The World Report on Disability in relation to the development of speech-language pathology in Viet Nam

Abstract

argue that recommendations made within the World Report on Disability provide an opportunity for speech-language pathologists to consider new ways of developing services for people with communication and swallowing disorders. They propose that current approaches to the delivery of speech-language pathology services are largely embedded within the medical model of impairment, thereby limiting the ability of services to meet the needs of people in a holistic manner. In this paper, the criticality of selecting an appropriate service delivery model is discussed within the context of a recently established post-graduate speech therapy education programme in Viet Nam. Driving forces for the implementation of the program will be explored, as will the factors that determined the choice of service delivery. Opportunities and challenges to the long-term viability of the program and the program's potential to meet the needs of persons with communication and swallowing disorders in Viet Nam will be considered.

Keywords::

• World Report on Disability
• speech therapy
• Viet Nam
• training
• service delivery models
• education
• university

Introduction

Wylie, McAllister, Davidson, and Marshall (2013) draw attention to key issues within the World Report on Disability (World Health Organization and The World Bank, 2011) in relation to service development, service provision, and service accessibility for people with disability in general and disorders of communication specifically. They rightly argue that current conceptualizations of disability do, by their very definition, limit identification of people with communication difficulties, with subsequent inadequate development of and access to services. They note that the chosen model of service delivery will be influenced by a range of factors, not least its environmental and cultural appropriateness. This commentary reviews the development of Viet Nam's first university-based postgraduate speech therapy education program in the context of key issues raised in the World Report on Disability, and highlights the complex factors that impact the professional education of speech-language pathologists and consequent delivery of speech-language pathology services.

Setting the scene

Viet Nam's population is over 87 million, ranking as the 13th most populous country in the world (United Nations, 2012). A majority of Vietnamese are of the Kinh ethnic group and there are 53 ethnic minority groups (General Statistics Office of Vietnam, 2009). Since its adoption of market friendly reforms in 1986, the number of poor households in Viet Nam has decreased from 58% in 1993 to 19% in 2006 (World Bank, 2012). Life expectancy has increased from an average of 63 years in 1996 to 75 years in 2011 (World Bank, 2012). Further, implementation and delivery of population-wide health and education services such as compulsory primary school education, vaccination, and public health programmes sees Viet Nam poised to meet most of its education and health-related Millennium Development Goals (World Bank, 2012).

Together with this remarkable development, Viet Nam has made significant progress towards recognizing the rights of persons with disabilities. Having signed the United Nations Convention on the Rights of Persons with Disabilities (United Nations, 2006) in 2007, on 17 June 2010, the National Assembly of Viet Nam enacted the first comprehensive national law mandating equal participation in society for persons with disabilities (Government of Vietnam, 2010). This law, which became effective on 1 January 2011, sought equal participation in society for people with disabilities through access to appropriate accommodation, healthcare, rehabilitation, education, employment, vocational training, cultural services, sports and entertainment, transportation, public places, and information technology.

Accurate figures regarding the incidence and prevalence of disability in Viet Nam, and more specifically communication and swallowing disabilities, are difficult to obtain. These difficulties relate not only to the use of different methods and parameters for data collection, but also to the complexity of describing and encapsulating the complex entity that is disability (Mont & Cuong, 2011). Citing data collected by the Vietnam Ministry of Labor Invalids and Social Affairs (MOLISA) 1994–1995, Kane (1999, p. ix) reports an overall disability prevalence in Viet Nam of between 5–7%. Speech and hearing disabilities are estimated to comprise 17–27% of all disabilities (Kane, 1999, p. 22). In their discussion on the association between disability and poverty, Mont and Cuong (2011) report findings of the 2006 Viet Nam Household and Living Standards Survey which sought information about disability associated with the functional domains of seeing, hearing, cognition (remembering and concentration), walking, self-care, and communicating. Almost 16% of the population indicated they experienced some degree of disability in one of these domains (Mont & Cuong, 2011, p. 327). Specifically in relation to hearing, cognition, and communication, nearly 30% of the total percentage of people in Viet Nam who report having a disability noted functional limitations in these three domains (Mont & Cuong, 2011, p. 328).

Data from the 2009 Viet Nam Household Living Standards Survey (Government of Vietnam, 2010) presents a somewhat different picture. Of the 78.5 million persons in Viet Nam aged 5 years and older in 2009, ˜ 6.1 million or 7.8% report living with some form of disability related to seeing, hearing, walking, or cognition (concentrating or remembering) (United Nations Population Fund, 2011, p. 11). Of note, self-care and communication were not included as separate domains in this survey. The vision domain had the largest percentage of people reporting functional difficulties, followed by walking and cognition; in the moderate-to-severe disability range, problems with walking and cognition were the most common. Multiple disabilities were frequently reported, with 49% of the 6.1 million people in Viet Nam with a disability indicating they experienced disability across more than one domain (United Nations Population Fund, 2011, p. 11).

Drivers of change in Viet Nam

Wylie et al. (2013) utilize the framework proposed by Burnes (2009) to discuss driving forces that influence change in organizations, policies, and/or practices, emphasizing that “the driving forces (and resistances) which shape change are complex” (Wylie et al., 2013, p. 1). McNamara (2005) adds a further dimension to the concept of “driving forces” by proposing that for effective, sustainable change to take place, four key “agents” must be involved in the change process: a “change initiator” (who identifies the need for change); a “change agent” (who is responsible for the overall organization and co-ordination of the change); a “champion for change” (who continues to champion the cause), and a “sponsor of change” (someone or an internal department within an organization who co-ordinates the change process and ensures the process stays on track). The principles of change theory and agents of change as proposed by Burnes (2009) and McNamara (2005) are highly relevant to the development of the profession of speech-language pathology (SLP) in Viet Nam, and it is to these principles that discussion will now turn. (The term used for SLPs in Viet Nam is speech therapist.)

The first reports of SLP in Viet Nam are of Ms Pat Landis, a SLP from the US, who came to Viet Nam in 1972 to provide “remedial speech services” for children with cleft lip and palate (Landis & Pham, 1975). Since that time, and particularly from the early 1990s onwards, SLPs have travelled to Viet Nam to assist local health professionals provide speech therapy services (Ducote, 2001; McAllister, Nguyễn, Woodward, Christie, Yễn, Đinh, et al., 2010). Cheng (2010) reports that hospitals and health centres in Hanoi were offering workshops in speech therapy from 2002 onwards, and health professionals were assuming the title of speech therapist. This scenario was mirrored in Ho Chi Minh City (HCMC), where health professionals were assuming the title of “speech therapist” (McAllister et al., 2010). It is apparent that significant interest in the profession and a tremendous desire for knowledge was already driving the development of the profession in Viet Nam prior to any formal education process being offered.

In 2008, a chance meeting between Mrs Sue Woodward, SLP from Australia, and Professor Nguyễn ThỊ Ngọc Dung, Director of the HCMC Ear Nose and Throat (ENT) Hospital, created the opportunity for discussion regarding how a formal speech therapy education program could be developed in Viet Nam. Mrs Sue Woodward had been travelling to Viet Nam since March 2007 as part of Project Boomerang (Australian Orthodontic Institute, 2012) and was acutely aware of the need for speech therapy services. Professor Nguyễn ThỊ Ngọc Dung had spent time as an ENT intern in Lyon, France, where the opportunity to learn about the profession within a medical context had arisen. On her return to HCMC, Professor Nguyễn ThỊ Ngọc Dung provided training in speech therapy to nurses at the ENT Hospital where she is Director, and on an ongoing basis arranged for visiting lecturers and specialists to provide further training (McAllister et al., 2010).

At the same time as this discussion ensued, a number of key driving forces internal and external to Viet Nam were asserting significant influence. Using the framework as outlined by Wylie et al. (2013), external influences on Viet Nam at that time which had the potential to drive change included the global push to meet the Millennium Development Goals and Viet Nam's commitment to meeting these, the impact of globalization, and Viet Nam's drive to being part of the global community, improved internet access, and associated increased awareness of information and services available, and the agendas of foreign non-government organizations and aid organizations that were focused upon improving health outcomes for the Vietnamese people. Internal driving influences included the government's ongoing agenda in relation to economic, education, and health reform, the in-country presence of health professionals who were already providing speech therapy services (thereby raising the profile of speech therapy and also community expectations for access to speech therapy services), and the Government's enactment of policy that mandated inclusiveness for people with disabilities.

In early 2008, a meeting was arranged between Mrs Sue Woodward, Professor Nguyễn ThỊ Ngọc Dung, Professor Lindy McAllister (then at Charles Sturt University, Australia) and Dr Aziz Sahu Khan (orthodontist with Project Boomerang) to discuss how Professor Nguyễn ThỊ Ngọc Dung's aspiration for a university-based speech therapy program in Viet Nam could be realized. The outcome of this meeting was the establishment of a long-term goal for a 4-year undergraduate baccalaureate degree in speech therapy by 2015, with the first stage being a short course in speech therapy in 2009 as proof of concept, and the second stage being a 2-year postgraduate training program in speech therapy to build a cadre of future clinical educators. As a direct result of the realization that funding and staffing would be required for these initiatives, Trinh Foundation Australia (2012) was formed (S. Woodward, personal communication, 14 May 2012). Since its inception, Trinh Foundation Australia (TFA) has been the enabling partner to Professor Nguyễn ThỊ Ngọc Dung, participating in, supporting, and guiding the development of working plans which saw the first university-based Post-Graduate Speech Therapy Training Programme open at Pham Ngoc Thach University of Medicine (PNTU), HCMC in September 2010.

When considering agents of change as proposed by McNamara (2005), it is apparent that the primary change initiator in this scenario is Professor Nguyễn ThỊ Ngọc Dung. As Director of the HCMC ENT Hospital and President of the ENT Society in Viet Nam, her sphere of influence is significant, both in terms of its range and dimensions. Without her initial will and drive to see formal speech therapy training become available in Viet Nam, the post-graduate training program would most certainly not have commenced when it did. It is also possible to identify a number of change agents, persons who were involved in the co-ordination and organization of the change. These include Professor Nguyễn ThỊ Ngọc Dung, TFA, Dr Nguyễn ThỊ Dx0169ễng (Vice Rector of PNTU), Dr Võ Hoàng Nhân (International Cooperation Office, PNTU), the Australian Government via way of Australian Volunteers International (who are also an enabling partner), and the co-ordinators of the speech therapy program at PNTU. Champions of change, those persons who promote the importance of speech therapy to Viet Nam on an ongoing basis, include the agents of change and TFA's patrons and supporters. Sponsors of change are all who contribute to the current running of the programme, including lecturers and clinicians.

Wylie et al. (2013) place “cultural appropriateness” as the number one priority for service development and delivery, and rightly argue that, without a developed understanding of the country to which a service is being developed, assumptions about what is required and how things should be delivered are prone to error. It is interesting to consider these insights in relation to the initial discussions that ensued between key stakeholders in the speech therapy programme in Viet Nam. Very early on a number of key ideological differences emerged in relation to what the structure of the program should look like and who the students should be. Whilst TFA argued that the program should reflect consideration of disability outside of the medical model (i.e., disability not as a consequence of illness and disease but as the outcome of complex interactions between an individual and their physical, social, and attitudinal environment), the framework eventually implemented was clearly embedded within a medical model. The reasons for this are complex and relate not only to the manner in which health services are currently provided in Viet Nam, but also to the specific context in which the program was being established and the professional backgrounds and experiences of the drivers and champions of change who facilitated the beginnings of the program.

Adams (2005) notes that, whilst over recent years increasing emphasis in Viet Nam has been upon active health prevention program and public delivery of healthcare at the “grass roots” level, health services in Viet Nam remain primarily within a medical model of care (Adams, 2005, p. 4). This is of significance as it was within the context of the hospital/medical system in Viet Nam that the groundswell of understanding regarding the benefits of speech therapy services arose (S. Woodward, personal communication, 14 May 2012). It was, therefore, not unexpected that the development to the programme proceeded in this direction. Secondly, the main driver and champion of the programme (Professor Nguyễn ThỊ Ngọc Dung) is a doctor and ENT surgeon who not only works within a medical model but had seen speech therapy practice within a medical model in France. As a key person and driver of the program's development and its future, it was important that the initial program structure reflect speech therapy within the context that Professor Nguyễn ThỊ Ngọc Dung was familiar with. Thirdly, within Viet Nam, training in medically-related fields (as speech therapy is perceived) has always taken place within medical universities; Professor Nguyễn ThỊ Ngọc Dung's pre-existing association with PNTU as Deputy Head of the ENT Department created the pathway by which the program could be developed within this context.

The post-graduate speech therapy programme

The Post-Graduate Speech Therapy Training Programme commenced at Pham Ngoc Thach University of Medicine, HCMC in September 2010. PNTU is one of three medical universities in HCMC, and caters for students studying medicine, nursing, and midwifery. It is a young municipal university (opening in 1989) and reports to the HCMC People's Committee, an arm of the provincial government that is responsible for formulating and implementing policy at the local level. Eighteen students made up the first cohort which graduated in September 2012. A key criterion for selection into the program was that applicants be employed in the public health sector and already be providing services to people with communication and swallowing difficulties in their current roles as physiotherapists, medical doctors, or nurses. The students alternated between 3 months at PNTU undertaking lectures, and 3 months in their workplaces where they returned to their normal roles and undertook clinical practice in speech therapy, supervised by visiting clinical educators (Table I).

Table I. Pham Ngoc Thach University of Medicine Post-Graduate Speech Therapy Training program: 2010–2012 syllabus.

Term	Activity	Curriculum content
1	Theory	Anatomy and Physiology for Speech Therapy Clinical Practice in Speech Therapy Communication Across the Lifespan Linguistics–1 Medical Speech Therapy Normal Speech and Language Development Voice
2	Clinical work and supervision	Students in their workplaces undertaking clinical practice and supervision
3	Theory	Childhood Speech Sound Disorders Clinical Practice in Speech Therapy Medical Speech Pathology—Paediatric and Adult Dysphagia Head and Neck Cancer Linguistics–2 Neuroanatomy and Neurophysiology
4	Clinical work and supervision	Students in their workplaces undertaking clinical practice and supervision
5	Theory	Clinical Practice in Speech Therapy Communication Disorders of Neurological Origin Paediatric Language Disorders Professional Projects in Speech Therapy Stuttering—Paediatrics
6	Clinical work and supervision	Students in their workplaces undertaking clinical practice and supervision
7	Theory	Audiology for Speech Therapy Autism Clinical Practice Complex Disability Developmental and Behavioural Psychology for Speech Therapy Professional Projects in Speech Therapy Stuttering—Adults
8	Clinical work and supervision	Students back in their workplaces undertaking clinical practice and supervision

PNTU's development of the speech therapy training program meets Recommendation 2 of the World Report on Disability “Invest in specific programs and services for people with disabilities”. However, as rightly stated by McAllister, Atherton, Wylie, Woodward, and Winkworth (2011), a medical model has strongly influenced the development of the program, thereby risking disability being conceptualized as part of the individual, rather than as a result of the relationship between an individual and their environment. As a means to address this concern, biopsychosocial constructs of disability, reflective of the International Classification of Functioning, Disability, and Health framework (ICF) (World Health Organization, 2010), were embedded into the program and its teachings, and are being used extensively to inform curriculum changes and future curriculum development. Lecturers from Australia who employ a biopsychosocial model of disability into their teachings have been approached by TFA to lecture to the students and encouraged to generate discussion and activities that develop students’ understanding of disability, as extending beyond medical diagnosis and treatment. Supervising speech-language pathology clinicians have been encouraged to facilitate opportunities within the clinical setting that demonstrate practical application and examples of the principles of the ICF (World Health Organization, 2010). An important future objective is for all local lecturers to become familiar with these principles and include them within their lectures and teachings.

Focus within the curriculum is also upon broadening the scope of students’ perceptions of the profession beyond clinical skills and knowledge, to include advocacy, public education, health promotion, and research (World Report on Disability Recommendations 7, 8, and 9). Indeed, as part of the subject Professional Projects, the students completed research and quality projects that involved interviewing of clients and their families, collection of data, and the development of resources that targeted primary healthcare, lobbying, and health promotion.

Future opportunities and challenges

The successful graduation of the first cohort of university-trained speech therapy students is a significant milestone for the profession of speech therapy in Viet Nam. The training of local professionals is a major step towards addressing issues of service context and accessibility, and also that of capacity building. Recognizing that dissemination of information and acquisition of knowledge take time, strategies to broaden the scope and speed of information dissemination and begin the process of capacity building have been embedded within the programme. Specifically, with regard to capacity building, the strongest graduates from the first and future student cohorts will be supported to assume the roles of clinical educators, providing supervision that is culturally and contextually appropriate and reducing reliance on international speech- language pathologists. As a further step to developing the capacity of PNTU to independently run the program, planning is underway for the most capable graduates to undertake higher degrees in SLP and training in running university program, teaching, and assessment. To this end, two graduates spent 3 months in 2012 in Australia undertaking an advanced learning program sponsored by Hoc Mai Foundation (The University of Sydney, 2012).

At the time of writing this commentary, the second cohort of speech therapy students had commenced, with a number of students coming from backgrounds that include education and psychology. An important next step will be for the post-graduate speech therapy training program to receive formal approval from the HCMC People's Committee and the Department of Health. This will provide legitimacy for the program and the profession, and will open the way for the program to move to a 4-year undergraduate Baccalaureate Degree. Whilst at this early stage PNTU continues to seek guidance and support from TFA and Australian SLPs to implement the program, it is anticipated that, as knowledge and understanding of the profession develops and as the pool of locally-trained speech therapists increases, these new “experts” will assume responsibility for the running of the program. It is also anticipated that clinical education sites will be expanded to include primary healthcare, education, and disability settings, so as to better mirror the context of persons with communication and swallowing disorders. As emphasized within the World Report on Disability and by Wylie et al. (2013), it will only be when services for people with disabilities become culturally and environmentally relevant, and consider the needs of intended recipients in a holistic manner, that long-term sustainability of services will be realized.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.