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

Communicating accessible messages for food insecure communities in Northern Mozambique: Supporting Sustainable Development Goal 2

PURPOSE

This paper describes a collaborative project between Trinity College Dublin in Ireland and the United Nations' World Food Programme (WFP) Mozambique country office. The Sphere standards require that information on humanitarian assistance should be in languages and formats accessible to people who cannot read or who have communication difficulties. Nevertheless, there remains a gap in both implementing this guidance consistently and in understanding the impact of doing so when engaging with affected populations.

METHOD

This commentary describes the process of developing key messages regarding targeting of humanitarian food assistance in communication-accessible formats, and field testing of these materials with community committees and partners.

RESULT

The communication-accessible materials were well received by communities, and humanitarian staff and partners found them to be useful in community engagement.

CONCLUSION

Materials designed to be maximally accessible to people with communication differences and disabilities may also address inclusion for affected populations with different education, literacy, and language backgrounds. This commentary focuses on Sustainable Development Goal (SDG) 2 as an exemplar of the use of communication accessible messaging in humanitarian response.

Designing equitable speech-language pathology services in the Maldives to achieve Sustainable Development Goals 10 and 4

PURPOSE

The United Nations adopted 17 Sustainable Development Goals (SDGs) in 2015 as a universal plan to address challenges experienced around the globe. SDG 4 focuses on inclusive and equitable education while SDG 10 aims to reduce inequality within and among countries. To achieve these goals for children with communication disabilities living in underserved communities, equitable access to services is required. Service delivery should be tailored to the unique characteristics of specific communities to best cater to the needs of the population. This commentary presents the Context-specific Service Delivery Framework (CSDF) that can be used to explore contexts systematically and identify suitable speech-language pathology service delivery approaches. CSDF focuses on the three dimensions of sustainability that are emphasised in the SDGs: environmental, social and economic.

RESULT

We present how CSDF was developed in the case of one Majority world country, the Maldives. Five studies were conducted to complete CSDF and the findings were used to derive recommendations for service delivery approaches that could help achieve SDG 4 and SDG 10. These included, building capacity by using asset-based approaches, collaborating with service providers and the community, using population-based methods to focus on prevention of communication disabilities and using available technology to provide support.

CONCLUSION

Other underserved communities could also benefit from using CSDF to design equitable services for children with communication disabilities in their countries. This commentary paper focuses on SDG 4 and SDG 10.

Community-based rehabilitation workers in Vietnam need assistance to support communication and swallowing: Sustainable Development Goals 3, 4, 8, 10, 17

PURPOSE

Communication and swallowing disabilities (CSwD) impact health and well-being (Sustainable Development Goal SDG 3), educational attainment (SDG 4) and employment (SDG 8) and contribute to poverty (SDG 1). In Vietnam, community-based rehabilitation (CBR) workers are often the first point of contact for people with CSwD. This commentary reports research exploring the knowledge, experiences and training needs of CBR workers and their preparedness to provide services to people with CSwD and their families living in a province of Vietnam.

METHOD

Two hundred and five CBR workers completed a written survey and eight participated in a semi-structured interview. Quantitative survey data were analysed using descriptive statistics and content analysis was used to analyse the qualitative data.

RESULT

Most participants were female, aged over 30 and worked in a variety of health settings. Multiple challenges to the delivery of services to people with CSwD were described, including lack of training and limited understanding of CSwD by CBR workers, communities and their leaders.

CONCLUSION

Limited knowledge and preparedness of CBR workers is threatening the achievement of the SDGs for people with CSwD in Vietnam. There is a need for comprehensive education, training and the raising of awareness of the cause and impact of CSwD, and for this to be in partnership with people who experience CSwD and their families, local speech-language pathologists, and international collaborators. Future research exploring the needs of people with CSwD in Vietnam is critical to guiding the development of contextually relevant services and support. This commentary focuses on good health and well-being (SDG 3), quality education (SDG 4), decent work and economic growth (SDG 8), reduced inequalities (SDG 10) and partnerships for the goals (SDG 17), and indirectly addresses no poverty (SDG 1).

Psychosocial care of people with aphasia: Practices of speech-language pathologists in South Africa

Purpose: The study aimed to explore the practices of a sample of South African speech-language pathologists (SLPs) in providing psychosocial care to people with aphasia. People with aphasia are at risk of adverse psychosocial disruptions and access to appropriate support may be particularly challenging for individuals with compromised communication abilities. The study considered the multilingual and multicultural context of South Africa. By understanding current practices, direction for improved psychosocial care to clients as well as support to SLPs is highlighted.Method: A 20-item previously published online survey was completed by 56 South African SLPs. Purposive and snowball sampling were used to recruit participants. Descriptive and inferential statistics, and qualitative content analysis, were used.Result: Respondents recognised addressing psychosocial wellbeing to be very important. A variety of psychosocial approaches were used in practice. However, 67.9% of the sample felt ill-equipped to provide psychosocial care to people with aphasia. Further barriers included: time/caseload pressures (60.7%) and feeling out of their depth (48.2%). Enablers were: access to more training opportunities (89.3%), adequate time (62.5%), and ongoing support from skilled professionals (55.4%). The majority of respondents also perceived mental health professionals to have limited expertise in working with people with aphasia, making onward referral challenging.Conclusion: Respondents support people with aphasia's psychosocial wellbeing by employing counselling strategies, including family, and person-centred goal-setting. However, many challenges to the provision of psychosocial care to people with aphasia were identified. To improve services, more training opportunities, improved role definition and interprofessional collaboration, are required.

Influencing discussions and use of neuroadvancements as professionals and citizens: Perspectives of Canadian speech-language pathologists and audiologists

BACKGROUND: Early involvement of stakeholders in neuroethics and neurogovernance discourses of neuroscientific and neurotechnological advancements is seen as essential to curtail negative consequences. Speech-language pathologists (SLPs) and audiologists (AUs) make use of neuroadvancements including cochlear implants, brain-computer interfaces, and deep-brain stimulation. Although they have a stake in neuroethics and neurogovernance discussions, they are rarely mentioned in having a role, whether as professionals or as citizens. OBJECTIVE: The objective of the study was to explore the role of SLPs and AUs as professionals and citizens in neuroethics and neurogovernance discussions and examine the utility of lifelong learning mechanisms to learn about the implications of neuroadvancements to contribute in a meaningful way to these discussions. METHODS: Semi-structured interviews conducted with 7 SLPs and 3 AUs were analyzed using thematic analysis. RESULTS: Participants stated that their roles expected from them as professionals and as citizens indicate the importance to be knowledgeable on ethical, legal, and social implications of neuroadvancements and that lifelong learning is not used to learn about these implications. CONCLUSION: More must be done to facilitate the participation of SLPs and AUs in neuroethics and neurogovernance discussions, which would enrich the neuroethics and neurogovernance discourses benefitting patients, professionals, and the public.

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.

Determining the core vocabulary used by Sepedi-speaking children during regular preschool activities

PURPOSE

In order to provide equitable communication intervention and support services to clients from diverse cultural and linguistic backgrounds, the development of language-specific resources for assessment and intervention is needed. The purpose of the study was to develop a core vocabulary list based on language samples from Sepedi-speaking children, in order to make it available as a resource to inform vocabulary selection for augmentative and alternative communication (AAC) systems for children in need of AAC from a Sepedi language background.

METHOD

The speech of six typically developing Sepedi-speaking children aged 5-6 years was recorded using small body-worn audio recording devices. Children were recorded during their regular pre-school day. The recordings were transcribed, coded and analysed.

RESULT

The composite transcript consisted of 17 579 words, of which 1023 were different words. The core vocabulary was determined by identifying all words that were used with a minimal frequency of 0.05%, and were used by at least half of the participants. The Sepedi core vocabulary consisted of 226 words that accounted for 88.1% of the composite sample.

CONCLUSION

The core vocabulary determined in this study represents a small pool of reusable linguistic elements that form the grammatical framework of the Sepedi language. As such, is a valuable resource that can be used to assist with vocabulary selection for children who require AAC and who come from a Sepedi language background.

What are the implications of climate change for speech and language therapists?

BACKGROUND

The emerging global issue of climate change has large-scale effects on health and well-being, including communication disorders. The broad range of the speech and language therapy profession's scope of practice incorporates prevention, advocacy and equality in service delivery. These act as a springboard for involvement in climate change and health.

AIMS

This is an appeal to speech and language therapists (SLTs) to focus and take action on this issue and its considerable effects on communication and swallowing disorders.

METHODS & PROCEDURES

This article discusses the importance of taking a public health position on prevention and equality of services to manage environmental determinants of communication and swallowing disorders. It also describes the extent to which climate change affects these disorders and exacerbates the inequality of healthcare services in low- and middle-income countries.

MAIN CONTRIBUTION

Five strategies are provided for action on fulfilling therapists' roles in reducing the incidence, development and exacerbation of climate-related communication and swallowing disorders, as well as the role of SLTs in acting as advocates. The case is made for expanding the scope of services to focus on prevention and service equality so as to best meet the needs of the wider community.

CONCLUSIONS & IMPLICATIONS

Despite other challenges currently facing SLTs, climate change and its increasing effects on communication disorders and dysphagia is difficult to ignore. SLTs owe it to their clients, the wider community, low- and middle-income countries, the economy, and the future to take action. What this paper adds What is already known on the subject Multiple studies published in peer-reviewed scientific journals show that climate change is extremely likely to be due to human activities. The global effects will be higher temperatures, changes in precipitation, more droughts and heatwaves, stronger and more intense hurricanes, and a rising sea level which directly threaten the health of entire populations. Other health professions are beginning to take climate change into account in training and practice. What this paper adds to existing knowledge Many disorders of communication and swallowing are caused or exacerbated by the effects of climate change. Increasing temperatures, extremes of precipitation, population displacement and air pollution contribute to cardiovascular and cerebrovascular events, respiratory disease, malnutrition, premature birth, air- and water-borne diseases, and mental illness. These may affect the communication and swallowing abilities across the lifespan, but particularly those of children and older adults. What are the potential or actual clinical implications of this work? SLTs' roles in prevention, advocacy and education act as a starting point for involvement in climate change and health. Three practical strategies for action include educating SLTs and other health professionals on climate change and its effects on communication and swallowing, promoting awareness with clients and their families, and gathering and disseminating reliable data.

How aware is the public of the existence, characteristics and causes of language impairment in childhood and where have they heard about it? A European survey

Public awareness of language impairment in childhood (Developmental Language Disorder (DLD)) has been identified as an important determiner of research and clinical service delivery, yet studies directly assessing public awareness are lacking. This study surveyed awareness across 18 countries of Europe.

METHOD

A questionnaire developed by an international team asked whether respondents had heard of language impairment affecting children, what they thought its manifestations and causes were and where they had heard of it. Respondents were also asked whether they had heard of autism, dyslexia, ADD/ADHD and speech disorder. The questionnaire was administered to members of the public in 18 European countries. A total of 1519 responses were obtained, spanning 6 age groups, 4 educational level groups and 3 income level groups.

RESULTS

Across all but one country, significantly fewer people had heard of language impairment than any of the other disorders (or 60 % compared to over 90 % for autism). Awareness tended to be lowest in Eastern Europe and greatest in North-Western Europe, and was influenced by education level, age and income level. People in countries with overall low and overall high awareness differed in their views on manifestations and causes. People had heard of language impairment and autism the same way - most frequently through the media, including Internet, and less frequently through their child's school or a medical professional.

DISCUSSION

The study confirms that awareness of language impairment and knowledge of the breadth of its manifestations are low. It also suggests opportunities for how to increase awareness, including greater media coverage of language impairment and more efficient use of venues such as schools and healthcare. Ways in which cultural and linguistic differences may influence public awareness efforts are discussed, including the translatability of clinical labels and scientific terms. These may impact the acceptance of a common term and definition across all countries. As awareness campaigns are gaining momentum, the findings of this study can serve as a baseline against which to compare future findings.

Community service providers' roles in supporting communication disability rehabilitation in Majority World contexts: An example from Ghana

Purpose: In Majority World countries, where speech-language pathology services are extremely limited, people with communication disabilities (PWCD) may seek help from a range of service providers. This qualitative research aimed to explore the nature of community services offered to people with communication disabilities who seek help in Accra, Ghana.Method: Semi-structured interviews were conducted with nine individuals from three professions: pastors (3), doctors (3), and herbalists (3) exploring services that they may offer to PWCD seeking help. Interviews were analysed using Thematic Network Analysis.Result: Six global themes described beliefs about communication disability, types of intervention, explanations provided to people with communication disabilities, promoting communication, processes for selecting treatments, and links between service providers. Interventions encompassed physical, spiritual, psychosocial and environmental approaches, with the notion of plural beliefs interwoven through a number of themes.Conclusion: In Ghana, and other Majority World contexts, service providers in sectors not commonly associated with communication disability rehabilitation may have important roles to play in supporting people with communication disabilities. Understanding the contributions of other service providers may assist the growing profession of speech-language pathology to collaborate across sectors, to develop specific, culturally responsive approaches to service development.

Growing a profession: Clinician perspectives on the evolving practice of speech-language pathology in Vietnam

Purpose: This paper reports findings from phase two of a multiphase cross-cultural research programme exploring the professional practice of a group of Vietnam's first university-qualified speech-language pathologists.Method: Employing qualitative research methodology, this study involved a series of workshops with seven Vietnamese speech-language pathologists in which visual research methods were used to explore the evolution of their work, the challenges they faced, and opportunities to progress their professional practice. Thematic analysis employing a mixed deductive-inductive approach was used to analyse the textual data.Result: Heightened awareness of the speech-language pathology profession in Vietnam, movement into specialisation and expansion of services into the private sector were described. Dual professional roles, limited access to culturally-relevant resources to support practice and lack of experience in advocating for services posed challenges, whilst community education, the conduct of research, and the training of others in speech-language pathology were progressing the profession.Conclusion: The professional practice of a group of Vietnam's first speech-language pathologists is growing. Opportunities to advance their practice will best be informed by knowledge that reflects local context and culture and includes the experiences and preferences of persons living with communication and swallowing disabilities in Vietnam and their families.

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.

Consequential differences in perspectives and practices concerning children with developmental language disorders: an integrative review

BACKGROUND

Inter-professional collaboration (IPC) has been recommended for many years as a means by which the needs of children with developmental language disorders (DLD) can be met at school. However, effective IPC remains difficult to achieve and our knowledge of how to support it is limited. A shared understanding between those involved has been identified as critical to IPC.

AIMS

To examine the literature, as one source of data, for evidence of a shared understanding between the fields of speech and language therapy (SLT) and education about children with DLD and how such needs can best be met at school.

METHODS & PROCEDURES

An integrative review of the literature was undertaken. A systematic search of the published, peer-reviewed literature (between 2006 and 2016) was conducted for empirical and theoretical papers and a manual search was undertaken to obtain a representative sample of policy/professional guidelines. A total of 81 papers across SLT and education were included in the review. The papers were scrutinized using a qualitative content analysis.

MAIN CONTRIBUTION

Although some commonality between perspectives in the literature was identified, differences between the fields dominated. These differences related to how DLD is conceptualized; how children's needs are assessed; which outcomes are prioritized and how best these outcomes can be achieved. We also found differences about what constitutes useful knowledge to guide practice. We suggest that the nature of the differences we identified in the literature may have negative implications for practitioners wishing to collaborate to meet the needs of children with DLD in school. The perspectives of practising SLTs and teachers need to be sought to determine whether the findings from the literature reflect dilemmas in practice.

CONCLUSIONS

Effective IPC is essential to meet the needs of children with DLD in school; yet, it remains difficult to achieve. Our review of the literature across SLT and education indicates evidence of a lack of shared understanding about DLD. If these differences are also evident in practice, then a conceptual model to support IPC may be warranted.

A Cross-cultural Mixed Methods Investigation of Language Socialization Practices

This embedded mixed methods study explores how cultural differences in language socialization practices influence parent-child verbal interactions. The Language ENvironment Analysis (LENA) System audio recorded families of children who are and are not deaf and hard of hearing in Canada and Vietnam. Software automatically calculated an average conversational turn count. Canadian families participated in more turns than Vietnamese families regardless of hearing status. Interviews with the children's caregivers provided context for these results. Within Vietnamese families, the language socialization practice "Intelligence" results in reduced opportunities for turn-taking, while the Canadian focus on creating personal "Identity" encouraged them. "Intelligence" encompasses Vietnamese participants' desire to ensure their children are learning and "Identity" expresses the Canadian participants' appeal to encourage individuality in their children. The findings suggest directions for the adaptation of intervention. It is the first known study to incorporate LENA results into a mixed methods design.

A qualitative metasynthesis of the meaning of speech-generating devices for people with complex communication needs

The aim of this metasynthesis review of published qualitative research was to investigate the lived experience and meaning ascribed to speech-generating devices (SGDs) by people with complex communication needs and their familiar communication partners. Bibliographic databases were searched up to June 2016, and selected articles were assessed for their relevance to the research aim. The metasynthesis included 21 original articles and resulted in the identification of six main themes, each of which was comprised of two or more sub-themes that related to the experience of using SGD: It's an Inefficient Voice, It's Not a Natural Voice, Making the Most of This Voice, It's My Voice, It's More Than a Voice, and Having a Voice: Being Heard. The findings depict how use of an SGD is a complex process of understanding the limitations of the device, acknowledging expectations of society, using strategies to optimize communication, being aware of what an SGD represents, and using the SGD to enable social participation and a sense of empowerment.

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.

From individual to global: Human rights and aphasia

This commentary marks the 70th anniversary of the Universal Declaration of Human Rights by examining Article 19 and its application to people with aphasia. This group of people still face lack of access, stigmatisation, exclusion, disadvantage and social withdrawal as well as poor public awareness of aphasia and inadequate prioritisation of support and resources. Nevertheless, a range of creative initiatives at individual, healthcare, local community, national and global levels have helped to connect and empower people with aphasia. Such initiatives include provision of accessible information in a range of media, inclusion of people with aphasia in decision-making and as research partners, awareness raising campaigns to counter attitudinal barriers, organisation of community aphasia groups, development of guidelines for best practice, national aphasia associations and international collaborations such as Aphasia United. While ongoing work and resourcing is needed to expand these efforts further, they have helped people with aphasia to be heard and to protect their sense of dignity which underlies human rights. A human rights approach can unite, politicise and refocus these efforts, and highlight the essential role of communication in fostering a better quality of life.

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.

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.

The World Report on Disability: an impetus to reconceptualize services for people with communication disability

Challenges to the conceptualization and delivery of services for people with communication disabilities (PWCD) have been described in the lead article in this issue, which was itself a response to the World Report on Disability. A number of commentaries followed the lead article, where authors from around the world responded to the lead article (Wylie, McAllister, Davidson & Marshall, 2013), and the World Report on Disability. This paper synthesizes the issues, ideas, and challenges raised in the preceding commentaries. This has been done by addressing each of the four key issues posed in the lead article. A number of proposals for better responding to the needs of PWCD are outlined. These include: engaging with the collection of epidemiological data, consideration of which PWCD are under-served and how this may be changed, the use of documentation, adoption of new roles and strategies for speech-language pathologists, the challenges of community-directed vs individually-focused approaches, and the suggestion of public health communication disability workers and mid-tier workers, who could work alongside more traditional speech-language pathologists.