Collaborations to address barriers for people with communication disabilities in Ghana: Considering the World Report on Disability

Abstract

The World Health Organization's World Report on Disability underscores the need to identify and address barriers that limit people with disabilities from having access to services. Wylie, McAllister, Davidson, and Marshall (2013) consider the impact of that report on people with communication disabilities (PWCD). Over the past 5 years, the authors have worked together in Ghana to address the needs of PWCD. With only about 10 university-trained speech-language pathologists (SLPs) in Ghana, the barriers to PWCD receiving services are quite high. The authors are working together and with others to establish the first speech-language pathology program in Ghana. The authors also work to identify ways to share with PWCD and their families knowledge and skills on how to improve the communicative function of PWCD. In doing so, the authors have learned valuable lessons about the role of an SLP, especially when considering under-served PWCD, lessons that are applicable to both Majority and Minority World countries. This commentary describes the authors’ work over the past 5 years, and describes initiatives that have had some measure of success in reducing barriers to access to information and services needed by PWCD and their caregivers and communities.

Keywords::

• World Report on Disability
• World Health Organization
• people with communication disability
• under-served
• sustainability
• Ghana
• Africa
• cleft palate
• intellectual disabilities
• professional development
• alternative and augmentative communication

Introduction

Over the past 5 years the authors have worked together in Ghana to address the needs of under-served people with communication disabilities (PWCD). Crowley and Baigorri, faculty member and clinical supervisor, respectively, in the program of speech-language pathology (SLP) Teachers College Columbia University (TC), each year bring 15 TC master's degree SLP students to Ghana (TC Team) (Crowley & Baigorri, 2011). The TC team provides clinical services for PWCD while working to build capacity and share knowledge and skills with their Ghanaian colleagues. Ntim and Bukari, graduates of the special education program at University of Education, Winneba in Ghana, currently teach students with intellectual disabilities in schools overseen by Ghana's Ministry of Education. OseiBagyina, an SLP educated in the US, has been working for decades with PWCD in Ghana. Kitcher, a medical doctor, heads the Ear Nose and Throat Department at Korle Bu Teaching Hospital at the University of Ghana in Accra. Paintsil, Ampomah, and Laing, all medical doctors, lead the cleft palate team at Korle Bu Teaching Hospital.

Speech-language pathology services in Ghana

The World Report on Disability (World Health Organization and The World Bank, 2011) and the lead article (Wylie, McAllister, Davidson, & Marshall, 2013) raise important issues that the authors discuss frequently. Foremost is to consider how to meet the needs of PWCD in Ghana by identifying and then addressing the barriers to accessing SLP services. These discussions inform the authors’ work in both Majority and Minority World countries (Wylie et al., 2013).

University-trained speech-language pathologists in Ghana today

Currently there are approximately 10 SLPs in Ghana, all of whom were educated in Minority World SLP university programs. Several Ghanaian SLPs received their degrees from US programs decades ago and are past retirement age, but continue to provide SLP services at least on a part time or interim basis. Several Ghanaian SLPs were educated in the UK, including one seasoned SLP with ˜15 years of clinical experience initially in the UK and for the past 6 years in Ghana, and two who recently graduated from UK programs sponsored by the University of Ghana's School of Allied Health Sciences with service commitments in Ghana (Bampoe, 2012; Owusu, 2012). Adding to this group are non-Ghanaian SLPs from Minority World countries who live in Ghana on a temporary basis and practice as SLPs for periods ranging from several weeks to several years. While the term SLP is used throughout this journal, in Ghana the term is “speech-language therapist”.

These SLPs work primarily in Accra in private practices with clients generally from medical referrals and private schools. One SLP also has established a non-governmental organization providing services to PWCD. OseiBagyina works 4 days each week with the ENT Departments at Komfo Anokye Teaching Hospital at Kwame Nkrumah University of Science and Technology (KNUST) in Kumasi and 1 day a week at Korle Bu Teaching Hospital in Accra.

Efforts to establish the first SLP university program in Ghana

With a population nearing 25 million (Ghana Statistical Service, 2012), the current ratio in Ghana of SLPs to people is ˜1 per 2.5 million. The Dean of the School of Allied Health Sciences along with the Head of the ENT Department and others at the University of Ghana have a plan to create the first SLP program in Ghana. Many critical elements are coming together, including the newly qualified Ghanaian SLPs mentioned previously. Domestic and international sources are making initial funding commitments. Ghana's Ministers of Health and Education have met with several of the authors and have affirmed their support and commitment to creating the first SLP program. The academic and clinical faculty are expected to be comprised, at least initially, of the few experienced SLPs in Ghana, Ghanaian university faculty from related programs, and temporary faculty from Minority World institutions.

Audiology and disability master program in Ghana

Ghanaian PWCD receive some support through two recently established university programs. In September 2011 the University of Ghana began the country's first audiology program, leading to a master of audiology degree. In September 2009, KNUST began a 2-year master of disabilities studies program including some SLP coursework taught by OseiBagyina. The first cohort of students graduated from the KNUST master of disability program in November 2011.

The outlook for most Ghanaian people with communication disabilities

While this movement towards graduating university-trained professionals is promising, Ghanaian PWCD cannot wait for adequate numbers of SLPs to graduate. A similar ratio of SLPs to the population as is currently in the Minority World will take many decades (Wylie et al., 2013). Future SLP graduates are likely to work with PWCD from higher socio-economic classes who can pay higher fees than those paid through Ghana's National Health Insurance (Republic of Ghana, National Health Insurance Act, 2003). Moreover, as in the Minority World (World Health Organization and The World Bank, 2011; Wylie et al., 2013), it is virtually certain that services will remain elusive for PWCD living in rural or remote areas, the infirm and elderly, those from lower income backgrounds, and those who do not speak English or one of the more widely spoken languages in Ghana.

Sharing knowledge and skills to support services for PWCD

The lack of traditionally-educated SLPs in Ghana is a significant barrier to services. Yet, the World Report on Disability asks that barriers to access for people with disabilities be considered and addressed, shifting the focus to how to make information and skills accessible to PWCD. How can the knowledge and skills of an SLP be shared in a more widespread way and still maintain quality? What can SLPs in the Minority World who continue to have under-served populations learn from these approaches? (World Health Organization and The World Bank, 2011; Wylie et al., 2013).

For the US authors, the work in Ghana has been a refreshing change from what in some ways is an over-regulated and bureaucratic special education system in the US. In the US changes designed to enhance the quality of services often meet resistance from the entrenched powers and fossilized ways (Caesar & Kohler, 2007). In Ghana there is no time for creating and feeding bureaucratic systems for PWCD. In Ghana, the question is immediate— what does this person need to function better in the family and community? This question is much more in line with the International Classification of Functioning, Disability, and Health (ICF) (World Health Organization, 2001).

What follows are examples of what the authors do in Ghana. These examples are consistent with several World Report on Disability recommendations, including to improve access to mainstream systems and services; to build human resource capacity; and to increase public awareness and understanding of disability.

Developing AAC cards to purchase food in the local market

In Ghana the authors work within a biopsychosocial model (World Health Organization and The World Bank, 2011; Wylie et al., 2013). Crowley, Baigorri, and Bukari have been working on improving the functional communication of students in the Effiduasi unit school where Bukari is the head teacher. Unit schools are schools for students with intellectual disabilities located within general education schools and overseen by Ghana's Ministry of Education, Division of Special Education. Thirty-five students with cognitive disabilities, and communication challenges, attend the Effiduasi unit school.

When this work began 5 years ago, the authors asked the parents what they wanted for their children. The parents agreed that they wished their children could take on a traditional Ghanaian child's role—to buy food for the family in the local village's open air market. Working together, Bukari and her staff, the parents, and the TC Team created an AAC system of cards that the students could use in the market. In the classroom, the teachers, parents, students, and the TC Team role-played using the AAC market cards.

On the first trip to the market some of the market women seemed apprehensive about selling to students with obvious disabilities. After some initial hesitation, one woman said to the others in the Twi language, “Look at these Americans; if they can have the patience to work with our children, certainly so can we” (Thompson, 2011). While cultural perceptions about the value of Minority World professionals may have initially eased the market women's fears, the AAC system worked because the parents, teachers, and students themselves embraced it. Over the years the AAC market card system has grown, with teachers and parents creating cards for additional needed food items. The market women now greet the students from the unit school by name and welcome them to buy food using the AAC market cards (Crowley & Baigorri, 2012b).

The lessons from this work go beyond its benefits to PWCD in Ghana. Every year during discussions the TC Team considers the functionality of AAC systems in general. This invariably leads to anecdotes of seeing AAC systems that are rarely used outside of therapy sessions. Upon returning to the US, the TC Team applies these lessons learned in Ghana to design more functional communication systems for PWCD (e.g., Brown, 2012).

Exchanging information and skills with interpreting collaborators

The exchange and transfer of knowledge and skills needed to provide services to PWCD occurs regularly among the authors. In Ghana, the TC Team needs interpreters to gather and share information needed to assess and make recommendations. As a former British colony, virtually all Ghanaian universities conduct classes in English, which means that all teachers, doctors, nurses, and, of course, the SLPs, speak English, along with at least one local language. The Ghanaian colleagues act as both interpreters and cultural brokers. Rather than inhibiting the flow of information, this linguistic situation is ideal. To interpret, the Ghanaians must understand the information, communicate it fully, and bring back parent concerns. The Ghanaian colleagues raise cultural concerns and ask questions if the information does not make sense. With each session the Ghanaian colleagues develop deeper understanding of the nature of communication disorders and possible strategies to meet the PWCD's functional communication needs. The TC Team acquires deeper understanding of culture and learns how to share one's knowledge and skills, all of which is immediately applicable wherever they work.

Exchanging information and skills through professional development

The authors have also offered professional development workshops. In January 2012, Ntim and Bukari, Crowley and Baigorri, and the TC Team organized a professional development retreat on AAC for Ghana's unit school teachers. Over 40 unit school teachers attended, from all 24 unit schools located throughout all of Ghana, representing a total enrolment of ˜1000 students with intellectual disabilities.

Because Crowley, Baigorri, Bukari, and Ntim have worked together for several years developing AAC systems for the students in Bukari's and Ntim's unit schools, Ntim and Bukari had the expertise to teach their fellow teachers (Bukari, 2012; Ntim, 2012). Ntim did most of the organization for the day and demonstrated how to create AAC communication passports. Bukari introduced the AAC name tags, where each student's name in the unit school is written on laminated cardstock, and the TC students showed how to use them for literacy and math activities. Finally, Crowley, Baigorri, and Bukari presented the AAC market card system (Crowley & Baigorri, 2012a).

After each activity was introduced, the TC Team worked with the unit school teachers in small groups to identify students who would most benefit, to create actual materials, and to problem solve ways to use the material in the classroom. Each teacher left with many educational resources and materials which meant they could continue using AAC in their own classrooms.

Exchanging knowledge and skills with the cleft palate team

Certain areas of practice in SLP tend to be limited to a relatively small group of experts as with the SLP's work with cleft palate patients. When this work began 5 years ago, OseiBagyina, who had worked with Smile Train in Ghana, asked for information on how to improve the speech of patients post-cleft palate surgery. In response, the TC Team provided OseiBagyina with textbooks and instructional DVDs. He also served as interpreter for the TC Team for many cleft palate patients in Komfo Anoyke Teaching Hospital. Over the years, OseiBagyina has acquired high level skills in cleft palate speech therapy and provides SLP services to these patients throughout the year.

The TC Team works with the Korle Bu Teaching Hospital cleft palate team led by Paintsil, Ampomah, and Laing, and including nurses, SLPs, audiologists, ENTs, dentists, and outreach. Prior to the cleft palate team meeting, the TC Team meets with the patients. Members of the hospital's cleft palate team interpret as the TC Team assesses and then provides recommendations to the parents. The parents receive written recommendations and must demonstrate that they can use the recommended strategies with the child at home.

The surgeons invite the TC Team to observe cleft palate operations and describe the surgery for them. The cleft palate team also welcomes the TC master of SLP students to participate in the cleft palate team meetings and report on their assessment of the patients. The doctors ask questions both to learn more about SLP issues in cleft palate and to give the TC SLP master's degree students an opportunity to be part of a world-class cleft palate team.

Each year at least one patient from the prior year returns with significantly improved speech. These parents invariably say that they learned the strategies to improve their child's speech during the sessions with the TC Team prior to the team meeting (A. Paintsil, personal communication, 14 January 2012).

Further considerations on the exchange of knowledge and skills

The effectiveness of the Ghana work is built on a foundation of trust among the authors. The trust develops over time and allows frank discussions of how to improve the work. The use of technology can spread information and skills. Attempts to build capacity must be tailored to the available technologies in a particular country. For example, Crowley and Baigorri (2012c) have developed six video tutorials for use in Spanish-speaking countries on how to improve cleft palate speech post-repair for patients who do not have access to an SLP. In Ghana this model is not practical because internet access continues to be quite limited. The concept of developing ongoing capacity through technology, however, is quite applicable. In Ghana cell phones are ubiquitous and affordable and the authors are working to identify similar ways to use cell phone technologies.

Conclusion

Over the past 5 years, the authors have developed an understanding of the vast unmet needs of PWCD in Ghana. This understanding has deepened the commitment of the authors to work to address the functional communication needs of PWCD. The World Report on Disability helps to sharpen the authors’ focus on how to best address the needs of PWCD.

Acknowledgements

Thanks to the University of Ghana, KNUST, Ghana's Ministry of Health, and Ghana's Ministry of Education for ongoing leadership and collaboration. Generous support from the Wyncote Foundation, Teachers College Columbia University, Rotary International, and the Central Coast Children's Foundation ensures sustainability. Many thanks to all the TC students who have come to Ghana.

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