The human right to communicate: A survey of available services in Saudi Arabia

Abstract

Article 19 of the Universal Declaration of Human Rights states: “Everyone has the right to freedom of opinion and expression.” However, people with communication disabilities may be more likely to lose the right to express their opinions as a consequence of their atypical communication methods; hence they may be denied a basic human right. The purpose of the current study was to investigate the availability of speech-language pathology services in Saudi Arabia’s public-health sector. The data were collected using a telephone survey. The results found a shortage of and an uneven distribution of health-based speech-language pathology services. Of the 196 major governmental hospitals surveyed, 29 were identified as having speech-language pathology services, which were distributed over 7 of Saudi Arabia’s 13 Administrative Regions. Obtaining accurate information regarding the availability of these services is an important first step in informing policy development and aiding health-service planners to train more professional staff, expand services methodically and use existing resources effectively to meet the rights of people with communication disabilities.

Keywords:

• Article 19
• Universal Declaration of Human Rights
• United Nations
• speech-language pathology services
• Saudi Arabia

Introduction

As the 70th anniversary of the Universal Declaration of Human Rights approaches, Article 19 of the Declaration (United Nations, 1948) underscores the right of everyone to freedom of opinion and expression. However, Article 19 poses a challenge to the delivery of services for people with communication disabilities in parts of the world where speech-language pathology services are limited.

Saudi Arabia covers over 2 150 000 square kilometres (830 000 square miles), is divided into 13 administrative regions, and has a population of 27 136 977 people, of which 65.0% is concentrated in three main administrative regions namely, Riyadh, Makkah and Eastern Province (General Authority for Statistics, 2010). Although epidemiological data on communication disabilities in Saudi Arabia are lacking, the literature provides some useful indicators. A national survey in Saudi Arabia reported the prevalence of major disabilities among children under the age of 16 years to be 6.33%, with motor disability being the most common type of disability followed by learning disability (Al-Hazmy, Al Sweilan, & Al Moussa, 2004). In another survey in the eastern Jeddah area, the prevalence of functional disabilities among children has been reported as 3.6%, with communication disorders being the most common. Parents reported low rehabilitation service provision for their children as only one-third of these children received it (Milaat, Ghabrah, Al-Bar, Abalkhail, & Kordy, 2001).

In 1987, the Saudi government passed the Legislation of Disability (LD), the first legislative act in Saudi Arabia to guarantee that people with disabilities receive equal rights as individuals in society (Al-Jadid, 2013). In 2000, the Disability Code was passed to guarantee that people with disabilities had access to free and appropriate services (Al-Odaib & Al-Sedairy, 2014). Although the Saudi government has led a clear and steady progression towards provision of improved services to persons with disabilities, a lack of effective implementation has created a gap between the framework of the laws mentioned and the appropriate provision of services (Al-Jadid, 2013). Apart from the private sector, speech-language pathology services within healthcare settings are the only speech therapy available for individuals with communication disabilities outside of educational and social services institutions. However, educational institutions reportedly have a paucity of speech-language pathology services (Alquraini, 2010), and many of the social service institutions serving persons with special needs also lack speech-language pathology services, although no studies have documented this shortage.

Currently, data describing the availability of speech-language pathology services in Saudi Arabia are lacking. The goal of this survey was to produce a snapshot of the overall availability of speech-language pathology services in Saudi Arabia and to identify barriers that limit people with communication disabilities from accessing these services. The study also makes recommendations for removing these barriers.

Method

The present study was approved by the Unit of Biomedical Ethics Research Committee of the King Abdulaziz University Hospital. Hospitals in Saudi Arabia fall under the supervision of various ministries and organisations. Using the online databases of these bodies, the researchers identified 206 hospitals (including university and rehabilitation hospitals) and classified them according to the supervising ministry, as follows: 190 hospitals under the Ministry of Health (MOH), 3 under the Ministry of Education (MOE), 2 under the Ministry of the National Guard (MNG), 9 under the Ministry of Defence (MOD) and 2 under the Royal Court.

The data were gathered via a semi-structured telephone interview conducted by the researchers between February and July 2016. The telephone interview was chosen mainly because many hospitals are located in rural areas and the ministries’ databases listed no websites or email addresses for them. Each hospital was telephoned until either a response or a refusal was obtained. Then, the data were obtained, if possible, directly from the most senior speech-language pathologist (SLP). The interview aimed to gather information about the number, qualifications, and caseloads of the speech-language pathologists (SLPs); the types of services provided; and the instruments available to assess patients’ voices and ability to swallow. To ensure a full and accurate record, each telephone interview was transcribed during the interview.

Data storage and analysis

All transcribed responses were coded and stored by the researchers directly in Excel files before they were entered into SPSS version 17.0 for analysis. The data were analysed descriptively and simple proportions were calculated for each response.

Result

The researchers contacted 206 government hospitals in Saudi Arabia and received responses from 196. Ten hospitals in the MOH category did not respond to calls, and no e-mail addresses were listed for them.

Of the 196 hospitals surveyed, 29 (14.7%) had speech-language pathology services, which were distributed across 7 of the 13 regions. Most of the services were reported to be concentrated in the three largest regions of Saudi Arabia, namely Riyadh, Makkah and Eastern Province. Usually, the speech-language pathology services were clustered within one city in the region. Table 1 details the availability of speech-language pathology services in Saudi Arabia by region. The distribution of the speech-language pathology services among the five categories of hospitals surveyed showed that almost half of the services identified (16 of 29) were within the MOH hospitals. However, considering that there are 190 MOH hospitals, the percentage (8.4%) of these hospitals providing speech-language pathology services is considerably low. Out of the 9 hospitals under the MOD, 6 had speech-language pathology services. All the hospitals under the MNG, MOE and Royal Court had speech-language pathology services.

Table 1. Availability of speech-language pathology (SLP) services in Saudi Arabia’s 13 regions.

		Hospitals surveyed	Hospitals providing SLPs		No. of SLPs
Region	Population	n	n	%	n	per 100 000 population
All regions	27 136 795	196	29	14.7	183	0.67
Albaha	411 888	5	0	–	0	–
Al-Jouf	440 009	7	0	–	0	–
Al-Madina	1 777 933	13	2	15.4	4	0.22
Aseer	1 913 392	22	1	4.5	1	0.05
Eastern Prov.	4 105 780	27	5	18.5	14	0.34
Hail	597 144	7	0	–	0	–
Jazan	1 365 110	6	0	–	0	–
Makkah	6 915 006	22	9	40.9	33	0.48
Najran	505 652	5	0	–	0	–
Northern Borders	320 524	6	0	–	0	–
Quasim	1 215 858	18	1	5.6	2	0.16
Riyadh	6 777 146	49	10	20.4	128	1.89
Tabouk	791 535	9	1	11.1	1	0.13

The 29 hospitals having speech-language pathology services employed 183 SLPs, but they were not distributed equally among the regions. Riyadh City, in the Riyadh Region, reported the highest number of SLPs (n = 128, 69.9%), while the regions of Aseer and Tabouk each reported having one SLP. A total of 33 (18%), 14 (7.7%) and 4 (2.2%) of the SLPs were reported to be working in the regions of Makkah, Eastern Province and Al-Madina, respectively. A total of 138 (75.4%) of the SLPs were females and 153 (83.6%) were Saudis. The majority of the SLPs had a Bachelor’s degree (n = 106, 57.9%) or Master’s degree (n= 41, 22.4%), while the remainder were interns (n = 15, 8.2%), had a PhD (n = 15, 8.1%) or an MD (n = 5, 3.2%). Regarding the distribution among hospital categories, the most common job location for the SLPs was in the MOH hospitals (37.7%), followed by the MOD hospitals (26.8%). The remainders of the SLPs were almost equally distributed among the other three hospital categories with 21 to 22 SLPs within each hospital category. The daily clinician’s caseload was approximately the same for all clinicians among all five hospital categories, ranging between six and ten cases for each clinician.

Of the 29 hospitals that provided speech-language pathology services, 28 served patients with speech and language disorders, and 20 (68.9%) also provided voice and swallowing assessments. With regard to assessment services involving instruments, 20 (68.9%) hospitals offered stroboscopy, 7 (24.1%) had a computerised speech lab, 14 (48.3%) conducted fibrotic endoscopic evaluation of swallowing and 9 (31%) offered a modified barium assessment of swallowing.

Discussion

The survey data confirmed that speech-language pathology services in Saudi Arabia are severely limited, largely due to shortages of staff and the unequal distribution of the facilities. The survey identified several barriers to the development of services. The first was the limited number of professionals in the field. The ratio of SLPs to inhabitants in Saudi Arabia was 0.67 per 100 000. Similar findings have been reported in other developing countries. For instance, South Africa has reported a ratio of SLPs to inhabitants of 0.227 per 100 000. In contrast, the United Kingdom has reported 16.3 per 100 000 (Fagan & Jacobs, 2009). Although other studies (Fagan & Jacobs, 2009; Wylie, McAllister, Davidson, & Marshall, 2013) have identified financial barriers to the delivery of speech-language pathology services, financial barriers are not an issue in Saudi Arabia, where most services are well equipped. The Saudi government’s expenditures on the MOH increased from 6.49% of the total government budget in 2010 to 7.25% in 2015 (Ministry of Health, 2015). Although the government has made progress regarding rehabilitation services, the development of speech-language pathology services has not been a priority, possibly because of low awareness of the services provided by SLPs. Al-Jadid (2013) reported that despite the fact that many of the hospitals under the MOH have medical rehabilitation departments, their services are mainly physiotherapy for outpatients. This is not surprising, as the speech-language pathology profession is still in its infancy in the Arabic-speaking Gulf Cooperation Council (GCC) countries, including Saudi Arabia, and there are significant shortages of assessment tools, SLPs and research studies (Shaalan, 2009).

The present study identified two barriers to the delivery of services that have been found in several other studies (Dew et al., 2013; Keane, Smith, Lincoln, & Fisher, 2011): the unequal distribution of speech-language pathology services among Saudi Arabia’s 13 regions and the tendency for these services to be clustered in the largest cities. Although the results of the present study showed that the majority of speech-language pathology services were within the three administrative regions where most Saudis live, these regions are quite large, and patients may still need to travel long distances to reach services in the main cities in those regions. For example, in Riyadh Region, the driving distance between Wadi ad-Dwaser and the main city of Riyadh, where services are located, is 741 kilometres (460 miles), which takes an estimated time of 6 hours to drive, signifying a considerable lack of accessibility to speech-language pathology services. The critical maximum distance past which patients become unable or unwilling to travel to access weekly speech-language pathology services has been suggested as being 50 kilometres (Verdon, Wilson, Smith-Tamaray, & McAllister, 2011).

The low number of SLPs may be attributed to the limited number of speech-language pathology university programs. Until recently, there was one undergraduate program, founded in 1979, for both male and female SLPs. Over the last few years, two more programs have been established exclusively for female students. The geographical imbalance in the distribution of SLPs noted in the present study is to be expected, because health professionals reportedly see urban areas as having more advantages, both professionally and culturally (Dew et al., 2013; Dunkley, Pattie, Wilson, & McAllister, 2010). The fact that two out of the three educational programs available are exclusively for females may result in a predominance of females in this speciality and may further affect the distribution of SLPs in Saudi Arabia, as Dussault and Franceschini (2006) have suggested that women are less likely to accept positions in remote areas, which could reduce the supply of personnel in rural areas.

Recommendations

Collaboration among healthcare organisations can result in successful adoption of a human-rights approach to communication disabilities. It has been suggested that Saudi Arabia lacks coordination and clear communication channels among health-service providers, despite the multiplicity of healthcare services, which results in wasted resources and duplication of effort (Almalki, Fitzgerald, & Clark, 2011).

The first step towards increasing the number of speech-language pathology services that are available is raising the government and the ministries’ awareness of the social and personal effects of communication disabilities. It has been suggested that Saudi society’s view of people with disabilities is that they are helpless, dependent and lacking in productivity (Al-Gain & Al-Abdulwahab, 2002). Therefore, it is the responsibility of SLPs to find ways to provide targeted, sustained education about communication disabilities in order to increase public and political awareness.

Another much-needed step towards facilitating service development is to address the gaps in existing knowledge about the prevalence and nature of communication disabilities in Saudi Arabia. Studying the prevalence, psychosocial aspects and economic effects of communication disabilities would help guide policy and programmatic decisions.

Several solutions for recruiting health professionals to rural areas have been suggested, including recruiting students from rural areas, as they understand both rural living and the health needs of their hometowns (Keane et al., 2011). These students can be offered incentives, including full scholarships, direct financial incentives and professional support (Grobler et al., 2009).

Another means of addressing the lack of access to speech-language pathology services in rural areas is to implement home programs planned by SLPs. Kurland, Wilkins and Stokes (2014) suggested using computers to enable individuals with aphasia to practice speech and language tasks at home. Another possibility is to train community-based therapy assistants to work remotely, implementing programs designed by SLPs (Dew et al., 2013).

Some studies have suggested the use of telehealth to deliver speech-language pathology services in underserved geographic areas (Mashima & Doarn, 2008). Saudi Arabia has recently witnessed a rapid, decisive movement towards e-learning, with e-learning units being established in universities and educational organisations (Al-Shehri, 2010). A survey conducted in several parts of Saudi Arabia to determine patterns of internet use found that the internet was widely used by citizens of all ages (Simsim, 2011) and that organisational support and training tended to promote its use (Al-Gahtani, 2004). Further studies are needed to determine whether telehealth would be an acceptable, feasible method of service delivery in Saudi Arabia in terms of cultural acceptability, technical specifications, clinical efficacy and outcomes.

It has been said that the biggest challenge for people with communication disabilities is to be heard (Wylie et al., 2013). Article 19 of the Universal Declaration of Human Rights provides an opportunity to increase awareness and to advocate for services that are accessible to all people with communication disabilities.

Declaration of interest

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

Acknowledgements

We thank all of the participants who gave their time and energy to complete our questionnaire.