover letter with the survey link was sent to these clinics. Data were collected from August to September 2020, and a total of 64 SLPs participated the survey.

Participants

In 2019, 650 members were registered in the PASP (PASP, n.d.), but the number of practicing and non-practicing PASP members in the country and overseas is unknown (Chua & Gorgon, 2019). According to the PASP website, most SLPs in the Philippines practice within the Greater Manila area. For α = .05 and an effect size of 0.4, statistical power is 0.91 for 64 respondents and 0.84 for 47 respondents (Cohen et al., 2003). The sample size retained its confidence level in all effect sizes despite a higher false negative likelihood (Kennedy, 2008). The current analyses yielded good quality results for factors, with factor loadings over 0.60 (de Winter et al., 2009).

Reliability and factor analyses

Given that the survey was validated in Lam et al.’s (2020) study, Bartlett factor scores were computed according to the factor structure stated (Joreskog & Sorbom, 2018). The reliability of each factor was also reported.

Regression analyses

Multiple regression analyses were conducted to examine the factors that predicted the perceived effectiveness of telepractice and the future adoption of telepractice. In the first stepwise multiple regression analysis, nine variables (i.e., years of experience, three subscales under telepractice difficulties, three subscales under attitude of clinicians and two subscales under training and protocol) were entered as independent variables, while perceived effectiveness of telepractice was the dependent variable. In the second analysis, 10 variables (i.e., years of experience, three subscales under telepractice difficulties, three subscales under attitude of clinicians, perceived effectiveness of telepractice, and two subscales under training and protocol) served as independent variables, while future adoption of telepractice served as the dependent variable. The aim of the regression analyses was exploratory rather than theoretical testing. Although stepwise multiple regression is considered controversial, these analyses were appropriate given the large number of independent variables in that the predicted variable accounting for the most variability could be identified (Menard, 1995; Mendenhall et al., 1996; Tabachnick et al., 2007). The predictive power of the independent variables was classified as follows: large (R² > .5), moderate (.3 < R² < .5), and small (.1 < R² < .3) (Cohen et al., 2003).

Variables

Bartlett factor scores were first computed (questions under each variable are shown in online Supplemental Material 2), and the variables showed acceptable- to good-fit on the fit indices. All questions and statements were answered using a Likert-type scale that ranged from 1 (lower difficulty or strongly disagree) to 5 (higher difficulty or strongly agree).

Telepractice difficulties comprised three subscales: (a) material preparation difficulties (one item; i.e., task materials), (b) teaching and demonstration difficulties (four items; α = .83; e.g., explaining treatment goals), and (c) additional caregiver support (three items; α = .84; e.g., skill transfer to caregivers).

Attitude of clinicians consisted of three subscales: (a) implementation difficulties (four items; α = .79; e.g., “Treatment goals related to social communication are hard to achieve”), (b) barriers in handling clients (five items; α = .67; e.g., “It was harder to attract clients during telepractice”), and (c) confidence in implementing telepractice (six items; α = .77; e.g., “Overall, I am well prepared for telepractice”).

Telepractice effectiveness comprised one item (i.e., “Please consider the treatment effectiveness of telepractice and on-site sessions”).

Training and protocol comprised two subscales: (a) training and further education (three items; α = .81; e.g., “I hope to continue learning more about telepractice”), and (b) resource availability (four items; α = .64; e.g., “There are not enough learning materials for telepractice”).

Continuous usage of telepractice comprised three items (α = .68; e.g., “I believe that telepractice is a possible method of service delivery”).

Adoption of Telepractice During the Pandemic

Fifty-seven of the 64 SLP respondents provided speech therapy services for school-age children. Of these, 47 had adopted telepractice, and their responses were used for the following analyses. Within this sub-group of 47 SLPs, only two respondents had been implementing telepractice before the pandemic, while the others were first-time users. Most respondents were experienced SLPs, with 37.50% reporting 4 to 5 years of practice, 18.75% 2 to 3 years, 9.38% a year, and 3.13% less than a year. Most of these SLPs worked in therapy centers (89.36%) and the rest in speech clinics (6.38%).

The majority of the practitioners had begun implementing telepractice between March (34.04%) and April (38.30%) 2020. Among the available platforms that could be utilized for telepractice, Zoom was used by all SLPs in conjunction with other platforms such as Google Meet, Google Hangouts, and Facebook Messenger. Most SLPs provided language intervention (81%), while a few provided speech (25.77%) and fluency (19%) intervention. The speech therapists mostly provided individual therapy (97.87%), parent consultation (93.62%), and assessment (55.32%).

A notable decrease was found in the number of sessions conducted via telepractice compared with onsite sessions. No SLPs conducted more than 31 sessions per week in telepractice, while 31.91% conducted 31 to 40 sessions per week onsite. Over half of the SLPs using telepractice (63.83%) conducted one to 10 sessions per week compared with 12.77% who conducted the same number of sessions onsite.

Descriptive Statistics for the Questionnaire

Factors Influencing the Perceived Effectiveness of Telepractice

To answer RQ2, a correlation analysis among constructs was conducted (see Table 1). Perceived effectiveness had a significant negative correlation with teaching and demonstration difficulty (r = −.47, p = .001) and with implementation difficulties (r = −.49, p = .001) but a significant positive correlation with confidence of clinicians (r = .31, p = .03), resource availability (r = .38, p = .01), and continuous usage of telepractice (r = .32, p = .03). Perceived effectiveness did not significantly correlate with years of experience (p = .69), additional caregiver support (p = .08), material preparation (p = .31), client difficulties (p = .74), and training and continuous education (p = .08).

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Table 1.

Intercorrelations Among Variables Regarding Telepractice.

Variable	1	2	3	4	5	6	7	8	9	10	11
1. Years of experience	—
2. Additional caregiver support	.23	—
3. Material preparation difficulty	−.06	.49**	—
4. Teaching and demonstration difficulty	.01	.53***	.18	—
5. Perceived effectiveness	.06	−.26	−.15	−.47**	—
6. Implementation difficulties	−.14	.20	.03	.60***	−.49**	—
7. Client difficulties	−.18	.26	.16	.38**	−.05	.50**	—
8. Confidence in implementing telepractice	−.03	−.12	.00	−.38**	.31*	−.18	.03	—
9. Training and further education	−.15	.06	−.22	.04	.26	.05	.28	−.14	—
10. Resources availability	.21	−.14	−.22	−.39**	.38**	−.60***	−.32*	.11	−.09	—
11. Continuous usage of telepractice	.06	.06	−.26	−.02	.32*	−.06	.09	−.19	.72***	.26	—

*

p < .05. **p < .01. ***p < .001.

Multiple linear regression was conducted to further address RQ2. The factors that predicted the perceived effectiveness of telepractice are reported in Table 2. In addition to the regression coefficients and standardized regression betas, variation inflation factors (VIFs) are also reported to evaluate the correlations between the included variables to prevent problems of multicollinearity and singularity (Mendenhall et al., 1996). No multicollinearity and singularity were identified since the VIF was ≥1. Implementation difficulties, t(44) = 3.75, p = .01, confidence of clinicians, t(44) = 2.67, p = .02, and training and further education, t(44) = 2.27, p = .03, were significant predictors of perceived effectiveness of telepractice, accounting for 39% of the variance.

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Table 2.

Regression Predicting Perceived Effectiveness and Future Adoption of Telepractice.

Variable	Perceived effectiveness							Future adoption
	Regression coefficients					Fit of model		Regression coefficients					Fit of model
	t	B	95% CI	β	VIF	R	R 2	t	B	95% CI	β	VIF	R	R 2
Implementation difficulties	3.75	.45**	[.22, .75]	.45	1.03	.62	.39
Confidence in implementing telepractice	2.27	.28*	[.03, .52]	.28	1.05
Training and further education	2.67	.32*	[.08, .56]	.32	1.02			7.82	.74***	[.50, .93]	.71	1.00	.78	.61
Resources availability								3.43	.33**	[.13, .52]	.33	1.01

Note. CI = confidence interval; VIF = variation inflation factor.

*

p < .05. **p < .01. ***p < .001.

Factors Influencing SLPs’ Willingness to Adopt Telepractice in the Future

RQ3 was concerned with SLPs continuous usage of telepractice. Willingness to use telepractice was correlated significantly with perceived effectiveness (r = .32, p = .03) and resource availability (r = .72, p < .001). However, it did not have a significant correlation with years of experience, telepractice difficulties subscales, clinician attitude subscales, and training and education subscales, ps > .05. These results are shown in Table 1.

Multiple linear regression was conducted to further address RQ3. The factors that predicted the future adoption of telepractice are reported in Table 2. Training and further education, t(44) = 7.82, p < .001, and resource availability, t(44) = 3.43, p = .01, were significant predictors of the future adoption of telepractice, accounting for 61% of the variance.

Adoption of Telepractice in the Philippines

The current study highlights the uptake of telepractice usage in the Philippines due to the pandemic. Almost all SLPs were first-time users, indicating that telepractice had not previously been implemented in the country and was utilized only as a response to lockdown measures brought about by the pandemic. However, the SLPs were willing to adjust their delivery method and were able to use telepractice as early as March and April 2020, when the first nationwide lockdown occurred. Most SLPs provided individual therapy. Interestingly, caregiver consultation was the second most popular service provided. This demonstrates that telepractice has the advantage of involving parents in their child’s therapy. Since caregivers have more interaction with their children, their involvement is crucial in their children’s speech development (Washington et al., 2012). Furthermore, caregiver coaching ensures continued practice at home for children’s sustained development (Edwards et al., 2012).

Factors Affecting the Effectiveness of Telepractice

Our survey results showed that SLPs believed that telepractice was an effective service delivery method. However, implementation difficulties affected the SLPs’ perceptions of its effectiveness. Although the SLPs believe that services such as assessment and parent consultation could easily be transferred to telepractice, they found that other components of intervention were best implemented through face-to-face interaction, especially in managing students’ behavior. In this regard, parents and caregivers, who are physically present to facilitate and monitor the session, are vital in managing student behavior during telepractice as SLPs are unable to do so due to physical barriers (Tucker, 2012).

Another challenge that the SLPs encountered in telepractice was providing cues when teaching. The SLPs believed that some effective cues could not be delivered through telepractice, and that skill acquisition was difficult to assess accurately. This stems from the difficulty in building rapport during online therapy. Since SLPs cannot physically interact with the child and are bound to a two-dimensional image on the screen, they have less social presence (Richardson et al., 2017) and must rely heavily on facial expressions to give precise cues (Overby, 2018). For example, SLPs can provide a physical prompt to elicit a certain speech sound when students fail to produce it. However, distinguishing between a poor network connection and confused understanding of the prompt when the trials are unsuccessful is difficult during telepractice.

Task preparation did not affect SLPs’ perceptions of the effectiveness of telepractice. There may be two reasons for this. First, SLPs spent more time preparing for telepractice than for onsite therapy and may have had more time to create learning materials that they deemed appropriate for telepractice. They also had time to find more evidence-based learning resources that can help enhance their sessions. Second, the SLPs in this study were handling fewer cases per week in telepractice compared with onsite. Fewer students imply less preparation time, which may be another reason why the speech pathologists did not perceive preparation as a factor influencing their effectiveness in implementing telepractice. However, the decrease in the number of sessions during telepractice should be noted. This decrease may indicate that the caregivers were not comfortable about allowing their child attend online sessions during the start of the pandemic. This can be attributed to the caregivers’ lack of knowledge about telepractice. One of the primary concerns caregivers have regarding telepractice is how their child will respond to these sessions (Yoo et al., 2021). Since they are not familiar with the effectiveness of telepractice, they might be hesitant to allow their child attend online therapy sessions. Thus, caregiver orientation is essential in raising awareness about the effectiveness of telepractice.

Factors Affecting SLPs’ Future Adoption of Telepractice

For RQ3, the factors that predicted SLPs willingness to adopt telepractice in the future were explored. Two factors that correlated with the SLPs’ continuous use of telepractice were professional training and further education, and lack of resources. Therefore, for telepractice to be widely adopted, resources should be in place before implementation. The lack of available resources, including learning materials, empirical research, and professional training, may hinder the future use of telepractice for SLPs in the Philippines. This suggests that if SLPs continue to have limited resources, SLPs will not be able to continue using this model. The SLPs believed that they needed more therapeutic materials and empirical research. The development of therapeutic materials should be suited for telepractice. In Overby’s (2018) study, SLPs believed that, unlike materials for onsite therapy, materials for telepractice should be more interactive to better engage children and sustain their attention. To develop suitable materials, evidence-based research should be conducted. Funding for this research is crucial and should be prioritized to ensure that telepractice is suitable for students with special needs. However, SLPs in the Philippines rarely engage in producing and disseminating research (Bondoc et al., 2017). As a multilingual country, the Philippines should have developed assessment and learning resources suited for the population. However, due to a lack of research, the country is still using Western assessments and materials since there are no established norms, cultural adoption, or validation of online administration (Amora et al., 2020; Bondoc et al., 2017).

The consensus among SLPs is that professional training is needed to make telepractice successful (Aggarwal et al., 2020; Fong et al., 2020; Hines et al., 2015). Research shows that SLPs believe that training is integral to the adoption of telepractice (Mohan et al., 2017; Tucker, 2012). However, most SLPs have not received formal telepractice training and they rely on personal experience when adopting telepractice. Furthermore, standard protocols should be established so that the quality of telepractice is on a par with that of onsite practice (Mashima & Doarn, 2008). SLPs believe that the lack of clinical protocols hinders their adoption of telepractice (Swales et al., 2020). This needs to be addressed because the Philippines has no specific procedures and regulations for conducting telerehabilitation (Leochico et al., 2020).

In line with the two-factor Davis’s (1989) Technology Acceptance Model, our results suggest that continuous professional development should also be considered when predicting the future use of telepractice in the Philippines. Since its inception, researchers have added components to Davis’ simple model to illustrate direct and indirect factors that can influence the adaptation of new technology (Chen et al., 2011; Scherer et al., 2019). It is reasonable that SLPs will discontinue the use of telepractice if they believe that they are not equipped to deliver effective online therapy. Current results indicated that the SLPs already had a positive attitude toward telepractice as they found it easy to adopt and effective for most case types. The next step is to provide professional training and develop materials to encourage SLPs to continue using telepractice.

Limitations

There were several limitations of this study. First, the sample size was small. Second, the survey was distributed in August, so most SLPs had used telepractice for 6 months or less. Further studies can examine the use of telepractice after SLPs have used it for a longer time period. Third, the data gathered in this study were mostly from Greater Manila area. Comparing telepractice for city and rural/remote areas might offer a different perspective on this topic, with the barriers faced in rural areas, (e.g., internet connection and access to gadgets) almost certainly more challenging than those in urban centers. In addition, interviewing SLPs is helpful in gaining a better understanding of the factors that contribute to a positive telepractice experience.

Implications

The first major finding in this study is the importance of resources for SLPs in the Philippines. Since the continued use of telepractice will benefit more students, the issue of limited resources should be addressed. Research-based academic programs should be provided for SLPs. The four universities in the Philippines offering speech-language pathology degrees could consider adding telepractice to their curricula and offer practical, hands-on experience in conducting therapy sessions online. Overby (2018) indicated that demonstration and professional development are the most effective methods for teaching future SLPs how to conduct telepractice. Demonstration is particularly effective in providing real-life experience to overcome barriers in actual telepractice settings. The SLPs can observe and engage in solving problems when conducting online therapy. In addition, the creation of training manuals and workshops, as elements of professional development, will guide SLPs in adopting telepractice. At the start of the COVID-19 pandemic, the PASP offered a step-by-step set of guidelines for determining client candidacy in telepractice (PASP, 2020). By having access to resources such as this, SLPs will be better equipped to use telepractice, which can minimize, if not fully resolve, implementation difficulties they may encounter.

Another key finding of this study is the importance of parent consultation during telepractice, which helps assure the child’s online participation. When caregivers are involved in the child’s therapy, they can better understand the effectiveness of telepractice and facilitate the treatment (Lam et al., 2021; Snodgrass et al., 2017). Positive attitudes of caregivers will lead to the successful implementation of telepractice.