The World Report on Disability: An impetus to reconceptualize services for people with communication disability

Abstract

Challenges to the conceptualization and delivery of services for people with communication disabilities (PWCD) have been described in the lead article in this issue, which was itself a response to the World Report on Disability. A number of commentaries followed the lead article, where authors from around the world responded to the lead article (), and the World Report on Disability. This paper synthesizes the issues, ideas, and challenges raised in the preceding commentaries. This has been done by addressing each of the four key issues posed in the lead article. A number of proposals for better responding to the needs of PWCD are outlined. These include: engaging with the collection of epidemiological data, consideration of which PWCD are under-served and how this may be changed, the use of documentation, adoption of new roles and strategies for speech-language pathologists, the challenges of community-directed vs individually-focused approaches, and the suggestion of public health communication disability workers and mid-tier workers, who could work alongside more traditional speech-language pathologists.

Keywords::

• World Report on Disability
• World Health Organization
• people with communication disability
• under-served
• equity
• service delivery
• mid-tier workers
• community-based rehabilitation
• public health communication disability professional
• speech-language pathology
• ICF

Introduction

The lead article (Wylie, McAllister, Davidson, & Marshall, 2013) invited commentary and debate in response to the World Report on Disability (World Health Organization and the World Bank, 2011) and its implications for people with communication disability (PWCD). In particular, we opened discussion on the need for changes within the speech-language pathology profession in responding to under-served populations. Thus, in the lead article we sought to critique current approaches to service delivery for PWCD, arguing that speech-language pathology has not embraced the opportunities inherent in the bio-psychosocial perspective of the International Classification of Functioning, Disability and Health (ICF, World Health Organization, 2001), and in many ways has remained grounded in a medical model, taking a therapist- to-client model of service delivery. We called for new approaches to service delivery that would be responsive to the needs of under-served PWCD in both Minority and Majority World contexts, and would engage drivers of change to improve policies, services, and practices, and promote equity. We also cautioned against unquestioned importation of models of service delivery from Minority World to Majority World countries, suggesting these may not be culturally appropriate, fail to address population level needs, or not support participation in society. Further, we suggested that developments in services and speech-language pathology education in Majority World countries could inform improved and far-reaching models of service delivery in the Minority World, which would better address the needs of under-served populations and individuals with communication disability.

In the lead article we posed four key questions for consideration (Wylie et al., 2013, p. 2):

(1) Of the estimated one billion people with disabilities, how many have a communication disability?

(2) Where are the gaps in speech-language pathology service provision?

(3) How do we ensure that population level needs for people's communication and swallowing receive adequate public attention?

(4) How can the speech-language pathology profession be responsive to the needs of under-served PWCD, in ways that will influence change to improve policies, services, and practices, and promote equity?

The commentary that has ensued from the invited contributions is both diverse and challenging. Responses came from authors in the US, South America, UK, Africa, Asia, and Australia, writing about their work in their own country or development activities undertaken in other countries, to build capacity and capability in services for PWCD. Some authors used the structure of the lead article to frame their response; others aligned their work to the recommendations of the World Report on Disability; yet others took radically different approaches to addressing the questions at the heart of the lead article. Ongoing debate is needed and inevitable if change is to occur. We now attempt to synthesize the key themes from the contributed papers in relation to the four key questions we posed, and link these to core concepts in our lead article. We conclude with proposals for how speech-language pathology might rise to the challenge to more equitably respond to the needs of PWCD.

Epidemiology

The World Report on Disability (World Health Organization and the World Bank, 2011) presents a valuable compilation of both qualitative and quantitative data, perspectives, and directions on disability across the globe. As noted in the lead article, however, data on PWCD is under-represented. The issue of relevance and means of obtaining epidemiological data on communication disability elicited a range of views. Wickenden (2013) argues that, rather than focusing energies on identification and measurement, we should direct attention to participating in policy and practice improvement at a wider disability level. Conversely, Goldbart and Sen (2013) support the value of epidemiological data as a platform for awareness raising and policy development around service provision, and provided examples of how questions about communication disability have been refined and re-positioned in the Indian National Census to obtain better quality and more useful data, offering an example of disability and epidemiology collaboration. Roulstone and Harding (2013) noted data are needed for both Minority and Majority World countries, but discussed challenges in measurement, including varying social constructs of disability. Buell (2013), writing about her work in Bolivia, reflects on grass roots approaches to data collection such as participatory rural appraisal and key informant methods as a more sustainable approach to measurement and establishment of services.

There are many approaches which speech- language pathologists (SLPs) could use to engage with the processes of communication disability epidemiology, including collaboration with existing public health bodies and raising awareness of communication and participation in multi-sectorial research programs. We are not suggesting that SLPs go out alone and measure rates of communication disability in populations. SLPs have knowledge to assist statisticians, epidemiologists, disability organizations, and governments to engage in research that establishes rates and the impact of communication disability. We can raise awareness and seek funding to enable such research to be undertaken. We can keep informed about international developments in measurement in this area. We can publish information about the impact that communication disability has on individuals, families, and communities. We can engage with economists and politicians. We can become activists. We can do this as individuals, organizations, and professional groups, and hence work at micro-, meso-, and macro-levels. Collection of useful epidemiological data requires multidisciplinary and multi-sectorial engagement.

We argue that, despite resource and methodological issues, there is no doubt that ultimately knowing even more about communication disability, its impact, rates, and perceived needs in varying contexts is likely to assist in driving change to produce improvements in services and service delivery. Epidemiological and impact data (in terms of health, social, and economic costs) have proved critical in the development of population level health services such as breast screening and diabetes management (Australian Institute of Health and Welfare, 1997). More studies like the Early Language in Victoria Study (ELVS) (Reilly, Bavin, Bretherton, Conway, Eadie, Cini, et al., 2009) are required in the field of communication disability. Later in this paper we will argue for population health approaches regarding communication disability.

Under-served populations of PWCD

The majority of contributors highlighted the lack of services, gaps in services, or under-served populations within the communities discussed in their papers. Authors writing about the development of speech-language pathology university programs in Majority World countries (see Ahmad, Ibrahim, Othman, & Vong, 2013; Atherton, Nguyn, & Võ, 2013; Barrett & Marshall, 2013; Crowley, Baigorri, Ntim, Bukari, Oseibagyina, Kitcher, et al., 2013; Topouzkhanian & Mijiyawa, 2013) refer to the lack of services and the numbers of under-served PWCD as drivers for these educational developments. In writing about speech-language pathology service development and delivery issues from a range of countries including Australia, Bolivia, Brazil, China, India, Malaysia, South Africa, the United Arab Emirates, the UK, and the US, contributors highlight under-served populations in those countries and outline philosophical, cultural, political, and practical frameworks for identifying, engaging with, and meeting the needs of these populations (see Buell, 2013; Cheng, 2013; Davidson, Hill, & Nelson, 2013; Goldbart & Sen, 2013; Jones, Marshall, Lawthom, & Read, 2013; Kathard & Pillay, 2013; Roulstone & Harding, 2013; Van Dort, Coyle, Wilson, & Ibrahim, 2013; Westby, 2013).

Davidson et al. (2013), Lowell (2013), and Westby (2013) all write on developing culturally appropriate and relevant services for Indigenous populations in Minority World countries. Westby (2013) describes the PRECEED-PROCEED model (Green & Kreuter, 2004) as a useful framework that may be applied to communication disability programs for intervening at both the community and individual level, and for working across cultures. Such an approach is a highly relevant example of community-directed intervention and a change from the traditional individualistic models of SLPs’ practice. Lowell (2013) extends this approach by calling for the Indigenous community to be placed at the centre of defining needs, determining appropriate approaches and operating services. Davidson et al. (2013) illustrate lessons in dialogue, collaboration, and development of cultural competency through situating a multidisciplinary student clinic within an Indigenous community school. Lowell (2013) identifies levels of disenfranchisement by writing about the needs of migrant workers in both Minority and Majority World countries, an arguably even more invisible and under-served group than other PWCD in the same country.

While there is agreement amongst contributors that some PWCD and some communities are under-served, Roulstone and Harding (2013) reflect on the meaning of under-served. The lead article (Wylie et al., 2013) identified a number of ways in which communities might be under-served in terms of lack of services or inability to access services. Stakeholders and communities may not agree on who is under-served (e.g., families who SLPs see as hard-to-reach or non-engaging may not perceive a problem for which they need speech-language pathology services). Roulstone and Harding (2013) explore how the notion of social capital might be used to better understand who is under-served and in what ways. This construct can also inform discussions about how SLPs can best work to address the needs of under-served PWCD.

A number of the contributions provided examples of knowledge transfer and exchange between Minority and Majority World countries, or more developed services to less developed services, as examples of strategies to meet the needs of under-served PWCD (see Cheng, 2013; Crowley et al., 2013; Goldbart & Sen, 2013; Worrall, Howe, O’Callaghan, Hill, Rose, Wallace, et al., 2013). Contributors advocate for increased input on communication disability within the training of other disciplines (see Goldbart & Sen, 2013; Worrall et al., 2013) to build knowledge and skills in responding to PWCD. Buell (2013) adds to this theme by raising a need to assist in building grassroots capacity of PWCD to create supportive networks, advocate for services, and educate their communities to overcome attitudinal barriers experienced by PWCD. Van Dort et al. (2013) illustrate knowledge exchange with parents, teachers, and volunteers in a community-directed early intervention service in Kuala Lumpur. Their project aimed to shift early intervention from largely inaccessible medical model services to a community-based service, focusing on capacity building and information sharing.

We, as authors, are cautious about uncritical and uni-directional transfer of knowledge from Minority to Majority World countries, or from dominant cultural groups to minority groups within a country. This sentiment is expressed effectively by Buell (2013), who discusses the inability and inappropriateness of attempts to reproduce services and models of intervention from one region to another, in the presence of vastly different context, culture, language, and disability perceptions.

The topics in this following section relate to both questions 3 and 4: Question 3 “How do we ensure that population level needs for people's communication and swallowing receive adequate public attention?” and Question 4 “How can the speech-language pathology profession be responsive to the needs of under-served PWCD, in ways which will influence change to improve policies, services and practices, and promote equity?”.

Meeting population level needs and the needs of under-served PWCD

A synthesis of the key themes in the contributed papers leads us to suggest a number of ways in which the speech-language pathology profession could respond differently to the needs of PWCD. Authors of several contributed papers agree that there are a number of powerful documents which SLPs can use to effectively engage on broad disability issues and advance the provision of services for PWCD. In the lead article, we highlighted the potential of the World Report on Disability as one such document to guide directions for change. Wickenden (2013) contends that the Convention on the Rights of Persons with Disabilities (CRPD) (United Nations, 2006), Community Based Rehabilitation Guidelines (World Health Organization, 2010) and the ICF (WHO, 2001) are a trio of more influential documents which will ultimately advance the provision of models and services. Wickenden's assertion that the ICF (WHO, 2001) is a powerful tool for advancing services contrasts with the views of Kathard and Pillay (2013), who feel that the ICF lacks political influence because it conveys a limited view of rehabilitation needs, focuses on individuals not groups or communities, and does not address the “poverty, abuse, exploitation and oppression which are the lived realities of PWD” (p. 86). Perhaps the key dilemma here is whether disability should be managed at an individual or a community level. This is a crucial area if we are to consider how the future could look for services for PWCD.

Kathard and Pillay (2013) and Wickenden (2013) argue for a human rights approach to meet the needs of PWCD, with Kathard and Pillay emphasizing the need to address traditional power inequities at the national and political levels rather than at an individual level. Wickenden (2013) believes it is the UNCRPD which ultimately will advance services for PWCD because, as countries ratify the Convention, they become obliged to implement strategies to achieve and monitor its goals. In addition, Wickenden promotes the revised community-based rehabilitation (CBR) guidelines (WHO, 2010) as a potentially powerful tool in addressing the needs of PWCD (indeed all PWD) because of its focus on inclusive community development, direct involvement of PWD in decision-making, and a foregrounding of empowerment as a targeted domain for development. Wickenden (2013) argues that CBR is “now seen as a natural vehicle for the implementation of the UNCRPD and therefore as essentially espousing and driven by a Human Rights approach” (p. 16).

A number of the contributed papers, including Buell (2013), Roulstone and Harding (2013), Lowell (2013), Kathard and Pillay (2013), and Wickenden (2013), suggest ways in which SLPs could become more responsive to the needs of PWCD through increased roles in advocacy and in empowering others through the sharing of knowledge and skills, particularly to grassroots and consumer groups (see Buell, 2013), thus promoting autonomy. Roulstone and Harding (2013) provide an important perspective on empowerment for PWCD in raising the notion of capital. Having or not having economic, social, or cultural capital could inform understanding of why services for PWCD are not provided, accessible, or utilized when available. An appreciation of capital could assist SLPs to strategically advocate, improve service accessibility, and empower PWCD and their communities to shape services relevant to their needs. This notion of building capital is implicit in the work of Worrall et al. (2013) in their international (macro) and national (meso) level work with and on behalf of people with aphasia. A focus on capital and self-determination might also help alleviate the concerns of Kathard and Pillay (2013, p. 86) who state “We must be vigilant that in our attempts to advocate for PWCD, professionals do not usurp their power creating a new form of dominance via so-called advocacy and empowerment”.

A number of authors (see Goldbart & Sen, 2013; Kathard, 2013; Pillay, 2013; Wickenden, 2013) have provided examples of lobbying and political activism as mechanisms to improve information about, or services for, communication disability. A further example of the effectiveness of political lobbying includes the Bercow Review (Bercow, 2008), examining needs for children in the UK with speech, language, and communication difficulties, and the subsequent government policy shifts (Department of Health (UK), 2008). Speech Pathology Australia is lobbying the government to establish an inquiry into the social and economic impact of communication disability in Australia (Speech Pathology Australia, 2011).

Individual or community level engagement?

The use of strategies such as awareness raising, lobbying, political activism, and strategic use of documents are determined by whether SLPs work at a community or individual level.

Further distinctions between an individual focus and community direction are given in Table I. We would consider activities completed with a focus on a particular PWCD would be individually-focused (e.g., training identified communication partners), whereas work completed for the benefit of improving conditions for PWCD in the community generally or preventing communication disability and its sequelae would be community-directed.

Table I. Examples of activity with an individual focus or a community direction.

Examples of individually-focused activities (with a particular individual with communication disability)	Examples of community-directed activities (with and on behalf of a range of PWCD)
• 1:1 or group therapy, working at ICF impairment, participation, or activity levels.	• Assisting PWCD to establish or maintain consumer groups for self-determination.
• Functional communication therapy—including community education (i.e., TBI).	• Raising awareness of communication disability, its impacts in the community, and promoting the inclusion of PWCD.
• Training conversational partners with a specific individual with communication disability.	• Obtaining funding for research on communication disability or its impact.
• Advocating on behalf of an individual.	• Primary prevention of communication disability, including communication health promotion. For example, universal interventions that sensitize/teach parents about the importance of early play for language development, teaching trainee teachers about vocal hygiene.
	• Universal training on communication disability and interaction strategies for community-based groups.
	• Improving communication environments, i.e., environmental modifications, such as increasing picture based signs in healthcare or retail environments for people with comprehension difficulties, establishing telephone relay services for PWCD.
	• Assisting PWCD with lobbying for policy change and inclusion of PWCD on political agendas.

ICF, International classification of functioning, disability and health; PWCD, people with communication disability; TBI, traumatic brain injury.

Operating at a broader community-directed level is necessary if SLPs are to address communication disability holistically. The following three issues are relevant here:

(1) If SLPs are to intervene using a bio- psychosocial model of disability, the societal aspects of communication disability (i.e., that disability may be created, at least in part, by the nature and expectations of the community in which the individual resides) must be addressed.

(2) A commitment to equity for all PWCD cannot assume that all PWCD will access traditional services. We know that people with less social capital, including families from lower socio-economic groups or Indigenous people, may not access or may actively reject traditional or mainstream services. Community-directed interventions may be more accessible, and indeed more desirable, than traditional medical-model or individual-focused services, and assist in improving equity for such populations.

(3) Some communication disabilities and the impacts of communication disability may be prevented or minimized (e.g., through newborn hearing screening, infection control, smoking cessation). Primary prevention is required within communities to prevent communication disability where possible (primary prevention) and minimize the impact of the disability and its sequelae (secondary prevention). In the UK, the Every Child Matters policy shifts now require services for children across universal, targeted, and specialist levels (see Box I) (Gascoigne, 2006, 2008). We contend that communication disability services should also span this spectrum.

Box I. Universal, targeted, and specialist serviced defined.

Universal services target whole populations and are designed to promote positive functioning and reduce the risk of specific conditions developing.

Targeted services are available to selected groups or individuals who are seen to be at risk of developing a particular health or developmental condition, and aim to reduce the risk of the condition developing.

Treatment/Specialist services are available to individuals or families who have an established condition and aim to minimize the negative impact of the condition or problem.

Adapted from: Moore, T. G. (2008). Rethinking universal and targeted services. CCCH Working Paper 2. Parkville, Victoria: Centre for Community Child Health.

Traditional speech-language pathology services operate with a focus on service to individuals. While client-centred care has its place, traditional intervention is insufficient in responding to communication disability in community and global contexts. The individually-focused approach assumes PWCD will seek and receive services equitably. The contributed papers in this issue have highlighted that inequity exists across the countries and contexts represented. An individually-focused approach fails sectors of the community who are under-served, as the priority is on managing those individuals who make it onto speech-language pathology caseloads. It is acknowledged that it may be difficult for SLPs working in a traditional model to re-orient themselves to community-based activities in a substantial and systematic way if the nature of their roles dictates an individual orientation, including structural, reporting, or funding mechanisms. Thus, a new orientation is required. Community-directed intervention holds dual meaning: services may be directed by the community (by people with disabilities themselves in keeping with their cultural priorities); and/or services are directed towards the community (as opposed to the individual) and, thus, are community-centred. Community-directed services demand both a population-based response and a paradigm shift to foregrounding the voice of people with communication disability.

New questions

Should SLPs be concerned with the prevention of communication disability, minimizing impacts, and ensuring equity of clinical service provision for all sectors of a community? If the answer is affirmative then SLPs have a mandate to engage in community-directed approaches. How can this change be achieved? Do SLPs:

(1) Leave community-directed approaches to the (relatively few) SLPs who have workplaces that can accommodate significant amounts of community activity and do not focus largely on individual occasions of service?

(2) Leave community-based activities to speech-language pathology associations, other organizations, or grass roots groups?

(3) Attempt to accommodate community- directed activities around traditionally core (i.e., individually-focused) work?

(4) Assume community-directed intervention is done by someone else?

(5) Or should community-directed practice reflect another intervention stream for communication disability altogether, with particular sub-sets of skills which may not be held by traditionally trained SLPs?

Broad policy shifts in disability provide an opportunity for role re-design which can cut across traditional professional and sector boundaries (Gascoigne, 2006). Over previous decades, the role of SLPs has expanded and evolved. In as much as the profession grew out of the needs of particular client groups in particular historical contexts (such as adult rehabilitation for repatriation of injured soldiers; communication and education for deaf children after the rubella epidemic), Speech-language pathology is part of new shifts in globalization, policy changes, burgeoning demand for services, and awareness of inequities in services. Speech-language pathology again needs to re-invent itself and expand both scope of practice and models of communication service delivery. As part of this re-invention we offer two roles which could assist SLPs to address both community and individual level need.

Public health communication disability professional

Fully adopting the ICF and the biopsychosocial model on which it is based would require SLPs in both Minority and Majority World countries to work across both an individual impairment-focused level and embrace a social model of disability, which focuses on the full participation of PWCD in whole communities. Additionally, population demands would require SLPs to respond to community needs, engage in activism, and work to reduce the risk and impact of communication disability. Are SLPs in Minority World countries able to make this significant shift in practice, both philosophically and practically? Are they trained to effectively engage in evaluation, population level interventions, awareness raising, lobbying, training, and empowering others? Are the philosophical foundations of their degrees congruent with this approach to practice? The answer to these questions is probably no; speech-language pathology education programs in Minority World countries tend not to prioritize these areas. While content may be included on health promotion and educating others, the demands for placement hours to satisfy accreditation boards and professional associations may preclude educational experience in a broader scope of practice.

The paper by Barrett and Marshall (2013) is important as it describes a university speech- language pathology degree program in Uganda that aims to prepare graduates to work in both community and individual contexts. Community-directed skills are also targeted in the speech-language pathology program in Sri Lanka (Wickenden, 2012). Whilst such models have yet to be evaluated in terms of their outcomes, particularly in economic and social structures that support a fee-for-service or individually-focused way of working, it offers an alternative approach. Minority country universities may have much to learn from such Majority World initiatives; such knowledge transfer could usefully inform a re-visioning of education of SLPs for a broader scope of practice.

Practically, the challenges of SLPs working across both individual and community models of intervention may be considerable. Few current work settings can accommodate SLPs working in both individually-focused and community-directed ways. To address community-based population health needs of PWCD, we propose that at least one new breed of professional to work in the field of communication disability is needed: a public health communication disability professional. Such a professional would have skills in population health, community development, health promotion, public health planning and evaluation, advocacy and lobbying skills, as well as communication and swallowing theory and practice skills. Such a diverse range of skills typically is not developed in mainstream speech-language pathology graduates. A public health communication disability professional would work with communities to prevent and minimize impacts of communication disability across populations.

To illustrate this distinction between a traditional speech-language pathologist and a public health communication disability professional, we offer the analogy of the case of two related but distinct occupations: public health nutritionists and clinical dieticians. Certified practicing dieticians work clinically to assess the nutrition of individuals, plan appropriate dietary strategies, and educate patients and their families about dietary change (Nutrition Australia, 2011). Public health nutritionists focus on nutritional issues impacting whole populations rather than the specific needs of individuals. The emphasis is on promoting health and disease prevention. Public health nutritionists have specialist skills in program planning, implementation, evaluation, and policy development to help improve the health of populations (Nutrition Australia, 2011). In the Majority World context non-government organizations frequently engage with public health nutritionists to plan and evaluate programs with a nutritional basis for the benefit of whole communities.

It is timely for speech-language pathology to consider that there may be a role, particularly in under-served communities, for a public health communication professional—with a specialist skill set designed for working within communities, promoting communicatively healthy families and communities, creating opportunities specifically for PWCD to engage more effectively within their communities in a variety of roles. It may be argued that, with adequate training, this is a role for CBR workers and could occur in both Majority and Minority World countries.

The guidelines for CBR (WHO, 2010) provide for both an individual and community approach which addresses a sub-set of the issues above, yet we question if a generic CBR worker would have the skill set required to operate such focused programs and projects as we envisage. Is this role one that requires formal training and process? Ultimately as education programs and CBR systems evolve, a well-developed model for community-focused communication disability intervention, including primary prevention, may emerge from the Majority World. Further extensive debate is required about how to best meet the community level needs for communication disability, across both Minority and Majority Worlds.

Mid-tier communication workers

Whichever path is taken in regard to communities, the demand for speech-language pathology clinical services appears to be insatiable in the Minority World. Figures such as waiting lists for speech- language pathology services reaching 18 months (Parliament of Western Australia, 2010) are common, despite an increasing number of speech- language pathology graduates. Further consideration of innovative models which could meet increasing demand for individually-focused interventions is urgently required.

Several papers in this edition have described knowledge exchange programs between SLPs and colleagues designed to empower non-SLPs to support PWCD in under-served groups (see Crowley et al., 2013; Worrall et al., 2013). Such papers illustrate evolution to the development of mid-tier workers (World Health Organization and the World Bank, 2011) in order to expand the reach of speech- language pathology services. Such informal training initiatives would be generally well supported amongst the speech-language pathology community, and in many sectors speech-language pathology assistants are achieving more recognition (American Speech-Language-Hearing Association, 2004). However, more formalized training of mid-tier workers such as speech-language pathology assistants has met resistance, in large part due to turf wars (Threats, 2009) and concerns about quality of services. We acknowledge that the vision of mid-tier workers is controversial. Fernandes and Behlau (2013) argue that this approach is not fair to PWCD, does not address the complexity of need or specialization required, and may in fact be no more cost effective than providing sufficient numbers of SLPs to provide speech- language pathology services.

Mid-tier workers in other fields (such as medicine and nursing) are becoming more accepted and autonomous globally, particularly in the areas of workforce shortage, and are proving cost and quality effective (MacLachlan, Mannan, & McAuliffe, 2011). Mid-tier communication disability workers perhaps with more autonomy and training than previously conceptualized when considering speech-language pathology assistants—may eventually form part of the solution. If the speech-language pathology profession is to address population demand for rehabilitation of PWCD equitably then a trained mid-level worker could work in a complementary way to both the individual and community-based models we propose.

We suggest, therefore, to meet the needs of whole communities, new breeds of professionals to work in the field of communication disability are needed: a public health communication disability worker and a mid-tier worker educated in a rehabilitation approach, to work alongside a more traditional speech-language pathologist. These paradigm breaking ideas require further conceptualization, debate, research, and evaluation. Yet, consideration of such issues and ideas may assist in visioning a way forward for the profession to promote equity.

Conclusion

The release of the World Report on Disability and its recommendations proved an impetus for a review of the needs of PWCD throughout the world. In the lead article, we initiated discussion on implications of the World Report on Disability in responding to communication disability in under-served populations. The responses embedded in the commentaries have provided an exceptional breadth and depth of thought on equity of services for PWCD and contemporary issues in speech-language pathology. Respondents have stimulated new questions and ensured the debate will continue.

In the lead article (Wylie et al., 2013) we suggested that a population level approach may be one way to meet the needs of under-served PWCD and may inform a revisioning of education of SLPs or associated professions for a broader scope of practice. Issues raised in the commentaries, from both Majority and Minority World countries, have challenged readers to take a global view and to be open to new directions in SLPs’ practice. As stated by Wickenden (2013, p. 14), “SLPs need to broaden their focus to consider wider aspects of the disability arena”. We have also proposed that, in seeking creative and sustainable ways to respond to the needs of children and adults with communication disability, new breeds of professionals be considered: a public health communication disability worker and a mid-tier worker educated in a rehabilitation approach, alongside a more traditional speech-language pathologist.

A range of drivers including philosophical and educational changes, economic climates, government reform, and global developments are likely to shape changes in how services are operated in coming decades. The profession of speech-language pathology has the opportunity to engage across micro-, meso-, and macro-levels to ensure under-served people with communication disability are heard. A challenge exists to re-evaluate our speech-language pathology scope of practice; to move beyond a traditional therapy model; to reorient to community-directed services; to foster new types of workers in communication disability, and to embrace a public health role in responding to the needs of all people with communication disability. How revisions to the speech-language pathology scope of practice, structures, and workers will interface should be the subject of ongoing discussion within our profession, but there is an imperative to engage in real change if SLPs are to be part of the solution and not part of the problem in better meeting the needs of PWCD.

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