Designing equitable speech-language pathology services in the Maldives to achieve Sustainable Development Goals 10 and 4

Abstract

Purpose

The United Nations adopted 17 Sustainable Development Goals (SDGs) in 2015 as a universal plan to address challenges experienced around the globe. SDG 4 focuses on inclusive and equitable education while SDG 10 aims to reduce inequality within and among countries. To achieve these goals for children with communication disabilities living in underserved communities, equitable access to services is required. Service delivery should be tailored to the unique characteristics of specific communities to best cater to the needs of the population. This commentary presents the Context-specific Service Delivery Framework (CSDF) that can be used to explore contexts systematically and identify suitable speech-language pathology service delivery approaches. CSDF focuses on the three dimensions of sustainability that are emphasised in the SDGs: environmental, social and economic.

Result

We present how CSDF was developed in the case of one Majority world country, the Maldives. Five studies were conducted to complete CSDF and the findings were used to derive recommendations for service delivery approaches that could help achieve SDG 4 and SDG 10. These included, building capacity by using asset-based approaches, collaborating with service providers and the community, using population-based methods to focus on prevention of communication disabilities and using available technology to provide support.

Conclusion

Other underserved communities could also benefit from using CSDF to design equitable services for children with communication disabilities in their countries. This commentary paper focuses on SDG 4 and SDG 10.

Keywords:

• Sustainable Development Goals (SDGs)
• communication disability
• underserved communities
• Maldives
• speech-language pathology
• quality education (SDG 4)
• reduced inequalities (SDG 10)

Introduction

The Sustainable Development Goals (SDG) were adopted in 2015 as a universal plan to end poverty, protect the planet and ensure prosperity and peace (United Nations, 2015). All 17 interconnected SDGs are to be achieved by 2030 and each goal is composed of several targets which address global problems ranging from gender inequality, access to clean water and sanitation, and provision of affordable and clean energy. This commentary will focus on two SDGs and three targets (United Nations, 2015) specifically for children with communication disabilities in underserved communities:

SDG 4 – Quality education: Ensure inclusive and equitable quality education and promote lifelong learning opportunities for all…

Target 4.5 By 2030, eliminate gender disparities in education and ensure equal access to all levels of education and vocational training for the vulnerable, including persons with disabilities, indigenous peoples and children in vulnerable situations…

Target 4.a Build and upgrade education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive and effective learning environments for all…

SDG 10 – Reduce inequalities within and among countries…

Target: 10.2 By 2030, empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status (United Nations, 2015)

Most children with communication disabilities are likely to require speech-language pathology services to participate fully in their communities. However, equitable access to these services is currently not available universally, with significant differences observed between Majority World countries (previously known as developing countries) and Minority World countries (previously known as developed countries) (Hartley & Wirz, 2002). Hence, Majority World countries will be required to discover means to provide the necessary support if they are to achieve the SDGs for children with communication disabilities. The World Report on Disability (World Health Organization & The World Bank, 2011) highlighted the challenges people with disabilities face to access services, especially in the Majority World. Their report recommended developing methods to explore the contexts around people with disabilities and how it impacts different aspects of disabilities.

Several models have been presented as possible solutions to provide more equitable speech-language pathology services in underserved contexts. The Communication Capacity Research program presented by Hopf (2018) aimed to identify culturally and linguistically sustainable services in Fiji. This study demonstrated the different ways underserved communities could collect relevant data to help inform change (e.g. gathering information from the community and understanding their communication usage). The Communication Disability Model proposed by Hartley and Wirz (2002) highlighted the importance of communication disability interventions in underserved communities to consider the individual’s environmental and social needs. Certainly, such studies provide probable paths for equitable service delivery. However, if we confine solutions only to the areas recommended in these studies, we may overlook other possible solutions tailored to the unique characteristics of specific communities. Hence, Wylie et al. (2013) suggested speech-language pathologists (SLPs) assess contexts individually and reflect on appropriate service delivery approaches that best cater to the needs of specific populations. The current challenge is recognising how to undertake this task.

To support the development of customised service delivery approaches and build on existing literature, we created the Context-specific Service Delivery Framework (CSDF). CSDF (Figure 1) presents areas that can be explored in underserved contexts to identify characteristics that could influence the development of these approaches.

Figure 1. Context-specific Service Delivery Framework (CSDF) © 2022 by Zahir, M. Z., Miles, A., Hand, L., & Ward, E. C. All Rights Reserved.

Context-specific service delivery framework (CSDF)

CSDF is based on the challenges people with communication disabilities face in Majority World countries as outlined in the World Report on Disability. It involves exploring the three dimensions of sustainability (environmental, social and economic) emphasised in the SDGs. CSDF requires the examination of these dimensions within three major components of a context: the current situation, resources and opportunities and technological capacity (Figure 1).

The objective of the current situation component is to collect a baseline of conditions related to people with communication disabilities. It explores the existing services, the facilitators, barriers and the costs required to access these services, and the need for services. The World Report on Disability recommended developing and reallocating existing resources to improve access to services. Hence, the resources and opportunities component explores how resources are currently used, the attitudes and behaviour of the people in relevant sectors and the availability of relevant funding. The Report also identified technology as a factor that could help remove barriers to disability services. The technological capacity component in CSDF looks at the availability and affordability of information and communication technology (ICT), and the use of and attitudes towards ICT in the community. CSDF allows the substantial characteristics of a context to be comprehensively evaluated by exploring all three components. This information can then be used to design tailor-made services for a local context. 

Case study: the Maldives

A series of studies was conducted to complete CSDF and identify context-specific speech-language pathology service delivery approaches for one Majority world country, the Maldives. The Maldives is an archipelago in the Indian Ocean made up of 1,192 islands. (National Bureau of Statistics – Maldives, 2015). A third of the 402,071 residents of the Maldives live in the capital island, Malé while the rest are scattered across 187 islands (National Bureau of Statistics – Maldives, 2015). The geographical make-up and population distribution, therefore, present many challenges common to Majority World countries and archipelagos. Maldivians share a unique culture and first language, Dhivehi, though English is a close second evident through its deep roots in the national curriculum (National Institute of Education – Maldives, 2014). Table I displays five separate studies conducted to complete CSDF for the Maldivian context. Since this commentary particularly focuses on children with communication disabilities and achieving SDG 4, schools were specifically targeted in studies 3 and 5.

Table I. Studies used to complete CSDF.

Study; framework component	Research aim	Research design	Data	Analysis
1. Current situation (Zahir, Miles, Hand, & Ward, 2021a)	A preliminary exploration of the environmental, social and economic conditions in the Maldives and how they affect equitable access to speech-language pathology services.	Parallel convergent mixed methods	40 Online documents Online surveys: 107 teachers 73 parents of children with communication disabilities	Examining and interpreting documents Deductive content analysis
2. Resources/opportunities: (Zahir, Miles, Hand, & Ward, 2021c)	To explore speech-language pathology and related resources available in the Maldives, in order to identify sustainable approaches that could yield the most out of existing resources.	Qualitative exploratory	Interviews: 6 atoll councillors (representing 30% of atoll councils) 3 NGO representatives (50% of NGOs) 3 SLPs (50% of the contacted sample)	Deductive content analysis
3. Resources/opportunities: (Zahir, Miles, Hand, & Ward, 2022)	To explore what the education sector and classrooms in the early years of schooling currently offer as support for children with communication disabilities in the Maldives, with an objective to identify opportunities to enhance this support.	Qualitative multi-method	Observations of 12 early-year classrooms (pre-school, grade 1 and 2) in 4 schools. Interviews: 1 Ministry of Education official 4 special education teachers in these schools	Communication supporting classroom (CsC) observation tool Deductive content analysis
4. Technological capacity (Zahir, Miles, Hand, & Ward, 2020)	To explore the environmental, social and economic conditions around ICT in the Maldives that could influence equitable and sustainable delivery of speech-language pathology services.	Parallel convergent mixed methods	21 online documents Online surveys: 25 island councillors 73 parents of children with communication disabilities Interview with 1 ICT government official	Examining and interpreting documents Deductive content analysis
5. Technological capacity: (Zahir, Miles, Hand, & Ward, 2021b)	To explore the environmental, social and economic conditions around ICT in remote schools of the Maldives that could influence equitable and sustainable delivery of speech-language pathology services.	Parallel convergent mixed methods	13 online documents Online surveys of 103 teachers Observation data from 4 schools Interviews: 31 teachers 4 principals of the 4 schools	Examining and interpreting documents Deductive content analysis

We used convergent deductive content analysis (Fetters et al., 2013) to explore the three components of CSDF. The completed CSDF (Figure 2) displays the characteristics of the Maldivian context that could influence the development of customised service delivery approaches. More appropriate services could be designed using these findings, leading to more equitable service delivery, which could help achieve SDG 4 and 10 for children with communication disabilities in the Maldives.

Figure 2. The completed CSDF for the Maldivian context.

Recommendations arising from CSDF

Using asset-based approaches to build capacity among parents and the community

In contexts where certified professionals are not available, the World Report on Disability (2011) recommends gradually developing and reallocating resources to build community support systems. In the Maldives, speech-language pathology services were mainly available in the capital island (Figure 2). Hence, an asset-based approach may be necessary to address the inequity of service delivery within the country (SDG 10). Asset-based community development approach involves locating and using local strengths and resources to sustainably develop the community (McKnight & Kretzmann, 1996). As Sen et al. (2008) suggested, the government could allocate funds for Non-governmental organisations (NGOs) to provide services in underserved communities. Funding could be utilised by SLPs and NGOs to develop skills and knowledge among target individuals and groups with interest and motivation in remote communities. This could help develop people within island communities to take on community-based communication worker roles, in turn empowering the community and developing sustainable support systems (Target 10.2).

Collaborating with service providers and the community to build capacity among teachers

The inclusive education system in the Maldives focuses on supporting children with disabilities, however, the support for communication disabilities particularly in remote schools of the Maldives can be greatly improved (Figure 2). There could be an emphasis on training teachers in remote regions where there are limited services for children with disabilities (World Health Organization & The World Bank, 2011). When guided by SLPs, support staff have effectively delivered interventions leading to progress in children’s communication skills (Lawton & Kasari, 2012). Special education teachers in the Maldives are well positioned to provide specialised support, as at least one special education teacher is available in every school (Figure 2). Early intervention could also be better targeted if pre-school teachers are provided with training to properly identify communication disabilities in children as young as 2 years of age. Hence, children in remote regions could receive the required support more consistently if SLPs and NGOs in the Maldives could team up with the Ministry of Education and build capacity among teachers in schools and preschools (Target 4.5).

Using population-based methods to focus on prevention

Individualised services do not often achieve national coverage in countries with limited resources (Wickenden, 2013), as is the case in the Maldives (Figure 2). The needs of underserved communities may be better addressed by SLPs focussing on prevention through population-level interventions (Wylie et al., 2013). Interventions could target parents and communities in remote regions to identify communication disabilities and improve children’s communication at an early stage. This could reduce communication disabilities and the need for assistance from external sources (Wylie et al., 2013). By intervening at the population level, a larger number of children are likely to receive support (Target 10).

Using available ICT and upgrading education facilities to improve access to services

CSDF revealed an unmet need for speech-language pathology in remote regions. People living in these regions currently bear high transport and accommodation costs to access services in the capital. Mobile devices with mobile broadband have been proposed as a possible solution in such contexts (e.g. Cheng, 2013). High degree of access to mobile phones, computers and mobile broadband internet was discovered both in the community and the education sector in the Maldives (Figure 2). Hence, the available ICT could be used to provide services remotely and meet SDG 10. Using available ICT could also help meet Target 4.a. Properly utilising the available ICT in school and home settings could greatly reduce the need for expensive upgrades of education facilities (e.g. to purchase and install new equipment). In a country with widely distributed populations, utilising ICT could also serve as an easy means to disseminate information to the population of interest (Buell, 2013; Target 10.2). Instead of using costly and time-consuming transport, the ICT-based professional development projects initiated by the Maldivian government (Figure 2) can also be used to provide guidance and training for teachers on communication disabilities (SDG 4).

Summary and conclusion

Of the 17 SDGs, SDG 4 focuses on ensuring inclusive and equitable quality education while SDG 10 aims to reduce inequality within and among countries. To attain these goals for children with communication disabilities living in underserved communities, SLPs are tasked with creating innovative, tailor-made solutions for individual contexts to achieve equitable service delivery. In the case study presented here, a framework, CSDF, was used which promoted systematic exploration of contexts to identify customised speech-language pathology services in underserved contexts. Identified strategies included building capacity by using asset-based approaches, collaborating with service providers and the community, using population-based methods to focus on prevention of communication disabilities, and using available ICT to provide support. Frameworks that explore the three dimensions of sustainability (i.e. environmental, social and economic) such as this, may be used within other Majority World countries to help achieve SDG 4 and 10 for children with communication disabilities.

Disclosure statement

No potential conflict of interest was reported by the authors.