Responding to the World Report on Disability in Australia: Lessons from collaboration in an urban Aboriginal and Torres Strait Islander school

Abstract

The timely release of the World Report on Disability serves as a challenge to members of the health professions to review and renew their response to inequity of access and provision of services to children and adults with a disability. This paper responds to the lead article by Wylie, McAllister, Davidson, and Marshall, and provides commentary on two of the recommendations of the World Report on Disability in the context of a novel inter-professional service for Aboriginal and Torres Strait Islander children with communication and learning needs. Speech-language pathology and occupational therapy students reported on their learning within a model of service delivery based on partnership with an Aboriginal and Torres Strait Islander school community and inter-professional collaboration. Lessons learned have the potential to inform future services for under-served populations and to impact on capacity building through health professionals gaining experiential knowledge and understanding of an urban Aboriginal and Torres Strait Islander community.

Keywords::

• World Report on Disability
• service delivery
• Aboriginal and Torres Strait Islander
• inter-professional learning
• clinical education

Introduction

As stated in the World Report on Disability, “Disability disproportionally affects vulnerable populations” (World Health Organization and The World Bank, 2011, p. 8). Wylie, McAllister, Davidson, and Marshall (2013) have highlighted that issues associated with communication disability have not been foregrounded in the World Report on Disability, yet it is known that the very nature of communication disability can inhibit those with speech and language difficulties “having a voice”. It is the purpose of this commentary to focus on two of the recommendations of the World Report on Disability in the context of a novel model of service provision for Aboriginal and Torres Strait Islander children¹ and families in an urban school. Through discussion of lessons learned from an inter-professional clinic within this Murri School², we aim to raise awareness of issues related to the World Report on Disability Recommendation 2: Invest in specific programs and services for people with (communication) disabilities, and Recommendation 5: Improve human resources.

Consistent with the lack of epidemiological data on communication disability, particularly in the Majority World (Wylie et al., 2013), there is little literature regarding the incidence and prevalence of communication disabilities within the Aboriginal and Torres Strait Islander Australian population. What is known is that the prevalence of otitis media occurs at much higher rates in Aboriginal and Torres Strait Islander populations than in non-Aboriginal and Torres Strait Islander Australians (Morris, Leach, Silberberg, Mellon, Wilson, Hamilton, et al., 2005). As otitis media commonly occurs with fluctuating conductive hearing loss, it can have significant effects on a child's ability to develop speech, language, and educational foundations necessary for their developmental progress (Williams & Jacobs, 2009).

Speech-language pathologists in Australia are beginning to argue for different approaches to assessment and intervention for Aboriginal and Torres Strait Islander children, including the use of oral narratives and dynamic assessments which take into consideration a child's home language (Gould, 2008). This home language may be a traditional Aboriginal and Torres Strait Islander language or Aboriginal English which is recognized as having different phonological and grammatical structures from Standard Australian English (Butcher, 2008; Pearce & Stockings, 2011; Toohill, McLeod, & McCormack, 2012; Williams & Masterson, 2010). Speech-language pathology services to rural and remote Aboriginal and Torres Strait Islander communities are also adopting more population-based approaches to their interventions (Coleman, Porter, Barber, Scholes, & Sargison, 2011).

Despite significant numbers of Aboriginal and Torres Strait Islander people dwelling in remote locations and the service delivery challenges that result, there are a greater number of Aboriginal and Torres Strait Islander people now living in urban and regional areas, with over 40,000 Aboriginal and Torres Strait Islander people residing in South-East Queensland. These Aboriginal and Torres Strait Islander people are often less visible within an urban landscape and therefore services do not necessarily cater for their needs (Armstrong, Hersh, Hayward, Fraser, & Brown, 2012). Reports from a study of urban occupational therapists, for instance, indicated that very few Aboriginal and Torres Strait Islander children attended their services, even in locations where there were up to 10,000 Aboriginal and Torres Strait Islander people in the local vicinity (Nelson, Allison, & Copley, 2006). Despite the seemingly easier access to services in a city, many Aboriginal and Torres Strait Islander people continue to be reluctant to access mainstream health and community services for a variety of complex historical, political, cultural, and socio-economic reasons, including access to transport and suspicion of mainstream services as a by-product of past government policies which discriminated against Aboriginal and Torres Strait Islander people (Lowell, Maypilama, Yikaniwuy, Rrapa, Williams, Dunn, et al., 2012; Nelson & Allison, 2000; Saggers, 1993). A challenge exists to not only work in collaboration with Aboriginal and Torres Strait Islander community organizations to address problems of access to services, but also to increase mutual learning, human resource development, and sustainable practices that are responsive to identified need and cultural diversity.

Learning from a novel service delivery model

This paper explores lessons learned from an initiative in which speech-language pathology and occupational therapy student clinicians participated in inter-professional clinical learning and service delivery within an urban Aboriginal and Torres Strait Islander School. Through this clinical practice experience, health professional students experienced a service delivery model built on mutual learning, collaboration, and understanding and respect of cultural difference, and were, thus, empowered to undertake similar service development as graduates.

Ethics approval was granted for a project to survey students’ perceptions of learning gained within this context. This survey was sent via an on-line link to eight students upon completion of their practical experience and then collated in an anonymous depository by an external source. Questions at the end of the survey sought short answer responses which were analysed thematically. These short answer responses from student surveys as well as informally collected feedback from teachers will serve to highlight focal issues and illustrate changes that relate to two key recommendations of the World Report on Disability.

Commentary in relation to Recommendation 2: Invest in specific programs and services for people with (communication) disabilities

There is some evidence to suggest that, in urban settings, services located within Aboriginal and Torres Strait Islander organizations are more accessible than those in mainstream health or education settings (Nelson & Allison, 2007). For instance, the speech-language pathology clinic based at The University of Queensland in Brisbane, Australia initially provided services to Aboriginal and Torres Strait Islander children who travelled with a staff member from their school to the university teaching clinic. However, attendance was inconsistent and this made it difficult to meet the dual need of providing support to the child and a student education opportunity. The university occupational therapy clinic had been providing a service based within this school for over a decade and, building on this well-established partnership, the speech-language pathology service was re-located to the school. This overcame many of the structural barriers and enabled the development of more effective partnerships with teachers, who participate in whole class skill development programs. The resultant inter-professional occupational therapy and speech-language pathology service has flourished in the new model of service delivery. Having a clinical educator from each profession was integral to a well-coordinated approach and has enabled opportunities to share supervision and to model inter-professional clinical skills for students to enhance their learning. The perceived benefits were described by one of the speech- language pathology students at the Murri School:

Receiving feedback from both speech pathology [SP] and occupational therapy [OT] supervisors allowed me to consider multiple aspects of my performance and better plan and run therapy to meet multiple objectives (e.g., receiving feedback from OTs about the students’ positioning at the desk and how improving this will increase their focus/attention and thus enable the child to focus more on SP tasks I lead) (Student 1).

This approach to service delivery is consistent with the World Report on Disability (p. 18) which states that “While there is a need for more services, there is also a need for better, more accessible, flexible, integrated and well-coordinated multidisciplinary services”.

Whilst cultural knowledge and practices are still important in an urban context, Aboriginal and Torres Strait Islander people are often sophisticated at navigating different cultural knowledge (e.g., traditional Aboriginal culture, contemporary Western culture, health promotion knowledge). There is now greater emphasis on the approach to therapy as a therapist than on needing to have knowledge of particular cultural protocols in an urban setting. For instance, there is a need for greater flexibility on the part of the therapist as well as the organizational structures (Nelson & Allison, 2007). Within the school service, students now plan for two children in one appointment slot or provide services in a whole-of-class format as this alleviates the potential difficulty of children being absent. Students also report developing greater flexibility due to the challenges of needing to adapt in this environment.

… through planning and implementing group therapy I have learnt many useful, new skills (e.g., behaviour management, creating flexible tasks) which can be easily graded to suit most participants’ needs (Student 2).

Students also build opportunities for the development of relationships into their sessions. Best practice with all clients mandates the development of rapport between a client and therapist, but it may take longer with Aboriginal and Torres Strait Islander clients for a trusting relationship to develop with therapists new to the community so service delivery should be planned to occur over several appointments and not as a one-off assessment (Nelson & Allison, 2007). In building this relationship, therapists need to give information about themselves as well as asking questions, so that the power differential between the “expert” therapist and the client can be reduced in part. For instance, therapists might share about their own family or children within appropriate professional boundaries which allows the client to understand where they are coming from (Nelson & Allison, 2007; Nelson et al., 2006).

Specific programs were developed with the school focusing on skill development and on intervention to support children identified with learning needs. Students worked within classrooms and in conjunction with teachers to provide whole class activities in gross motor, fine motor, sensory processing, and communication areas. In working within this model, it was recognized that long-lasting change and system-based change can only occur when there is mutual respect and understanding. School staff were included in planning about the clinic, its structure, and its goals. Creation of the learning environment where children's progress could be maximized depended on the involvement of the teachers in determining intervention targets and themes, in planning to meet individual students’ school-based needs, and in consideration of best groupings for skills development. Teacher involvement in individual client intervention was also important in goal-setting and implementation. Student observations of children in the classroom and classroom-based interventions provided teachers with opportunities to engage in discussion with students about children's individual learning needs, goals, and activities to meet goals and sustainable teaching practices to assist whole class engagement and participation.

I've implanted most of what I've observed from the service in my daily teaching practices since I've been here at the school and I would recommend fellow teachers to take on and use it (Teacher).

The success of the current inter-professional placement for students in speech-language pathology and occupational therapy has provided an incentive for capacity-building in this area. This model of inter-professional practice is now being trialled across a range of other services, for example within a community-controlled Aboriginal and Torres Strait Islander health service. Building sustainable services in settings such as these is seen as a priority.

Commentary in relation to Recommendation 5: Improve human resource

Recommendation 5 of the World Report on Disability suggests that improving human resource capacity provides a solution to barriers impacting on services for people with disabilities. One opportunity for increasing human resource capacity into the future is the model described above involving placement of students within Aboriginal and Torres Strait Islander health and education settings. Such placements support the need to raise students’ awareness of key factors to consider when working with Aboriginal and Torres Strait Islander children and their families and teachers, to encourage them to advocate for improvements in their health outcomes and to create a meaningful partnership between universities and Aboriginal and Torres Strait Islander facilities (Whitford, Russell, Taylor, & Thomas, 2010). Where students have positive experiences in placements within Aboriginal and Torres Strait Islander health and education settings, an outcome may be workforce increases in that area (Whitford et al., 2010).

I found the experience gave me greater insight into how the values of Aboriginal culture play out in the lives of Aboriginal children. In our lectures we are given some idea as to what these values might be. The only way I can explain this is that the placement helped me put faces, attitudes and personalities to these values which helped me find ways to adapt my approach to therapy (Student 3).

An important aim of student placements in Aboriginal and Torres Strait Islander settings is to provide students with the knowledge and opportunity to make an individual contribution to desired changes in Aboriginal and Torres Strait Islanders’ health and education outcomes (Whitford et al., 2010). In this context, students become change agents through immersion in such settings, and thereby sharpen their focus on holistic characteristics of their clients, including impairment, activity, participation, and environmental factors. The Australian Rural Health Education Network (Liaw & Kilpatrick, 2008) advocates some guiding principles for student placements within Aboriginal and Torres Strait Islander health settings, with a core principle being the fact that such placements are “a privilege, not a right” (cited in Whitford et al., 2010, p. 120).

Students in the clinic reported a range of personal learning goals at the start of the placement. At the conclusion of the placement, students evaluated their success in achieving their individual goals and were assessed on their development of professional competence using profession-specific competency-based assessment tools. In addition, students completed a survey designed to distil their impressions of the placement and to evaluate their learning in a more general sense. Developments in the following areas were reported:

1. Development of skills in an environment that was well-supported and assisted their development of practice in a culturally safe framework. Cultural safety is a term originating in New Zealand nursing practice which describes an approach to healthcare which takes into account the practitioner's own values and an appreciation of issues of power imbalances as a result of colonization (Taylor & Guerin, 2010). Awareness of cultural difference and individual attitudes contributed to a “richness of understanding” (Whitford et al., 2010., p. 130) of the environment in which they were immersed.

If anything I would say there was the potential to come away feeling discouraged by the enormity of what some of the kids have stacked against them in life. A sense of feeling like you couldn’t make much difference. BUT, the positive support from/attitude of the CEs [clinical educators] and some of the school staff had the opposite effect, I found (Student 4).

(2) Development of specific clinical skills related to working with Aboriginal and Torres Strait Islander children of early school age; for example, management of the individual presentation of children and consideration of cultural, linguistic, and personal difference, an understanding of holistic factors affecting Aboriginal and Torres Strait Islander children's presentation and progress, knowledge of key factors relating to Aboriginal and Torres Strait Islander language use such as its differences to Standard Australian English (SAE) (Pearce & Stockings, 2011; Toohill et al., 2012), and the consequent requirement to exercise caution when interpreting assessment results and profiling a child's language against that of his peers (Gould, 2008).

Learning more about the current state of Aboriginal and Torres Strait Islander health issues—the prevalence of OME [otitis media with effusion] with effusion and its global impact on the development of young Aboriginal and Torres Strait Islander students. Seeing these issues first hand really highlighted to me the need for speech pathologists to work with the Aboriginal and Torres Strait Islander population to improve educational outcomes (Student 5).

(3) Knowledge and implementation of “systems-based” or “population-based” intervention through the skills development program, which succeeds in embedding new processes or skills across a group within an inclusive learning environment. Wylie et al. (2013) encouraged SLPs to think more broadly about their intervention and to consider a population-based approach.

I loved working in a skills development program as I believe learning preventative skills can have a huge impact on a child's life (Student 6).

(4) An understanding of inter-professional collaboration as a means to most effectively meet the communication and learning needs of children in the school setting. Inter-professional learning for students is best facilitated in context (Copley, Allison, Hill, Moran, Tait, & Day, 2007), and opportunities for shared learning within the school setting were valued by students.

Working together with OT [occupational therapy] students helped to give me an appreciation of other aspects of ability and disability that I previously had no or little knowledge of and how these can impact learning (Student 7).

The lead article by Wylie et al. (2013) challenges readers to consider agents of change and the levels at which change may occur: macro, meso, or micro change (Price, 2009). While the examples above illuminate change at the micro level, it is important to emphasize the interdependence of micro and meso level changes in order for new models of service provision to be effective and sustainable. Adequate resourcing and tangible commitment at the organization level is required for ongoing development and delivery of services and evaluation of outcomes.

Conclusion

Wylie et al. (2013) introduced discussion and debate on the implications of the World Report on Disability for responding to communication disability. This provided the impetus for us to reflect on lessons learned from an inter-professional student clinic which offers a new model of service delivery for Aboriginal and Torres Strait Islander children with learning and communication disability. Key issues to emerge are the significance of seeking solutions by engaging with the Aboriginal and Torres Strait Islander school; and the importance of students being with experienced educators and teachers who understand both cultural and disability issues. We found that an inter-professional clinic demands both flexibility and collaborative planning, and also provides opportunities for the development of skills in cultural safety. The next challenge is to ensure sustainability of services and the development and evaluation of models of service provision that can enhance outcomes for those with communication disability. Future research is required to determine if students’ experiential learning translates into increased human resource capacity for currently under-served populations. Response to the World Report on Disability demands ongoing action and attention to models of service delivery and student education.

Notes

(1) The accepted definition of an Australian Aboriginal person is social more than racial. An Aboriginal person is defined as a person who is a descendant of an Indigenous inhabitant of Australia, identifies as an Aboriginal person, and is recognized as Aboriginal by members of the community in which she or he lives (Jonas & Langton, 1994). A Torres Strait Islander person is a descendant of an Indigenous inhabitant of the Torres Strait Islands (Queensland Government, 1991).

(2) Murri is a term used by Aboriginal people from Queensland and parts of Northern New South Wales to identify where they come from (NSW Department of Community Services). The Brisbane Aboriginal and Torres Strait Islander Independent Community School is also known as The Murri School.

Acknowledgements

The authors wish to acknowledge the staff and students of the Murri School for their ongoing partnership with the occupational therapy and speech-language pathology services.

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