Original Paper Folia Phoniatr Logop 2014;66:164–175 DOI: 10.1159/000365752

Published online: March 17, 2015

Adopting Public Health Approaches to Communication Disability: Challenges for the Education of Speech-Language Pathologists Karen Wylie a, c Lindy McAllister a Bronwyn Davidson b Julie Marshall d James Law e a

University of Sydney, Sydney, N.S.W., and b University of Melbourne, Melbourne, Vic., Australia; Korle-Bu Teaching Hospital, Accra, Ghana; d Manchester Metropolitan University, Manchester, and e University of Newcastle, Newcastle, UK c

Key Words Communication disability · Public health · Education

Abstract Public health approaches to communication disability challenge the profession of speech-language pathology (SLP) to reconsider both frames of reference for practice and models of education. This paper reviews the impetus for public health approaches to communication disability and considers how public health is, and could be, incorporated into SLP education, both now and in the future. The paper describes tensions between clinical services, which have become increasingly specialized, and public health approaches that offer a broader view of communication disability and communication disability prevention. It presents a discussion of these tensions and asserts that public health approaches to communication are themselves a specialist field, requiring specific knowledge and skills. The authors suggest the use of the term ‘communication disability public health’ to refer to this type of work and offer a preliminary definition in order to advance discussion. Examples from three countries are provided of how some SLP degree programmes are integrating public health into the SLP curriculum. Alternative models of training for communication disability public health that may be relevant in the future in different contexts and countries are presented, prompting the SLP profession to con-

© 2015 S. Karger AG, Basel 1021–7762/15/0665–0164$39.50/0 E-Mail [email protected] www.karger.com/fpl

sider whether communication disability public health is a field of practice for speech-language pathologists or whether it has broader workforce implications. The paper concludes with some suggestions for the future which may advance thinking, research and practice in communication disability public health. © 2015 S. Karger AG, Basel

Introduction

A number of recent publications have emphasized the changing nature of the practice of speech-language pathology (SLP) [1, 2]. These have focused on the need for speech-language pathologists to consider broadening their scope of practice to include alternative approaches to service delivery for communication disability, particularly in order to meet the needs of under-served, ‘at-risk’ or ‘hard-to-reach’ populations in both Minority and Majority World countries. (‘Majority World’ is a commonly used term in preference to the terms ‘developing countries’ and the ‘Global South’. The term Majority World reflects the view that most countries in the world live in circumstances with different resources from those in the Minority World. Minority World is used in preference to the terms ‘developed countries’ and the ‘Global North’.)

Dr. Julie Marshall Research Institute of Health and Social Change (RIHSC) Department of Health Professions, Manchester Metropolitan University Birley Fields Campus, 53 Bonsall Street, Manchester M15 6GX (UK) E-Mail j.e.marshall @ mmu.ac.uk

What Is Public Health? The WHO defines public health as… all organized measures … to prevent disease, promote health, and prolong life among the population as a whole. Its activities aim to provide conditions in which people can be healthy and focus on entire populations, not on individual patients or diseases. Thus, public health is concerned with the total system and not only the eradication of a

Fig. 1. Defining public health. Extracted

from WHO [36].

particular disease.

Table 1. Primary, secondary and tertiary prevention

Focus

Target

Primary prevention

Reduce the incidence of the condition in the population

Whole population or sub-populations

Secondary prevention

Reduce the risk of progression of the condition in ‘asymptomatic’ individuals (i.e. before the condition is established); early detection and intervention

High-risk groups or individuals with known high-risk factors

Tertiary prevention

Reduce the impact of the condition and improve function through treatment or rehabilitation

Individuals or groups with the condition

Extracted from National Public Health Partnership [40].

The adoption of a public health approach (fig.  1) in SLP practice is examined in this paper. Whilst clinical services traditionally focus on the health (or impairment) of individuals, public health employs interventions which target the health of populations. Such an approach originates from a philosophical position of equity that assumes individuals, communities and governments are all responsible for protecting and promoting health in their population(s) [3]. Public health focuses on efforts to prevent disease and disability, considers factors influencing disease and health outcomes (known as ‘determinants’) and adopts a multidisciplinary, multisectoral approach including community engagement [3, 4]. Law et al. [5] have explored the argument for public health in SLP and provide a useful overview of public health in this domain. This paper provides a rationale for the need for public health services that address communication disability and gives an overview of the state of public health in SLP. Tensions between traditional SLP services and public health approaches are described, and a case is made for a continuum of services from public

health, population-focused services (with an emphasis on prevention) to direct services for individuals with communication disability. This continuum maps directly onto traditional public health notions of primary, secondary and tertiary prevention. The goals of primary, secondary and tertiary prevention approaches are outlined in table 1. The skill and knowledge sets needed for speech-language pathologists effectively to engage in public health are reviewed. A key question for the development of adequate services across this continuum is posed: who is best placed to deliver communication disability public health services: a speech-language pathologist with additional training, or a new type of communication disability public health professional? Examples are given of how public health approaches have been integrated into SLP education in different countries, and possible models of education for practice in communication disability public health are proposed. Finally, factors that may determine the adoption of public health approaches to communication disability in different contexts and countries are considered.

Education for Communication Disability Public Health

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• Communication disability public health focuses on the development of communicatively healthy populations through organized efforts aimed at reducing both the risks and impact of communication disability within populations. • Work in communication disability public health addresses the development, implementation and evaluation of programmes and systems to achieve communicatively healthy populations. • Public health approaches to communication require an understanding of the impact that social determinants have on communication skill development, as well as an understanding of the impact of communication skills (as a social determinant) on other social, economic and environmental outcomes. • Communication disability public health typically targets whole populations or high-risk

Fig. 2. Communication disability public health: a draft definition.

groups rather than the provision of clinical services for referred individuals.

To frame the discussion in this paper, we offer a preliminary definition of ‘communication disability public health’. This definition is offered as a starting point for the profession to progress thinking on communication within a public health framework and to invite refinement and expansion of the concept of communication disability public health. The development of a comprehensive definition will require widespread consultation and consensus (fig. 2).

The Impetus for a Public Health Approach to Communication Disability

Public health has traditionally focused on acute health conditions impacting mortality and has been relatively slow to centre upon disability [6]. This has shifted in recent years as the degree of impact of disabilities in society has been identified and disability classification systems have improved [7]. Cognitive and communication disabilities specifically have rarely been a part of this narrative, although these issues are now receiving more attention. The WHO and UNICEF have in recent years focused on developmental difficulties in children as a population issue in Majority World countries [8, 9]. Whilst communication has not specifically been singled out for attention, it is clear that, ultimately, communication skills are instrumental in individuals’ effective participation in their society. As Ruben [10] has indicated, in modern economies, which rely heavily on communicative and cognitive skills rather than physical prowess, an individual with a communication disability may be much more ‘disabled’ than someone with a physical disability. There is little doubt that systemic change is required if expanded practice in the field of communication disabil166

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ity public health is to become a reality. The leadership and operationalization of such an agenda require explicit debate both within the profession and across sectors. Is this a field for speech-language pathologists? Is it a specialist field in itself? Whilst public health endeavours are crosssectoral, it would seem that communication disability public health itself needs a champion to drive change. Within this paper we do not make a judgement about where and how this endeavour should fit philosophically, but we acknowledge that different countries and contexts may choose to approach this issue differently. What is critical at this juncture is a debate and discussion about ways forward to best meet the needs of the populations we should serve. There are a number of reasons for reconsidering the role of speech-language pathologists in public health. While in some countries, such as the UK, SLP has been recognized as a universal service with coverage of the whole population, this role has historically been downplayed in preference to clinical services for referred individuals (tertiary prevention). Yet, population data reveal that many conditions that have a communication dimension (for example, stroke, learning disability and language impairment) are strongly associated with social factors in terms of aetiology, social inclusion and access to services [5]. Such social determinants are the economic and social conditions within the population that influence differences in health status and in the use of health and other resources and are likely to affect participation and, thus, the experience of disability more widely. The relationship between social determinants and communication disability is clearly seen in population studies of child language, where the most disadvantaged not only have the highest level of need for services, they are also less likely to access or to receive services [1]. Wylie /McAllister /Davidson /Marshall / Law  

 

 

 

 

The key to understanding more about determinants of communication disability, and ways to offer more equitable service delivery, are well-constructed cohort studies and population-level data. Such data are becoming increasingly available [11–13]. Geographical tools allow mapping of the relationship between where populations live and where services are located [14, 15]. These data are not yet available for all countries but will be increasingly available in coming decades. Understanding population data often requires access to a range of different data sources – for example, school and health records for children, and medical and social service records for adults. Whilst such service-level data are now, in theory, accessible, bureaucratic and ethical constraints can often make the integration of such data sets problematic. If speechlanguage pathologists understood more about the characteristics of the whole populations they served, the role of public health approaches in the prevention and minimization of communication disability across the life span would become clearer. Without population-based data it is not possible to plan universal services or to know whether the most appropriate groups have been targeted.

The State of Public Health and SLP

aphasia or other communication disabilities [19], thus improving community participation with populations who have a chronic communication disability. Of course, defining a public health intervention depends largely on both the objective and the target of the intervention; for example, increasing public awareness and broadening the skill base of those who have direct contact with the public can be viewed as a public health intervention. Public health programmes are also evident in Majority World countries. As in the Minority World countries, such programmes rely heavily on practitioners understanding the unique characteristics of their populations in order to maximize the equity of access. In recognition of the differing contexts in Majority World countries, some SLP training programmes in those countries have adopted a more population-based approach in some of their training, including foci on awareness raising, advocacy, policy development and skill transfer [20, 21]. It remains to be seen whether the graduates from these programmes ultimately engage in more population-based activities. As public health practice in the field of communication disability public health evolves throughout the world, models of services, service providers and training may need to differ substantially according to the unique needs of each region.

The extent to which speech-language pathologists already take a public health perspective is decidedly patchy. Universal interventions such as the Pathways to Prevention project in Australia [16] and the Sure Start initiative in the UK [17, 18] are examples of what are essentially largescale public health programmes for child development, including communication skills as a key focus. The latter saw speech-language pathologists coming out of their clinics and giving messages directly to the public, through work in community settings such as supermarkets. Such projects started with an assessment of need, based on health records, examining determinants of communication disability, including indices of social disadvantage. Future evaluations should reveal whether this is a comparable or more efficient way of working than treating individual clients. Smaller-scale public health interventions may include activities such as training teachers or health care workers in approaches to develop oral language skills in children, or working with high-risk community groups to reduce the likelihood of developing a communication disability. It is expected that these will ultimately have a direct and longterm impact on whole populations. Another example of a public health approach is the training of volunteers to become ‘effective communication partners’ for people with

The impetus to integrate population approaches and public health education into university-degree programmes for allied health professions is growing [22, 23]. There is an increasingly popular belief that allied health professionals, including speech-language pathologists, should develop skills and knowledge in population approaches and public health as part of their core pre-qualification education [24–26]. Public health, including the provision of population-based interventions, has been recognized by the WHO as a key competence for health (including allied health) professionals working with patients with chronic conditions [27]. Education programmes for SLP are beginning to integrate principles of public health into a number of university courses. How and why this is achieved differs between contexts. Examples from programmes in three countries are given in the Appendix. These examples are not intended to be exhaustive or standardized approaches. Rather, they are presented to outline some of the alternate approaches and reasoning taken to include public health education for SLP in differing contexts.

Education for Communication Disability Public Health

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Training for Public Health in SLP

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• Principles of public health • Epidemiology • Determinants of communication disability • Research skills in communication disability prevention • Community development • Project management • Project evaluation

Fig. 3. Skills and knowledge that may be beneficial for communication disability public health. From Davidson et al. [31].

Dilemmas around Public Health in SLP

Currently, while many small-scale prevention activities exist for clinical practice in SLP, a range of systematic population-directed programmes for the prevention of communication disability is lacking [5]. Particularly in the context of service limitations (e.g. strict prioritization criteria, waiting lists), speech-language pathologists can be caught in a dilemma between undertaking public health activities targeting populations versus the pressing demands for clinical treatment for referred individuals. It is well recognized that the most effective health care systems offer a balance across prevention and treatment services [28]. This paper does not advocate an ‘either-or’ model (public health or individual clinical services) for communication disability services. Instead, it calls for an approach that provides a balance and continuity between both prevention and clinical treatment services for communication disabilities.

Skill Sets Needed for Communication Disability Public Health Practice

The profession of SLP, with its evidence base traditionally aligned with the medical model, has been slow to take a lead in the public health arena. One possible contributing factor is that the knowledge and skills required to work in public health in SLP have not been clearly addressed within current SLP curricula or standards of competence, despite the WHO paper ‘Preparing the health workforce for the 21st century: the challenge of chronic conditions’ [27], identifying competencies required to respond to chronic conditions, including the skills to take a public health perspective. 168

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Public health requires a particular skill set for effective practice. General public health training traditionally includes epidemiology, determinants of disease, population research methods, health planning and policy analysis [29]. Public health is also being challenged to evolve to further address social determinants of health, systems modelling, new forms of research, complex multifaceted project evaluation as well as cross-sectoral and community engagement [30], as our understanding of preventable health conditions grows. If communication disability public health is to further evolve, it is vital that the additional skills needed in the workforce that leads this field are well defined. While universities educating speech-language pathologists may provide introductory teaching in areas such as population health or the determinants of good health, there is an argument to suggest that this foundational knowledge may be insufficient either to provide speechlanguage pathologists with specific skills across the whole spectrum of interventions (from communication disability public health to the provision of individualized clinical services) or for speech-language pathologists to effectively engage with other professionals who may deliver communication disability public health services. Davidson et al. [31] describe the knowledge and skills that may be necessary for effective communication disability public health practice (fig. 3). It is questionable whether the content listed in figure 3 could realistically be added to existing SLP curricula without significant compromise of the specialist clinical curriculum. Additionally, working with populations or communities requires a different philosophical stance. The two skill sets may be sufficiently different to warrant different types or levels of education. Another type of communication disability professional with specialist skills in public health may be needed. Indeed, a ‘role redesign’, cutting across traditional boundaries [32], will be critical to achieve this scope of practice. There is no doubt that communication disability public health warrants further consideration. Clearly, there is a need for system change, including the consolidation and dissemination of existing knowledge about public health practice for all speech-language pathologists. All the same, understanding public health issues is one thing, doing something about them is another. Increasing the profile of communication disability and attempting to influence the generic public health agenda is one possibility. Until now, however, communication disability has received minimal attention in the spectrum of competing priorities for public health. It appears that Wylie /McAllister /Davidson /Marshall / Law  

 

 

 

 

a more specific focus is required to drive this agenda. Who should be the leaders of this field and how do we ensure that they have appropriate skill sets to move the agenda for communication disability public health forward? Internationally, it is timely for the SLP profession to explicitly consider the philosophical and practical bases of the profession: what are the beliefs underpinning the practice of SLP? Is a public health perspective consistent with the current aims of SLP and its scope of practice? What are the costs and benefits of adopting a public health approach? If communication disability public health is of interest to the SLP profession, a key question is: who is best placed to drive and lead public health initiatives targeting communication disability and promoting effective and inclusive communication: a speech-language pathologist with additional knowledge or training in public health, or another type of professional with specific skills in communication disability public health? As the landscape of practice in communication disability evolves, could there ultimately be different types of qualification to work in the field – one focused on clinical training/direct patient care (SLP) and one focused on prevention, populations and the epidemiology of communicative health (communication disability public health)? Alternatively, could there be a streamed approach with basic courses and later units offering streams of training to qualify people to work in different areas of practice?

Educational Models for Communication Disability Public Health

There are many models which may ultimately lead to the development of a suitably skilled workforce in order to lead in the field of communication disability public health, and four are presented in figure 4. Whilst two of these educational models (A and B) are already in place and offer methods for increasing knowledge and skills in public health for speech-language pathologists, the other two are more speculative, relating to the creation of a new type of professional for communication disability public health. Whilst it is recognized that the creation of a complementary workforce can raise issues regarding professional boundaries and the blurring of roles [33], it is important to consider such possibilities in light of what they may add to the overall spectrum of services in communication disability. This possibility is raised to promote discussion of the best way forward. Education for Communication Disability Public Health

Educational Model A: SLP within Existing SLP Degree Programmes As our examples suggest, a gradual shift towards including public health education into entry-level SLP programmes may be occurring. The inclusion of public health into SLP curricula may be approached differently, depending on the contextual need. The difference between Ghana (a Majority World country) and the UK/Australia (Minority World countries) is a good example of the contrasting drivers and needs. In the latter model, both clinical treatment and public health domains are embedded in SLP curricula to enable speech-language pathologists to work across a continuum from primary and secondary to tertiary models of service, and with both populations and individuals. Tensions and trade-offs with regard to the addition of another element into an already crowded curriculum can, however, be challenging and may result in compromises over elements of the training. Educational Model B: Post-Graduate Specialization in Public Health Currently, with little or no public health training in many SLP programmes, speech-language pathologists have the opportunity to carry out post-qualification studies in public health independently and to attempt to link the knowledge and skills obtained within the public health training to their role in SLP. Whilst this approach provides speech-language pathologists with strong skills in both communication disability and public health domains, it also limits the numbers of those with public health knowledge and skills, as few speech-language pathologists will make the considerable commitment to this type of further education. A risk to the SLP profession is that speech-language pathologists with further public health qualifications may be lost from the SLP profession to the generic field of public health as few employment opportunities currently exist in the field of communication disability public health. To effectively utilize skills of speech-language pathologists who have specialist training in public health, and not lose them to generic public health roles, jobs in the field of communication disability public health need to be created. Educational Model C: Hypothetical – Separate Training (Communication Disability Public Health Professional) It is necessary to consider whether it is the best use of resources to deploy an SLP workforce that has high-level clinical skills in assessment and intervention with referred individuals in order to undertake additional public Folia Phoniatr Logop 2014;66:164–175 DOI: 10.1159/000365752

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Educational Model A: Within existing SLP education programmes (current)

Educational Model B: Post-SLP qualification Training in public health (current)

Educational Model C: Separate training SLP or communication disability public health

Educational Model D: Streamed training SLP or communication disability public health Communication sciences foundation training for speech-language pathologists and communication disability public health professionals

SLP entry-level training SLP entry-level training incorporating public health skills

then

SLP entry-level training

Communication disability public health training

Streamed training: SLP

Public health training

Speech-language pathologist with skills to work across the intervention spectrum from prevention services to populations to clinical services

or

Streamed training: communication disability public health

Communication disability public health professional, focusing on prevention services to populations

Speech-language pathologist focused on clinical services

Fig. 4. Representation of existing and hypothetical models for communication disability public health education.

health/population-focused work. Will there, in the future, be sufficient scope to offer alternative training in communication disability to enable a different type of workforce to operate at a community or population level? A new qualification in communication disability public health – including elements of communication disability epidemiology and research, prevention of communication disorders, health promotion and communication access, community development in communication disability and project evaluation – may ultimately allow a new, skilled workforce to engage specifically in population-based interventions and research for communication disability and communication enhancement. Such an approach may offer the potential to build separate workforces (in either communication disability public health or SLP for referred individuals). The authors, however, argue that speech-language pathologists would still require a basic understanding of public health principles, just as communication disability public health professionals would require foundational knowledge 170

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about the role and practice of SLP. Under such conditions, they could act as complementary professional groups, working in collaboration to deliver a spectrum of services from prevention to treatment. In times of limited resources, such a role delineation may reduce tensions between balancing the needs of clinical services to referred individuals and public health programmes focusing on primary and secondary prevention to populations. Educational Model D: Hypothetical – Streamed Training (Communication Disability Public Health Professional) If a role for a communication disability public health professional emerged in the future, it could be argued that there is a core set of knowledge and skills which could be taught to both groups of communication disability professionals (i.e. speech-language pathologists who are clinically focused and communication disability public health professionals who are focused on population needs). Students Wylie /McAllister /Davidson /Marshall / Law  

 

 

 

 

could then, as training progresses, ‘stream’ into clinically focused practice (SLP) or population-focused practice. Such an integrative model would allow students to engage more closely with the breadth of practice in communication sciences and disabilities and also to foster links between the clinical and public health dimensions of the SLP profession. The advantages and disadvantages of each model are outlined in table 2.

Drivers for and Barriers to Change

put based on episodes of care to individual patients (such as reporting numbers of ‘occasions of service’ or being able to invoice only for treatment services related to individuals). In such systems, jobs, by the very nature of the available funds, will be focused on individual patient care. The increasing privatization of SLP, insurance and health fund reimbursement arrangements, as well as government initiatives targeting individual patients, are likely to exacerbate this issue of individualized output measurement. If jobs are not available in environments that have the capacity and a mandate to consider whole populations, such as primary care settings, focusing on education for the prevention of communication disability may be an exercise in futility. In this context of models of health care focused on individuals, how population-focused interventions can increase their credibility and obtain equal footing with individually focused work is a critical question that requires much more open and rigorous discussion, research and support in the SLP profession. Professional associations have a key role in such policy debates as they recognize and adopt their role as drivers for change [1]. For example, whilst, in recent years, the Royal College of Speech and Language Therapists in the UK has been instrumental in promoting the view of ‘universal’ communication intervention, the next critical steps will be engaging in policy implementation and outcome evaluations. Such steps are needed to ensure that interventions occur right across the spectrum of prevention, including addressing social inequities and the structural, cultural and attitudinal barriers to community access for people with communication disabilities. Other vital steps are a reconsideration of core skills and educational requirements for speech-language pathologists and a consideration of whether prevention and health promotion are solely the domains of speech-language pathologists or whether there is scope and reason to consider an additional, allied profession. Closely tied to this reconceptualization is the role of other associated health workers such as allied health assistants, SLP assistants and community-based rehabilitation workers, and where they fit in the implementation of prevention programmes at community levels.

Despite mounting evidence supporting the need for public health approaches to communication disability and some developments in the educational and service delivery arenas, established jobs in the field of communication disability public health are lacking. This is unsurprising, as prevention spending in general health domains has typically ranked low on government agendas. For example, Australia devotes only around 1.7% of its total health expenditure directly to the prevention of health conditions [34], whilst the UK spends approximately 4% on direct prevention activities [35]. In part, the relatively low prevention spending is due to the fact that direct outcomes of population-targeted public health interventions are multifaceted, often only evident across long periods and difficult to measure and, thus, may be unpopular with governments. New research, however, suggests that in many health areas, prevention is at least as cost-effective as treatment [34], even though this evidence is lacking for communication disability. Research into the efficacy and cost-effectiveness of public health communication services is urgently needed. Advocating appropriate education and job creation in communication disability public health will take sustained effort from researchers, professional organizations, academic leaders and governments and is likely to cause substantial debate and discomfort. This type of meso-level change requires professional organizations, academic leaders and governments to act as change leaders [1]. Additionally, if communication disability public health gains traction in health systems, the development of such whole-system approaches may require the evolution of new structures and workers. Speech-language pathologists also need to carefully consider how health economic policy shapes the SLP workforce. In many SLP workplaces, including community health settings where primary health care and working with communities should be priorities, speech-language pathologists often continue to provide evidence of their work out-

This paper has made a case for the need for public health approaches in the design and delivery of services to people and populations with, and/or at risk of, communication disabilities. A growing body of evidence from pop-

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Conclusions and Future Directions

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Table 2. Advantages and disadvantages of possible models of professional education in communication disability public health

Advantages

Disadvantages

Educational Model A: within existing SLP degree programmes Encourages the profession to consider whole populations or communities when assessing demands for services and service delivery options, rather than just considering individuals with communication disability who present within clinical caseloads; ultimately, this may serve to both improve equity and access to SLP services and assist in increasing formal prevention programmes across primary, secondary and tertiary levels Develops a workforce with the capacity to work in different models of service right across the spectrum from prevention to treatment and targeting both communities and individuals Allows qualified speech-language pathologists a choice in terms of career pathways – both public health and clinical services Enables speech-language pathologists to have a shared knowledge base with public health specialists with whom they may engage, producing more research and formalized programmes in epidemiology and the prevention of communication disabilities [41] Educational Model B: post-graduate specialization in public health Provides in-depth public health training, with the speech-language pathologist possessing specialist skills and knowledge acquired in both SLP and public health domains

Potentially increases the proportion of public health work done by the SLP workforce, which may result in compromising the availability of direct one-to-one clinical care services, unless graduate numbers are increased Increases in education in public health may come at the cost of other types of SLP education (i.e. fewer educational units in clinical specialty areas) May over-extend the reach of the SLP profession. Is it truly effective (or necessary) to take graduates with high-level one-to-one clinical expertise and engage them in populationbased interventions which may require a different skill set and knowledge base?

Requires additional time and money to be invested in obtaining further qualifications Does not begin to shift the whole conceptualization of the profession to a universal approach to communication disability public health; instead, it produces only a few individuals with a pre-existing interest who develop further knowledge and skills Training is not communication disability specific Graduates may be lost to generic public health jobs

Educational Model C: separate training to become a communication disability public health professional At present, health funding models and a paucity of research Focused training provides a range of necessary knowledge and skills in public health communication have not yet created a in either population public health or individual clinical services demand for a workforce with this knowledge and skill set (SLP), depending on the programme followed Produces separate workforces, reducing potential tensions between clinical and public health programmes Offers the ability to build research bases in communication disorders at a population level

This model would not create strong links between the public health communication profession and speech-language pathologists working clinically to ensure a seamless continuity of services and programmes for communication disability

Educational Model D: streamed training to become a communication disability public health professional The field of communication disability public health would As Educational Model C above, plus the following: need to be well established before this is viable Allows students to engage more closely with the breadth of practice This model would also require reconsideration of how SLP in communication sciences and disabilities education is structured Fosters links between the clinical and public health dimensions of the profession, potentially producing richer collaboration Offers a flexibility of choice for students

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Wylie /McAllister /Davidson /Marshall / Law  

 

 

 

 

ulation studies clearly demonstrates the relationship between social determinants and communication disability and highlights that those more in need of services are less likely to access traditional clinical services delivered by speech-language pathologists. It is proposed that more cohesive and systemic preventative services for communication disability, delivered in the community and using public health approaches, are needed, as well as traditional, individual-focused clinical services. A new term, ‘communication disability public health’, is proposed, and four models are presented for consideration regarding the education of those who could operationalize such communication disability public health services in the future. To encourage critical debate in the SLP profession, we have included the hypothetical scenario that a profession other than SLP may undertake communication disability public health roles. It is acknowledged that the education, structure and delivery services for communication disability public health may vary according to contexts and population needs as well as political, economic and social drivers. We do not argue for an either-or approach (universal preventative public health vs. individual-focused clinical services) but rather for a continuum of services, so that the needs of people with communication disabilities as well as those of their carers and families are met at every level. We have deliberately posed challenging questions to the SLP profession, and in order to further this discussion, it is suggested that the following challenges should be addressed:

• The philosophical and practical bases of the SLP profession need examination to determine where and whether communication disability public health approaches fit. What beliefs underpin the practice of SLP? Is a public health perspective consistent with the current aims of SLP and its scope of practice? If so, what are the most effective models for ensuring that speech-language pathologists receive appropriate training in this area? • Professional associations, policy makers, researchers, academics and other stakeholders need to consider the best way forward for communication disability public health within their unique contexts. • A continued focus on both well-constructed cohort studies and the consolidation of population-level data will assist in understanding the determinants of communication disability and population needs. • A development of systematic research into preventative approaches to communication disability will offer the opportunity to develop thinking about effective prevention strategies in communication disability. The reconsideration of communication disability practice to embrace a continuum of public health services from primary prevention to clinical services is not new, but consideration is crucial about whether this is in fact a role for speech-language pathologists and how and whether the profession has the skills to take on such a role.

Appendix Example 1 – Australia: an inter-professional approach to public health in an Australian programme Context: rural university, Australia Charles Sturt University commenced the first rural university courses in SLP and physiotherapy in Australia in 1998. An occupational therapy degree had commenced several years previously. Given the mission of the SLP course to prepare graduates for communitybased rural and remote practice as part of inter-professional (IP) teams, the decision was made to develop an IP unit of study in the final year for all three courses that focused on the development of new allied health services for under-served communities. Students’ learning goals included the development of understanding and skills in health promotion and public health approaches, team work and project management. Structure and Activities: Students were assigned to IP teams and allocated a rural community as the focus of their project. They were required to undertake analyses of publicly available demographic data (e.g. census and local council information), a community needs analysis and community consultations to identify a public health need and a health promotion project of value to that community. The team’s brief was to plan a project and to develop the budget, timeline and resources for delivery of the project as well as an evaluation strategy. Due to time, distance and cost constraints, the team brief was not to implement the project; however, in several cases, the host communities adopted and implemented the projects. Projects included ear health for indigenous communities, early literacy programmes for disadvantaged families as well as parenting education and support programmes for teenage parents with low educational levels. Lindy McAllister and Lucie Shanahan Former Unit of Study Coordinators, Charles Sturt University

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Example 2 – Australia: public health in an Australian programme Context: urban, Australia Another example from Australia is the Master of Speech Pathology curriculum at the University of Melbourne. In their first semester, students take a subject titled Determinants of Good Health, which provides a foundation in public health. Subsequently, a public health dimension is woven through other subjects, including subjects on Planning and Integrating Intervention and Professional Issues and Practice. This foundation unit on public health and an interwoven approach to including public health ensures that graduates have knowledge and skills in both population-based approaches and individual service delivery models. Bronwyn Davidson Associate Professor in Speech Pathology, University of Melbourne Example 3 – Ghana: a system in development Context: Majority World country Ghana achieved lower-middle-income status in 2012 [32]. Services for people with communication disability are extremely limited, and speech-language pathologists are few [33]. Ghana has long aimed to establish an SLP training programme. The government has shown commitment by sponsoring three Ghanaians to obtain qualifications in SLP from the UK. The University of Ghana is now the largest employer of speech-language pathologists in the country. In 2013, the university commenced planning an entry-level Masters programme in SLP. Tensions and Priorities: – Debate regarding needs for both direct clinical services and population-based interventions – Tension between the diverse needs with the short duration of the planned training – Acknowledgement that any new programme needs to tailor its curriculum to the country’s unique circumstances Philosophically, the team agreed that because of issues such as the poor recognition of communication disability, stigma, costs of direct clinical services and large rural communities, a focus on populations needed to take equal priority with more traditional clinical services. However, there was a recognition that the key employers would likely be the Ministry of Health, NGOs or private practices, which would require graduates to have competencies in one-to-one clinical services. Action: The curriculum plan included – both clinical (individual-focused) and public health (population-focused) elements; – public health as a foundation unit; – a component of public health (population-focused activities) within each clinical placement, i.e. evaluating competencies at both the population level and in direct individual clinical services. Karen Wylie, Nana Akua Owusu, Clement Amponsah, Josephine Ohenewa Bampoe School of Allied Health Sciences, University of Ghana Example 4 – UK Context: Minority World university The Royal College of Speech and Language Therapists’ [34] Guidelines for Pre-Registration Speech and Language Therapy (SLT) programmes in the UK do not currently make explicit mention of the public health role of speech-language pathologists, although teaching about professional contexts is expected to include the context of service delivery, ‘current social policy initiatives which impact upon SLT practice’ (p. 22), SLP and health promotion. The guidelines take a predominantly individualistic approach, addressing client groups and specific conditions. However, changes in public policy and the commissioning of SLP services appear to be increasing the prominence that public health is given by some universities. Whilst some universities may not directly include public health in their teaching to their pre-registration SLP students, they may address elements indirectly, by embedding content about programmes such as Sure Start and issues such as the promotion of vocal hygiene in existing curricula and providing experience of these roles in clinical education. One example of such an approach is at Newcastle University, UK. For the past 5 years, Newcastle University has incorporated training on the public health role of speech-language pathologists, within professional issue units for both Masters and undergraduate pre-qualification programmes for SLP. Students learn about SLP services for both referred individuals and non-referred populations, including health education roles and universal interventions. Students also receive input about policy and legislation, and this may include public health. The teaching changes in response to current issues. Additionally, some students have clinical education experiences of public health work, and, in some cases, this can extend to speech-language pathologists being required to give advice on non-SLP matters such as diet, exercise and smoking. Helen Stringer and Janet Webster School of Education, Communication and Language Sciences, Newcastle University

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Adopting public health approaches to communication disability: challenges for the education of speech-language pathologists.

Public health approaches to communication disability challenge the profession of speech-language pathology (SLP) to reconsider both frames of referenc...
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