Addressing education of speech-language pathologists in the World Report on Disability: Development of a speech-language pathology program in Malaysia

Abstract

The current paper is a response to the Wiley, McAllister, Davidson, and Marshall lead article regarding the application of the World Report on Disability (WRD) to people with communication disorders. The current paper directly addresses recommendation 5 (improvement of human resource capacity) and indirectly addresses recommendations 7, 8, and 9 (related to improving local knowledge and data on communicative disabilities) indirectly. The paper describes Malaysia's initiatives in the early 1990s, in developing its local professional capacity to provide services for people with communication disorders (PWCD). It charts the history of development of a local undergraduate entry-level degree program for speech-language pathology (SLP) from the point of conceptualization to full execution. The article provides glimpses to the processes and challenges faced by Universiti Kebangsaan Malaysia as the pioneer university in the South East Asia region to undertake the training and education of the SLP profession and highlights relevant issues faced by newly introduced professions in a country where resources and practice traditions were previously unavailable. It underscores the important role played by government institutions and an international professional network in driving forward-looking policies to implement and sustain the program.

Keywords::

• World Report on Disability
• World Health Organization
• Universiti Kebangsaan
• Malaysia
• speech-language pathology program

Introduction

The World Report on Disability (World Health Organization and the World Bank, 2011) describes the shortcomings and challenges across the world, addressing services for people with disabilities in general. It included recommendations to address barriers to access services to these under-served communities. Wiley, McAllister, Davidson, and Marshall (2013), in the lead article, recognize that people with communication disorders (PWCD) may be under-represented despite their disabilities, and hence under-served in terms of services. The article proposes that speech-language pathologists (SLPs) look at PWCD from a broader perspective and act as agents of change for this group of people. It challenges SLPs to focus on overcoming the lack of epidemiological data on communicative disorders and proposes several mechanisms to affect change at the primary care and professional level.

The current paper is in response to Recommendation 5, 7, 8, and 9 of the World Report on Disability and the Wiley et al. (2013) article, and specifically addresses issues on (1) developing local professional capacity to provide services for PWCD without previous access to specialist services and (2) increasing focus on improving knowledge, local evidence, and research. Key elements for addressing these issues were: a sustainability plan for sourcing funding for higher degrees (to develop future academic staff), planning to ensure cyclic management of staff opportunities for higher degrees, and pursuing a diverse range of specialization.

History of speech-language pathology in Malaysia

Malaysia consists of 13 states and has a land size of a little over 300,000 square kilometres. It gained Independence from Britain in 1957. The current population is ˜ 28 million, with almost a third living in the rural areas (World Bank, 2012). The population is multi-ethnic and speaks diverse languages and dialects of Malay, Chinese, Tamil, and English. Indigenous languages are also spoken widely in the East Malaysian states.

For a long time, like in many developing countries, speech-language pathology services in Malaysia were almost non-existent, save a few sporadic and intermittent services provided by volunteers from developed or Minority countries through non-governmental organizations (Lian & Abdullah, 2001). Records of speech-language pathology services prior to the 1980s were patchy, but around the mid-1980s there were less than 10 local and expatriate SLPs, all of whom were foreign educated, serving the then population of 18 million. The services provided by most of these SLPs were through private practices in the urban areas. Services in a couple of university hospitals in the capital city were not well established and services in the public or general hospitals likewise were not formally available (Peters, personal communication, 15 June 2012).

In contrast, services in nursing, physiotherapy, radiography, and occupational therapy were more familiar and readily available at the public hospitals. Training for these professions at the certificate and diploma level was provided by the Health Ministry colleges. Speech-language pathology, however, was not given similar attention, and the situation remained unchanged until the beginning of 2000 (H. Said, personal communication, 15 June 2012).

Around the period between 1985–1990, the medical faculty of Universiti Kebangsaan Malaysia (UKM), the national university of Malaysia, began its clinical postgraduate Masters programs for their doctors. At the same time they also explored the feasibility of providing degree-level programs in major allied health areas. Six programs were initially suggested, of which speech-language pathology was one of them. The others included audiology, nutrition, dietetics, optometry, and biomedical sciences. The ear, nose, and throat (ENT) department was given the responsibility to explore the setting up of the audiology and speech-language pathology programs. The aim was to provide home-grown speech- language pathologists and audiologists who would be more in-tuned with local speech, language, hearing, and communication issues, and could take up job positions in the public hospitals and institutions.

At that time of development, statistics on the prevalence of speech and language problems in the Malaysian population were not readily available; hence calculation of the required SLP professionals and services could not be accurately determined. A conservative estimate of 3000 SLPs was targeted; however, with an almost total absence of local professional infrastructure and service tradition even the conservative figure was astoundingly large and almost impossible to achieve within a decade. Such an estimate, whilst speculative about its impact on people with communicative disorders, was a powerful factor in convincing the government of the urgency of establishing the SLP program in the country. It also reaffirmed the university's resolve to promptly allocate resources to get the program off the ground.

The UKM speech-language pathology program

In 1990 the university took the necessary step of sending one of its ENT registrars to the UK to pursue graduate level education in speech-language pathology with the specific intention to return and organize the setting up of the speech-language pathology program in the university. Work on planning and designing the program started upon her return in 1992. A separate faculty of allied health was set up to house the new allied health programs including the SLP program and provided the much needed autonomy and independence for professional growth.

Initial works involved communications with pioneer developers of programs in Hong Kong, Australia, and the UK to gain perspectives of the general issues and challenges of getting such a program started. Visiting Professor Grants from the UKM and from the British Council Committee for Co-operation in Higher Education (CICHE) programs were extensively exploited to bring in the experts. Different models were studied to determine the most suitable one, not only for a multi-ethnic and multi-cultural country like Malaysia, but also one that was able to make the most of the sparse availability of a SLP professional infrastructure. The community, medical, and educational approaches were discussed at length but for pragmatic reasons it was decided to implement the program with a predominantly medical model. It was envisaged that the educational and community approaches, such as the early intervention and community-based rehabilitation, would be gradually incorporated as the physical and professional infrastructure grew and expanded.

Professor Ann Zubrick, who founded and led the University of Hong Kong speech-language pathology program, was key to the initial planning process and oversaw the design of the core subjects to be in line with other international programs. Programs accredited by the American Speech-Language-Hearing Association (ASHA) and Royal College of Speech and Language Therapists (RCSLT) were referenced in terms of credit and clinical hour requirements. The foundation courses in medical, social sciences, and education were sought from existing departments within the UKM. Course descriptions, although written to fit the focus and depth for speech-language pathology curriculum, left the interpretation of the actual content to the teaching departments. The core subjects were also outlined to allow for flexibility of content in view of the many uncertainties of available teachers. A research component was inserted in the curriculum to allow for exploration of local speech-language and communication issues, thus making the degree an honours level degree.

Detailed curricula for the core subjects were completed and consolidated over 4 years with assistance from colleagues in the UK institutions. Faculty members from Universities of London, Birmingham, Cardiff, Reading, and City University who came through the CICHE and UKM visiting professor programs not only helped with the writing up of the curriculum, but also assisted in the teaching of the core subjects, examination, and training of clinical supervisors in those initial 4 years. Later, colleagues from Australia also came periodically to help with clinical supervisor training and as external examiners, using the UKM visiting professor grants.

In order to overcome the acute shortfall of clinical infrastructure, an in-house clinic building was planned to accommodate the clinical students. The building was ready by 1996 and the first cohort of clinical students received supervision from two part-time and two full-time clinical faculty members who at the same time doubled as teaching faculty. Clinical training for the first few cohorts of students was somewhat creative, to make up for the shortage of clinical supervisors. A peer-supervision model was adopted whereby students were paired with their colleagues within and across years. Clinical supervision was more indirect and informal; students sometimes assisted in the clinical supervisor's service clinics and learnt therapy skills through observation and direct participation. They were also sent out to local rehabilitation facilities and special needs schools around the city to explore and discover issues related to speech-language and communication.

The university received approval for the implementation of the programs in 1994 and the first cohort of nine students were registered in the new speech-language pathology program (Bachelor of Speech Sciences) in 1995. As soon as the program started, documentation requesting for creation of SLP job positions in public institutions were prepared and submitted to the government. Approval of SLP job positions in the public hospitals were received just before the first cohort of students graduated in 1999 (Van Dort, 2005).

Standards were maintained by inviting international external examiners to examine students each year from the time of its development until the present. Over the years professors serving on ASHA, RCSLT, and Speech Pathology Australia (SPA) committees had been invited to conduct viva examinations for the students’ theses and clinical practice. Formal reports and feedback by these examiners were useful in guiding and maintaining the standards of the program. The program was subsequently reviewed and accredited by the National Accreditation Board in 2005 and became the benchmark program for Malaysia.

Growth and focus

A 5-yearly plan was necessary to help focus the program in its teaching and clinical activities. However, with the enormous void in the country's overall services for speech, language, and communication disorders, it was impossible to ignore the urgency to establish simultaneous clinical services in all areas of disorders. Disorders involving adults and children were desperately in need of services and advocacy, but the obvious shortage of manpower and expertise within and outside the program halted much of the ambitious intentions and directed the focus to areas within available expertise of the university. The area of deafness was identified as the most feasible as an initial focus for clinical services. Existing strengths in the ENT and Audiology programs were taken advantage of in the classroom and clinic, teaching about hearing impairment. Speech-language pathology students were paired with their audiology colleagues and together they learnt about public awareness programs, school visits, sign language, hearing aid usage, and cochlear implants. Likewise, linguistics subjects were formulated to address languages and phonology of deaf speakers, whereas special education topics discussed issues in special schools of the deaf. The UKM Cochlear Implant program established in 1995 helped to consolidate the multidisciplinary approach and an early intervention program for children with hearing impairment started on campus in the year 2000, providing the much needed live laboratory to apply knowledge from the classroom (Saim, 2004). The team has implanted and habilitated more than 300 children with hearing impairment in the last 17 years, and the management model was adopted by the Ministry of Health's National Cochlear Implant Program in 2009.

The second phase of development (2000–2005) concentrated on the children's local languages, namely Malay and Chinese dialects. A linguist was brought in to join the program in 1999. The ultimate goal was to assist SLPs to understand linguistic patterns of normal acquisition and use the knowledge to interpret language data of local speakers. Throughout the 5-year period, various aspects of local speakers’ languages were studied and described. Recent development of local language assessment tools at various stages of normalization and standardization was the direct result of this phase of development.

The third phase of development (2006–2010) saw almost three quarters of the faculty members away at various stages of study leave. Returning faculty members replaced those waiting for their turn to go, and the turnover rate was exceptionally high, leaving only 2–3 members each year to take on the heavy teaching burden each year. Much of the clinical teaching could by then be given to hospitals and clinics around the city. Part time lecturers from the local pool of practicing SLPs were also available to ease some of the teaching load. Visiting professors were again invited for longer terms to help with some of the teaching of core speech-language pathology subjects. Due to the staffing shortage no specific areas were selected for development at this phase.

The fourth phase of development (2011–2015) may be the most exciting phase yet. Faculty members who have finished their studies began to return and, by the end of 2012, there would be a total of 10 faculty members with a PhD on the faculty board. Interest areas in research among the faculty were varied and extended beyond the traditional areas of disorders. Areas included: family-centred practices, clinical education, community-based rehabilitation, elderly care, multilingualism, telepractice, and neuroscience, which were the most relevant to the changing practices of today and the program is poised to take on forthcoming challenges.

Sustainability

The biggest test faced by the new program during the early phase was the overwhelming shortage of local teaching faculty. With only two founding faculty members on the teaching board and periodic short-term visits by the CICHE visiting professors, the speech-language pathology program needed to urgently put together plans for sustainability. The UKM Young Lecturers Program was fully exploited to recruit and send young lecturers for further education. Scholarships from the program support Masters and Doctorate level education for UKM young lecturers at institutions of higher learning worldwide. The initial cohort of two candidates from the linguistics and psychology background was sent to undertake their Masters in the UK. They returned to teach for a number of years before returning to continue their doctorate education. Subsequently, one-to-two candidates were chosen each year from UKM's own graduating class and sent to Australia, the UK, and the US for their higher education. In order to help cushion the teaching load of the remaining faculty members, those who left for their Masters degree returned to teach for a year or two before continuing with their PhD. Out of the 15 that were sent on the UKM scholarship, two dropped out and left the university. At the point of writing, 10 had obtained their PhDs and four were at various stages of completing their Masters and PhD. The program benefitted tremendously from the diverse educational background of the returning faculty and provided a rich pool of experience for the current students to draw on.

Challenges ahead

After 17 years of existence, clinical teaching remains a considerable hurdle. Although the number of practicing SLPs in the country has grown considerably, supervisory skills from this young pool of clinicians vary widely. Supervisor education was therefore conducted regularly and continues to be an important focus of the program.

The most profound obstacle faced by the new program in the initial years of development was poor student recruitment. Since the SLP profession was almost unknown to the Malaysian public and its career prospects still not in place, there was little interest among students to apply for the program. Understandably families also hesitated to support their children to apply for the program. Despite aggressive road shows conducted to recruit from feeder pre-university programs, none chose speech-language pathology as their first choice. The first cohort of nine students were high achievers who chose medical, pharmacy, and dentistry as their first and second choices but, due to the filled quota in those programs, were forced to accept the speech-language program offer. Fortunately, their reluctance was gradually overcome with career counselling and persuasion and they stayed on the program and graduated to become the first local SLP graduates.

Besides road shows, members of the faculty went on the national TV and radio stations to talk about various speech, language, and communication topics and at the same time introduced the profession to the public. Articles about the profession were written in the health, career, and education sections of the national newspapers to draw attention to the profession. The absorption of the SLP graduates from the local program into the Health Ministry hospitals helped provide further confidence in the locally-run program. Beginning in the academic year of 2012–2013, interested students who applied to enter the program were interviewed to ensure compatibility.

Employment opportunities for SLPs who graduated from the UKM program have been very encouraging. Sixty per cent of graduates were fully employed in health settings in the government and private services (Van Dort, cited in Van Dort, 2005). Thirty per cent of graduates work in the educational and rehabilitation centres across the country. The remaining 10% were employed in Singapore, Europe, and Australia (Alumni, 2011).

The way forward

This program has been in existence for 17 years, and 13 cohorts of students (176 students) have graduated. A total of 14 teaching faculty members (10 with PhDs and four MSc holders) and five resident clinical instructors currently support the program.

New developments are being planned to further improve the quality of the program at par with programs across the world. High on the list are efforts to benchmark the clinical competence of UKM graduating students with their regional and international counterparts. Active collaboration with the Asia Pacific SLP group is on-going and regular clinical education for supervisors is in place to ensure that training of the UKM SLPs reaches the desired standards.

The program has also embarked on postgraduate research programs in clinical linguistics since 2007 and speech and hearing in 2011. Since its commencement, seven local candidates and one international candidate have enrolled and are at various stages of completing their studies. Recently an institute to facilitate and house services and research in the area of speech-language pathology and hearing has been approved by the university. The institute is poised to function as a regional hub for the education of SLPs and related professions. Another exciting development is the on-going collaboration for cross-disciplinary projects for elderly care in the community, which will be used as a foundation for cross- and inter-disciplinary education.

Faculty members from the program work closely with members of the Malaysian Association of Speech and Hearing (MASH) and the Ministry of Health to draw up a legislative bill to control and gate-keep standards of practice for allied health professionals including SLPs. Once in place, SLPs who work in Malaysia will be required to apply for and maintain their annual practicing certificates.

Currently there is another university in Malaysia—Universiti Sains Malaysia—that offers a speech- language pathology program at the undergraduate level. Meanwhile, the International Islamic University of Malaysia has a speech-language pathology program under development and will possibly commence its program in a couple of years. For both universities, their faculty members comprised of mainly UKM's own speech-language pathology graduates. UKM faculty members are also actively involved in the planning and stake-holder meetings to ensure the standardization of education and training of speech-language pathology programs offered in all Malaysian universities.

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