Service development to meet the needs of 'people with communication disabilities' in developing countries

Pediatric speech-language pathology in East Africa: educational opportunities and availability of speech-language services

OBJECTIVE

This paper describes the current situation of the provision of speech-language services in East Africa. An overview of the educational opportunities, workforce density, communication rehabilitation planning, caseload, and ethical and/or cultural challenges is provided.

METHOD

A narrative review was performed. All papers referring to communication disorders in East African countries were identified from EMBASE, PubMed, ISI Web of Science: Science Citation Index Expanded, and ISI Web of Science: Conference Proceedings Citation Index-Science using the following search terms: speech therapy, speech pathology, speech-language pathology, speech-language rehabilitation, speech-language therapy, logopedics, East Africa, communication disorders, communication difficulties. Two concepts were combined with a Boolean operator 'AND'.

RESULTS

At present, there is an alarming shortage of speech-language pathologists in East Africa. This issue is mainly related to the limited availability of educational programs in speech-language pathology. Although more and more universities are beginning to offer such educational programs, the number of available speech-language pathologists is still too low to meet the needs of all children with communication disorders. In addition, speech-language pathologists are often faced with different cultural and ethical obstacles when they provide intervention to East African children with communication disorders. These speech-language pathologists are therefore challenged to take a broader view of their role as a therapist. These alternative roles often include training of other individuals in the context of community-based rehabilitation.

CONCLUSION

In the future, it will be important to carefully consider the development of sustainable learning opportunities in East African contexts. Initiatives, for example, "train-the-trainer" workshops, are needed to support the speechlanguage pathologists. Existing models like the communication disability model can aid to create holistic frameworks for the development of sustainable speech-language services in the East African countries.

A scoping review of Augmentative and Alternative Communication (AAC) interventions in Low-and Middle-Income Countries (LMICs)

Currently, a small number of studies discuss augmentative and alternative (AAC) interventions in low- and middle-income countries (LMICs). The primary purpose of this scoping review was to summarize the current evidence base on communication-based interventions and partner training in LMICs, to explore and identify gaps in the AAC evidence base and guide future research. A total of 18 studies were identified. The results revealed many positive outcomes arising from AAC interventions, including increased communication, improved participation, increased knowledge about communication, and increased use of partner communication strategies, thus adding to the evidence base that AAC can be successfully implemented in LMICs. However, these studies did not broadly represent most LMICs and there were only a handful of indirect intervention studies training communication partners. To this end, there is an urgent need to expand the level of AAC intervention research conducted in LMICs in order to better serve individuals with complex communication needs living in these countries.

Successes and challenges of speech language therapy service provision in Western Kenya: Three case studies

Background

The need for communication-related services in sub-Saharan Africa to support individuals experiencing communication disability is a longstanding and well-documented situation. We posit the inequities highlighted by coronavirus disease 2019 (COVID-19) make this a relevant time for speech language therapists and the professional bodies that govern us to broadly consider our roles and practices in education, health and disability in local, national and global contexts.

Objective

To illustrate what services developed with local knowledge can look like in Kenya in order to promote dialogue around alternative speech language therapy models, particularly in contexts where there are insufficient services, few trained speech language therapists and limited structures to support the emerging profession.

Method

This article examines three clinical case studies from Western Kenya, using a conceptual framework for responsive global engagement.

Results

Service needs in Western Kenya well exceed a direct one-on-one model of care that is common in the minority world. The service delivery models described here emphasise training, skills sharing and engaging the myriad of communication partners available to individuals with communication disabilities.

Conclusion

We offer up these case studies of collaborative practice as contextual realities that may be present in any speech language therapy programming in under-resourced communities. We dispel the idea that success in this work has been linear, progressed on planned time frames or come to fruition with targeted goal attainment. The fact that our relationships have endured in these communities since 2007 is our primary success.

Optimising existing speech-language therapy resources in an underserved community: A study of the Maldives

BACKGROUND

People living in Majority world countries face complex challenges regarding speech-language therapy services. As traditional individualised service delivery approaches may not suit the needs of the population, customised solutions are needed.

AIM

This study explored speech-language therapy and related resources available in the Maldives, a Majority world country, as seen by local government representatives and service providers. The goal was to identify service delivery approaches for children with communication difficulties that could yield the most out of existing resources.

METHOD

Semi-structured interviews were conducted with six service providers (three speech-language therapists (SLTs), three representatives from Non-Governmental Organisations (NGOs) related to disabilities) and six local government representatives (atoll councillors) of the Maldives. Interview questions related to services available for children with communication difficulties. The data were analysed via deductive content analysis.

RESULTS

SLTs predominantly delivered traditional individualised and rehabilitative therapy. Services were unevenly distributed across the Maldives with some atolls receiving no services. Support was available from community groups and atoll councillors in some atolls, for instance to access aids provided by the government. Some NGOs were trialling alternative service delivery approaches by conducting programs for parents and teachers in atolls. Participants suggested several possible measures including increasing awareness of speech-language therapy and communication difficulties amongst communities, engaging active community groups to support interventions and allowing less qualified professionals to provide services. The costs related to access and provide services were noted as a challenge.

CONCLUSION

While this study discovered limitations, the existing resources that were identified can be better directed to reach more children who require services in the Maldives. The following potential alternative service delivery approaches were derived from the results: focusing on prevention, using public health approaches to train families and teachers, creating awareness, building capacity within the community, and adopting cost-effective approaches to provide services.

Street-connected children with communication disabilities and their caregivers in Western Kenya: experiences, beliefs and needs

PURPOSE

Although street-connected children with communication disability have been identified in Western Kenya, little is currently known about the impact of communication disability on this group. In order to inform future service development, this qualitative study sought to understand the experiences, views and needs of street-connected children with communication disability, and of their caregivers at home and at school.

MATERIALS AND METHODS

13 children, 12 caregivers and 12 school-based Learning Support Assistants participated in interactive sessions, semi-structured interviews and focus groups respectively. Interviews were translated, transcribed and analysed thematically, using framework analysis.

RESULTS

Six main themes, with sub-themes, were identified: understanding and awareness of communication disability; the role of others; needs of the children and what might help; impact on those supporting the children; caregiver and Learning Support Assistant needs: support to better help the child; thoughts about the future. Participants' responses highlighted the importance of improving others' attitudes, awareness and willingness to adapt their communication, as well as a need for trusted relationships and some specialist help.

CONCLUSION

Organisations working with street-connected children should take communication disability into account in their services and interventions. Input based on a social model of disability is likely to be acceptable.Implications for rehabilitationThe attitudes and behaviour of others affect how communication disability is experienced by street-connected children and their families.Intervention based on a social model of disability and aimed at improving the communication environment around the child is likely to be acceptable to children, caregivers and education support workers.Caregivers and education support workers want more training and support alongside specialist intervention.Communication at the level of the child is central to building trusted relationships, which are important to the success of street-connected children's rehabilitation and re-integration.

Evaluating an AAC training for special education teachers in Sri Lanka,a low- and middle-income country

A majority of people with disabilities live in low- and middle-income countries where communication services for individuals with complex communication needs are scarce. It is essential that communication partners of individuals who have complex communication needs receive training to support communication. To address this issue, the current study evaluated an augmentative and alternative communication training for special education teachers living in a low- and middle-income country, Sri Lanka. The training was based on four key practices identified when training in low- and middle-income countries: investigate learner needs, provide contextually relevant instructional content, use engaging instructional activities, and assess the impact of instructional activities. This investigation implemented an interrupted time-series design with nine teacher-student dyads. Special education teachers were taught to provide evocative communication opportunities. Following the training, all nine special education teachers significantly increased the number of evocative communication opportunities provided to students with complex communication needs. Additionally, all nine students with complex communication needs significantly increased their number of communication turns.

Communication rehabilitation in sub-Saharan Africa: The role of speech and language therapists

Background

Workforce factors present a significant barrier to the development of rehabilitation services for people with communication disabilities in sub-Saharan Africa (SSA). Exploring how the work of speech and language therapists (SLTs) in the region is organised and delivered can provide insight into existing services, areas for future workforce development and improved rehabilitation access for people with communication disability.

Objectives

This paper describes the employment and service provision patterns and work roles of a sample of SLTs in SSA.

Method

A broad, purpose-designed, mixed-methods survey was designed to collect data from SLTs living in Anglophone countries of SSA. Descriptive statistics and qualitative content analysis were undertaken. This paper reports on a subset of data from the wider survey.

Results

A description of the employment and work roles of the 33 respondents to the survey and characteristics of their service users is presented. SLTs were commonly employed within private and not-for-profit sectors and frequently worked in temporary jobs. SLTs engaged in a range of work roles, including capacity building and training others. Services were provided by SLTs across age ranges, health conditions and settings, with paediatric, urban services commonly reported. Costs for service users and urban-centred services give indications of barriers to service access.

Conclusion

Knowledge of the way in which speech and language therapy services are organised and provided has the potential to shape the development of communication disability rehabilitation in SSA. This research has identified a range of issues requiring consideration as the profession develops and grows.

Self-help and help-seeking for communication disability in Ghana: implications for the development of communication disability rehabilitation services

BACKGROUND

In low and middle-income countries, such as Ghana, communication disability is poorly recognised and rehabilitation services for people with communication disability are limited. As rehabilitation services for communication disability develop, and the profession of speech-language pathology grows, it is important to consider how services can most appropriately respond to the needs and preferences of the community. Understanding the ways in which people currently self-help and seek help for communication disability is central to developing services that build on existing local practices and are relevant to the community.

METHODS

A qualitative descriptive survey was used to explore likely self-help and help-seeking behaviours for communication disability, in Accra, Ghana. The survey required participants to describe responses to hypothetical scenarios related to communication disability. A mix of theoretical sampling and convenience sampling was used. Qualitative content analysis was used to analyse data and develop categories and subcategories of reported self-help behaviours and sources of help and advice for communication disability.

RESULTS

One hundred and thirty-six participants completed the survey. Results indicated that community members would be likely to engage in a variety self-help strategies in response to communication disability. These included working directly with a person with a communication disability to attempt to remediate a communication impairment, altering physical and communication environments, changing attitudes or care practices, educating themselves about the communication disability, providing resources, and responding in spiritual ways. Participants indicated that they would seek help for communication disability across a range of sectors - including the Western healthcare, religious, and traditional sectors.

CONCLUSIONS

Understanding existing community actions to self-help and help-seek may allow emerging communication rehabilitation services, including the profession of speech-language pathology, to build on existing community practices in resource-limited contexts such as Ghana.

Communication rehabilitation in sub-Saharan Africa: A workforce profile of speech and language therapists

BACKGROUND

There is an urgent global need to strengthen rehabilitation services for people with disabilities. In sub-Saharan Africa, rehabilitation services for people with communication disabilities continue to be underdeveloped. A first step in strengthening services for people with a communication disabilities is to understand the composition and conditions of the current workforce.

OBJECTIVES

This research describes a sample of the speech and language therapists (SLTs) working in SSA (excluding South Africa). This study explores the characteristics of this workforce, including their demographics, education, experience and geographical stability.

METHOD

A mixed-methods survey was used to collect data from SLTs within Anglophone countries of SSA. Completed surveys were received from 33 respondents working in 44 jobs across nine countries. Analysis included descriptive and non-parametric inferential statistics. This study reports on a subset of descriptive and quantitative data from the wider survey.

RESULTS

A background profile of SLTs across the region is presented. Results indicated that the workforce of SLTs comprised a mix of local and international SLTs, with university-level education. Local SLTs were educated both within and outside of Africa, with more recent graduates trained in Africa. These data reflected the local emergence of speech and language therapy training in SSA.

CONCLUSION

This sample comprised a mix of African and international SLTs, with indications of growing localisation of the workforce. Workforce localisation offers potential advantages of linguistic diversity and stability. Challenges including workforce support and developing culturally and contextually relevant SLT practices are discussed.

Providing instructional support for AAC service delivery in low- and middle-income (LAMI) countries

PURPOSE

The majority of individuals with disabilities live in low- and middle-income (LAMI) countries; typically these individuals receive limited, if any, communication rehabilitation services. The present study investigated the experiences of eight augmentative and alternative communication (AAC) professionals who had provided instructional support for AAC service delivery in LAMI countries.

METHOD

An online focus group was used to explore the training experiences of eight AAC professionals.

RESULT

A thematic analysis of the focus group discussion resulted in four major recommendations when providing training for AAC service delivery in LAMI countries: (a) investigate learner needs, (b) provide contextually relevant instructional content, (c) use engaging instructional activities and (d) assess the impacts of instructional activities.

CONCLUSION

The instructional recommendations of the focus group participants are discussed within a theoretical framework of recommended best practices in supporting adult learning. The information shared by the focus group participants will benefit others providing instructional support for AAC service delivery in LAMI countries.

To be or not to be: Stuttering and the human costs of being "un-disabled"

PURPOSE

The centrality of communicating in human life means that communication difficulties are experienced at a deeply personal level and have significant implications for identity. Intervention methods may interact positively or negatively with these experiences.

METHOD

This paper explores this intersection in the case of stuttering, suggesting that some intervention styles may dovetail unhelpfully with the "mainstream" prizing of normalcy. In particular, most "western" societies offer a performance-oriented milieu which prizes efficiency, immediacy and competitiveness, diverting energy from the equally important work of understanding and integrating difference.

RESULT

Given that a person who stutters speaks fluently and with a stutter, stuttering can lean toward a complex view of disability identity-being both able and disabled. This split repertoire invites psychologically costly efforts at being "un-disabled".

CONCLUSION

Interventions which amplify this tendency can contribute to an alienation from self amid strivings for normalcy.

Students Involvement in Multilingual and Multicultural Community Services

Promoting cultural competence in serving diverse clients has become critically important across disciplines. Yet, progress has been limited in raising awareness and sensitivity. Tervalon and Murray-Garcia (1998) believed that cultural competence can only be truly achieved through critical self-assessment, recognition of limits, and ongoing acquisition of knowledge (known as “cultural humility”). Teaching cultural humility, and the value associated with it remains a challenging task for many educators. Challenges inherent in such instruction stem from lack of resources/known strategies as well as learner and instructor readiness. Kirk (2007) further indicates that providing feedback on one's integrity could be threatening. In current study, both traditional classroom-based teaching pedagogy and hands-on community engagement were reviewed. To bridge a gap between academic teaching/learning and real world situations, the author proposed service learning as a means to teach cultural humility and empower students with confidence in serving clients from culturally/linguistically diverse backgrounds. To provide a class of 51 students with multicultural and multilingual community service experience, the author partnered with the Tzu-Chi Foundation (an international nonprofit organization). In this article, the results, strengths, and limitations of this service learning project are discussed.

Caring for children with physical disability in Kenya: potential links between caregiving and carers' physical health

BACKGROUND

The health of a carer is a key factor which can affect the well-being of the child with disabilities for whom they care. In low-income countries, many carers of children with disabilities contend with poverty, limited public services and lack assistive devices. In these situations caregiving may require more physical work than in high-income countries and so carry greater risk of physical injury or health problems. There is some evidence that poverty and limited access to health care and equipment may affect the physical health of those who care for children with disabilities. This study seeks to understand this relationship more clearly.

METHODS

A mixed methods study design was used to identify the potential physical health effects of caring for a child with moderate-severe motor impairments in Kilifi, Kenya. Qualitative data from in-depth interviews were thematically analysed and triangulated with data collected during structured physiotherapy assessment.

RESULTS

Carers commonly reported chronic spinal pain of moderate to severe intensity, which affected essential activities. However, carers differed in how they perceived their physical health to be affected by caregiving, also reporting positive benefits or denying detrimental effects. Carers focussed on support in two key areas; the provision of simple equipment and support for their children to physically access and attend school.

CONCLUSIONS

Carers of children with moderate-severe motor impairments live with their own physical health challenges. While routine assessments lead to diagnosis of simple musculoskeletal pain syndromes, the overall health status and situation of carers may be more complex. As a consequence, the role of rehabilitation therapists may need to be expanded to effectively evaluate and support carers' health needs. The provision of equipment to improve their child's mobility, respite care or transport to enable school attendance is likely to be helpful to carers and children alike.

Widening the SLP lens: how can we improve the wellbeing of people with communication disabilities globally

This article responds to Wylie, McAllister, Davidson, and Marshall (2013) by arguing that the wellbeing of people with communication disabilities in the global south will be improved if speech and language pathologists widen their lens considerably. The numbers of speech-language pathologists (SLPs) in the Majority World is and will remain infinitesimally small. Therefore, to make any meaningful impact the profession needs to engage in debates and activities outside the health and service provision arenas, getting involved cross-sectorally and at various policy levels. It is contended that, although the World Report on Disability is a useful summary of the status quo, actually SLPs need to harness two other seminal documents: The International Classification of Functioning, Disability and Health and, more particularly, the United Nations Convention on the Rights of People with Disabilities in order to drive change. Historically the profession's focus has been on impairments, and current moves to social models are welcome. However, SLPs need to embrace human rights approaches and broader frameworks of inclusive community development, using global initiatives such as community-based rehabilitation to improve the lives of people with communication disabilities. Why SLPs should become critically engaged, particularly at the macro level, is explored.

Changing practice: implications of the World Report on Disability for responding to communication disability in under-served populations

The World Report on Disability provides a major challenge to the conceptualization and delivery of services for people with communication disabilities around the world. Many people, in both Majority and Minority World countries, receive limited or no support in relation to their communication disability. In this paper the prevalence of communication disability across the world (and the challenges to obtaining these data) are discussed, particularly in relation to disability more broadly. Populations that are under-served by speech-language pathology services in both Majority and Minority World countries are described. The paper describes organizational change theory and the potential it has, together with a biopsychosocial model of disability, to assist in understanding and influencing development of relevant services for people with communication disabilities (PWCD), particularly those who are under-served. Aspects of, and influences on, service delivery for PWCD are described. The need for novel ways of conceptualizing development of services, including population-based approaches, is highlighted. Finally, the challenges and opportunities for PWCD and for speech-language pathologists which arise from the nine recommendations of the World Report on Disability are considered and readers are encouraged to consider new and novel ways of developing equitable services for people with communication disabilities, in both majority and minority world settings.

Using community/researcher partnerships to develop a culturally relevant intervention for children with communication disabilities in Kenya

PURPOSE

The objective of this study is to develop a culturally relevant community-based intervention for children with communication disabilities in Kenya through a community/researcher partnership. The resulting intervention is for use in a randomized control trial which will be reported at a later stage.

METHOD

Using a qualitative approach, initial data was collected through focus group discussions with women, disabled people and traditional dancers. The groups examined the needs, problems and challenges faced by disabled children and their families. This generated the content and structure for a series of participatory workshops with a further two women's groups. These workshops strove to generate a culturally relevant community-based intervention programme for children with communication disabilities and their families. The content and balance of the resulting intervention was observed to be different from existing programmes described in the literature. Notably it included many culturally appropriate strategies for increasing social integration and raising community awareness.

RESULTS

The process of generating a locally relevant community-based rehabilitation intervention is potentially transferable and has particular relevance to the estimated 80% of the world where there are no formal rehabilitation services for children with disabilities and where women's groups are a strong element of local culture.

CONCLUSION

(i) Community/researcher partnerships can be used to develop interventions; (ii) such interventions are different from those imported from other cultures; and (iii) this process is transferable and can be part of the preparations for a Randomized Control Trial.

The evidence base for community-based rehabilitation: a literature review

Literature on community-based rehabilitation (CBR) published between 1978 and 2002 is reviewed to assess the evidence base for CBR. There were 128 articles found that met the criteria set by the authors. The articles have been classified according to the methodology used and the key aspects studied. The review showed an ever-increasing number of publications on CBR. Theory papers and descriptive studies are the most common types of papers in CBR literature. Intervention studies and case reports are relatively rare. No systematic review has yet been carried out although reviews on specific aspects of CBR have become available. The key aspects of 'implementation' and 'stakeholders' are relatively well presented but the numbers of articles on 'participation' and 'use of local resources' are noticeably low. This study reveals that there is no real focus of research in CBR and therefore the evidence base for CBR is fragmented and incoherent on almost all aspects of CBR. It is recommended that comprehensive review studies should be carried out on key aspects of CBR projects. This should be supported by systematic research in CBR projects in order to establish evidence-based practices.

Development of a 'communication disability model' and its implication on service delivery in low-income countries

This paper argues that higher priority should be given to the development of services which support people with communication disabilities in low income countries and that these services should be different from those in other countries. Present services for this population group have poor coverage levels, tend to be centrally located and are orientated to specialist services. WHO (Health Programme Evaluation, Geneva, WHO, 1981) argue that health services should be based on meeting people's needs. This paper describes an analysis of 'needs related' qualitative data concerning people with communication disabilities and their families in two low income countries and examines the results in relation to service development. The data was collected as part of five different studies concerning people with communication disabilities carried out in Uganda and Nigeria. Using the principles of established theory, these data helped develop, a theoretical model. This model is compared with WHO's classification of Impairment Disability and Handicap ICIDH-2 WHO (International Classification of Impairments Disabilities and Handicaps (ICIDH-2), A manual of classification relating to the consequences of diseases, Geneva, WHO. 1997a; 1999). Suggestions are made as to how this model might inform planning and practice from the perspective of the five major stakeholder groups; government and non-government organizations, people with communication disabilities, their families and professionals. Consideration is also given as to how this theory can be used to strengthen existing services, or encourage a complete paradigm shift, with the creation of different services in new and innovative ways.