Professional Documents
Culture Documents
Research Report
Investigation of practices to support the complex communication needs
of children with hearing impairment and cerebral palsy in a rural district of
Kenya: a case series
Karen Bunning, Joseph K. Gona, Susan Buell, Charles R. Newton and Sally Hartley
School of Allied Health Professions, Faculty of Medicine & Health, University of East Anglia, Norwich, UK
Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute, Kilifi, Kenya
Neuroscience Unit, Institute of Child Health, University College London, London, UK
Department of Psychiatry, University of Oxford, Oxford, UK
Faculty of Health Sciences, University of Sydney, Sydney, NSW, Australia
(Received January 2013; accepted June 2013)
Abstract
Background: Rehabilitation services are scarce in low-income countries, where under-representation of some
specialist professions has led to the role extension of others. An example of this can be found in Kilifi in Kenya
where the role of speech and language therapy has been taken on by occupational therapists and teachers.
Aims: To investigate the communication practices used by these professional groups to support children with
complex communication needs in a rural part of Kenya and to explore the ways in which this might be seen to
facilitate or obstruct improved communication by asking the following questions: What are the critical features
of interactional discourse in practitionerchild dyads with caregiverchild dyads providing a natural comparison?
What communicative modalities and practice techniques are invoked? And how does this information relate to
extending professional roles?
Methods & Procedures: An in-depth, descriptive study of a case series was conducted in a school for deaf children
and the occupational therapy department of a district general hospital. A mixed methodology was used involving
naturalistic observation and applied linguistics analysis. A convenience sample was established comprising six
practitionerchild dyads assigned to partnership types: (A) three children with hearing impairment and their
teachers; and (B) three children with cerebral palsy and their occupational therapists. As a natural comparator, the
same three children in B were also observed with their mothers (partnership type C). Dyadic interaction was video
recorded on three occasions. The video data were sampled, transcribed into standard orthography and translated.
Codes were applied to determine turn structure, linguistic move types and communicative modalities. Sequential
analysis was conducted on the move types.
Outcomes & Results: Partnership type A dyads showed a fairly even turn distribution between teacher and child.
A common pattern was teacher-initiated Instruct and Model/Prompt, followed by child response in the form of an
Action. The most frequently used modality was Sound Production and Hands-on-Articulators, which corresponded
to articulation drill practice. Partnership type B dyads revealed a tendency towards adult domination of turns.
The majority of adult-initiated moves required no response from the child. The practice technique Hands-on-
Articulators involved manipulating the oral musculature of the child. Partnership type C dyads showed resonances
of type B dyads, although focused more on Motor-Action in relation to task performance.
Conclusions & Implications: The assignment of speech and language therapy duties to teachers and occupational
therapists has resulted in suboptimal practice for children with complex communication needs.
Address correspondence to: Karen Bunning, School of Allied Health Professions, Faculty of Medicine & Health, University of East Anglia,
Norwich NR4 7TJ, UK; e-mail: k.bunning@uea.ac.uk
International Journal of Language & Communication Disorders
ISSN 1368-2822 print/ISSN 1460-6984 online C 2013 Royal College of Speech and Language Therapists
DOI: 10.1111/1460-6984.12042
690 Karen Bunning et al.
Children were drawn out of the classrooms for individ- The two occupational therapists had received no spe-
ual sessions of approximately 10-min duration in one of cific training in speech, language and communication,
the allocated rooms, twice weekly. In line with all educa- but had followed an interest in children presenting with
tional provision in Kenya, Spoken English was the pre- communication needs in their department. Both teach-
ferred language for the childrens education, which in- ers of the deaf had received training in audiology, hearing
cluded speech therapy. This was against a background aid management, Kenyan Sign Language, phonetics and
of the local languages used by families and communi- phonology.
ties being Giriama and Swahili. The second setting was
the occupational therapy department at Kilifi District
Hospital, where one day a week was dedicated to what Ethics
was termed speech work in the absence of a speech Ethical approval was given by the National Ethical Re-
and language therapy service. Their caseload comprised view Committee of Kenya and at the University of East
children aged 05 years with a variety of developmental Anglia in Norwich, UK. Informed consent was obtained
conditions. Children were usually seen individually in from all participants.
a small side room designated for this purpose. Ther-
apy was conducted in the language of the childs home,
which was usually Swahili or Giriama. In order to gain Methods
insights into natural communication taking place in
contrast to professional practice, it was decided to in- Data collection
clude the primary caregiver interacting with the child. Video recording was used to capture communication
A convenience sample was established comprising taking place in the nine communication dyads. For
three types of communication partnership: A, teachers partnership types A (teacherchild) and B (occupa-
of the deaf and children with hearing impairment; B, tional therapistchild), sessions designated specifically
occupational therapists and children with cerebral palsy; for communication support activities were targeted. For
and C, caregivers and children with cerebral palsy. The partnership type C (motherchild), video capture was
head of each of the two services nominated three chil- conducted during waiting time for an occupational ther-
dren who were currently in receipt of dedicated support. apy appointment. To accommodate individual variabil-
Departmental nomination and familiarity with the child ity across time, video capture for each dyad occurred on
were favoured over a more random sample because the three separate occasions in different weeks. By restricting
practitioners needed to feel confident about being ob- the temporal gaps between recording times, data stabil-
served in their work. The sample comprised six children, ity was considered more likely. The camera operators
three with hearing impairment and three with cerebral research status was known to persons present, but no
palsy; four service practitioners and three caregivers part was taken in the ongoing activity. The adult was
all mothers (a total of 13 participants). Table 1 displays asked to do what you usually do with the child and to
the characteristics of the adults. Table 2 presents sum- ignore the camera as far as possible. Filming followed
mary information on each child that was available at the usual amount of time allocated to the activity and
the time of recruitment. Three children were observed varied across partnerships accordingly. A typical speech
with teachers of the deaf. The remaining three children session in the school involved the teacher sitting with
were seen with the occupational therapists, and again the child, either at a desk or else on the floor. Using
with their mothers making nine partnerships in total. everyday objects or paper-based materials, the teachers
Practices to support communication needs in Kenya 693
Table 3. Distribution of turns across dyads in different
0 = No usable speech; 1 = a few words and sounds only; 2 = conversation about familiar things with help from the listenerfrequent failures in communication still occur; 3 = conversation about familiar things with little or no assistancesome
(see table 2)
Practitioner
failures in communication still occurs; 4 = discussion about new ideas as well as familiar thingsa few failures in communication still occur; and 5 = communication is adequate for purposeminimal discernible communication difficulties.
partnership types
OT1
OT2
OT2
T2
T2
T1
Partnership type A
T1 C1 T2 C2 T2 C3
Partnership type B
only child
OT1 C4 OT2 C5 OT2 C6
children
Mean 36 30.7 14.7 0.3 9 0.3
Range 2646 2043 1020 01 712 01
Partnership type C
difficultya
Areas of
3, 5, 6
M1 C4 M2 C5 M3 C6
1, 4
3
1
1
2
0
1
0
School for the Deaf
Data sampling
OT Department
As above
As above
Giriama; Swahili
Giriama; (a little
Chonyi; Swahili
Swahili
11;00
3;00
1;06
the case for the current study. The first 2 min of the ses-
sion were excluded to minimize any potential effects of
camera reactivity. One-minute-long segments were sam-
Female
Female
Male
Male
Male
Male
Sex
C3
C4
C5
C6
Lag 1: C1
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: T1
Initiation (I-)
I 40 76 15 9
ICE 10 22 78
MP 30 100
A 10 100
Q 10 25 25 25 25
SSE 0
Lag 1: C2
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: T2
Initiation (I-)
I 15 19 81
ICE 3.5 34 66
MP 76 80 15 5
A 4.5 25 75
Q 1 100
SSE 0
Lag 1: C3
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: T3
Initiation (I-)
I 20 78 6 16
ICE 5 25 75
MP 60 90 5 5
A 2.5 100
Q 2.5 70 10 20
SSE 0
Note: sp = simple probability expressed as a percentage for a given move per session.
dyads M1/C5 and M2/C6 compared with all the other given in the curved brackets. Where Swahili is used a
dyads, with M2/C6 occupying no turns at all. translation is provided immediately afterwards in square
Across all partnership types, the moves at lag 0 were brackets.
adult initiations and the moves at lag 1 were child re-
sponses. Moves at lag 2 were seen mainly in partnership
Partnership type A
type A, and on two occasions by OT1/C4 (partnership
type B). Tables 46 display the dyad matrices according The mean number of two-event sequences in partner-
to partnership type for the two-event sequences (lag 0 ship type A dyads was generally high, showing little vari-
to lag 1). The column sp displays the simple probabili- ation and with minimal presence of follow-up moves at
ties signifying the likelihood of the given move at lag lag 2. For dyad T1/C1, the mean number of two-event
0 preceding any target moves during a session. Each sequences was 25.3, of which six response moves at lag
cell of the matrix shows the transitional probability for 1 were followed up at lag 2. Dyads T2/C2 and T2/C3
each possible pairing of adult to child (lag 0 to lag 1) involved the same teacher. For dyad T2/C2, the mean
move types, which indicates the probability of the tar- number of two-event sequences was 25, of which 1.3
get event occurring at lag 1 after the given event at moves were followed up at lag 2. For dyad T2/C3, the
lag 0. Excerpts of dyadic dialogue are provided as exam- mean number of two-event sequences was 28, of which
ples. Non-vocal turns and contextual information are 4.6 moves at lag 1 were followed up at lag 2.
696 Karen Bunning et al.
Table 5. Matrices of transitional probabilities for two-event sequences (expressed as a percentage) in partnership type B dyads where
the occupational therapist (OT) is at lag 0; the child (C) is at lag 1
Lag 1: C4
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: OT1
Initiation (I-)
I 20 7 30 3 56 4
ICE 10 6 6 82 6
MP 50 73 2 10 12 3
A 0
Q 20 29 13 25 8 25
SSE 0
Lag 1: C5
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: OT2
Initiation (I-)
I 28 5 86 9
ICE 28 1
MP 9 14 57.5 28.5
A 14 82 18
Q 0
SSE 20 6 94
Lag 1: C6
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: OT3
Initiation (I-)
I 10 100
ICE 40 100
MP 20 100
A 10 100
Q 10 100
SSE 10 100
Note: sp = simple probability expressed as a percentage for a given move per session.
As shown in table 4, the most common initiation In dyads T2/C2 and T2/C3, the given move I-MP
move in dyad T1/C1 was Instruct (I-I = 40%) and then had the highest probability of occurring in a session,
Model/Prompt (I-MP = 30%), which had the strongest with a transitional probability for the target move R-
likelihood of triggering a target response of Active (R- Act occurring at 80% and 90% of the time in each dyad.
Act) by C1. The first excerpt features T1 sitting behind Instruct moves (I-I) had a lower probability of occurrence
a desk with C1 seated to the side. They are looking at than for dyad T1/C1. In dyad T2/C2 there was a strong
each other during articulation drill work, which lasted association between the given Instruct move and No
on this occasion for 14 separate turns. Response Expected (NRE). In both dyads T2/C2 and
T2/C3, the given moves Alignment (I-A) and Query
1. T1 (turns head slightly away) ah (looks back at (I-Q), whilst having a lower chance of occurring in a
C1) ba session, were more likely to be associated with a target
2. C1 (makes vocal soundapproximating target of NRE.
with nasal quality) ba
3. T1 a-a-a (vowel sound is prolonged)
Partnership type B
4. C1 (makes vocal soundapproximating target)
a-a For dyad OT1/C4, the mean number of two-event se-
5. T1 ba-a-a quences was 42.7, of which less than 1 move at lag 1
Practices to support communication needs in Kenya 697
Table 6. Matrices showing transitional probabilities for two-event sequences (expressed as a percentage) in partnership type C dyads,
where the mother (M) is at lag 0; the child (C) is at lag 1
Lag 1: C4
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: M1
Initiation (I-)
I 75 5 36 5 40 14
ICE 14 9 18 73
MP 0
A 3.5 33 33 33
Q 6 20 20 20 40
SSE 2 50 50
Lag 1: C5
Response (R-)
sp A F Act R NR NRE SSE
Lag 0: M2
Initiation (I-)
I 41 93 7
ICE 21 79 21
MP 25 18 12 70
A 5 25 50 25
Q 0
SSE 8 100
Note: sp = simple probability expressed as a percentage for a given move per session.
was followed up at lag 2 per session. For dyads OT2/C5 Expected (NRE). Whilst Query (I-Q) had a similar rate
and OT2/C6 the mean number of two-event sequences of occurrence, C4 was more likely to respond with a
was much lower, 25.3 and 14.6 respectively. No moves target move of Acknowledgement (R-A), Reply (R-R) or
at lag 1 were followed up at lag 2. Action (R-Act).
As indicated in table 5, dyad OT1/C4 had the high- In dyad OT2/C5, I-MP constituted a majority of
est occurrence of Model/Prompt (I-MP) as a given move given moves with R-Act as the most likely transitional
with a strong association to Action (R-Act) by C4. This is move at lag 1. No Response Expected (NRE) was a
shown in excerpt 2, which opens with OT1 holding up a highly probable target response to the given initia-
small toy and saying frog in Swahili, which C4 attempts tions of Instruct (I-I) and Inform/Comment/Explain (I-
to copy. The pattern shows OT1 modelling the spoken ICE). Excerpt 3 shows OT2 giving an explanation of
word and C4 responding with her own approximation, her actions. She addresses C5 in Swahili whilst sitting
which ran to 12 turns on this occasion. on the floor with her hands placed around the childs
jaw and mouth.
1. OT2 hii ni nini [what is this?] (points to detail
on toy frog) 1. OT2 mmmmmmmm (moves hands either
2. C4 (places hand on OT1s outstretched fore- side of C5s jaws and mouth, making for a
arm) nimee (looks towards OT1) repeated openclose movement)
3. OT1 ah? (looks up to C4) 2. OT2 fanya hivi useme vizuri sawa? [do this to
4. C4 (continues to make attempts at speech talk well, ok?]
sounds)
5. OT1 ulimi [tongue] Dyad OT2/C6 revealed an apparently one-sided di-
6. C4 (continues to make attempts at speech alogue where given event I-ICE was most likely to oc-
sounds) cur, followed by Model/Prompt (I-MP), but with a 100%
7. OT1 ulimi [tongue] probability of transition to No Response Expected (NRE).
8. C4 eh bimu (upper limb movement accom-
panies speech efforts)
Partnership type C
The use of Instruct (I-I) had a lower rate of occur- The mean number of two-event sequences recorded
rence with about half being associated with No Response for dyads in partnership type C were M1/C4 = 28.3;
698 Karen Bunning et al.
Table 7. Summary of communicative modalities and practice techniques across partnership type dyads: mean scores per session
M2/C5 = 22.6 with no follow-up moves from lag 1 to used Swahili mainly. Speech Production acts were preva-
lag 2. No moves were recorded for dyad M3/C6, where lent in partnership type A dyads and in dyad OT1/C4
the mother engaged in extending and flexing the childs (partnership type B). Gesture was used mainly by the
limbs. teachers (T1 and T2) with a more balanced dyadic usage
As shown in table 6, there was a high probabil- in OT1/C4 (partnership type B.) The practice technique
ity of the mothers in dyads M1/C4 and M2/C5 using Hands-on-Articulators was used by all the practitioners.
the given Instruct (I-I) move. This was associated al- The mothers (partnership type C) spoke in Swahili
most evenly with No Response Expected (NRE) and Ac- with some support from Gesture. The small presence of
tion (R-Act) in dyad M1/C4, and mainly with NRE Gesture and Hands-on-Articulators in dyad M3/C6 did
as the target in dyad M2/C5. Model/Prompt (I-MP) not constitute interactional turns, but were representa-
as the next most likely given move, had a strong as- tive of small body behaviours.
sociation to NRE. The small presence of Query (I-Q)
as a given move was associated with Acknowledgement
(R-A), Action (R-Act) and Reply (R-R), although there Discussion
was a 40% probability of a No Response (NR). In dyad
Turns were distributed fairly evenly between the teach-
M2/C5 Self/Shared Expression (SSE) was a likely target
ers and pupils in Partnership A and dyad OT1/C4 in
move to the given I-MP particularly. NRE was majorly
Partnership B. The remaining dyads in Partnerships B
associated with the given moves of I-I, I-ICE and I-
and C revealed the dominant role of the adult. Initi-
MP. This is illustrated in excerpt 3 where C5 is standing
ating moves were used exclusively by the adults across
against a therapy roll, with his mother holding onto his
all the partnership types with the child as the respon-
shoulders whilst supporting the small of his back. The
dent. Follow-up moves at lag 2 in the form of Feedback
mother talks to her child as she adjusts his position.
and Reply were used mainly by the teachers in part-
nership type A, although not consistently. The teach-
1. M2 C5 haya shika chini [hold down] (adjusts ers variously favoured the Instruct and Model/Prompt
C5s clothes and also his position) moves, which were similarly used by the occupational
2. C5 (continues in position) therapist in dyad OT1/C4. In correspondence to the
3. M2 angalia chini. [look down] weka mikono adults in these dyads, the children mainly responded
chini [put hands down] (moves roll forward with Action moves. In OT2/C5 and OT2/C6, there
with child whilst holding onto the backs of was preferred use of Inform/Comment/Explain by the
his legs) occupational therapist with low levels of Action re-
4. C5 (continues in position) sponses being recorded for the children. Partnership
5. M2 haya angalia [okay look] (tips roll forwards) type C (caregiverchild) revealed higher Instruct and
6. C5 (continues in position) Inform/Comment/Explain moves by the adults, whereas
7. M2 shika chini. shika chini tena. [hold down. the children used more Self-Shared Expression. Com-
hold down again] (holds onto C5s legs) municative modalities and practice techniques revealed
reliance on speech generally amongst the adults across
all partnership types. Both Speech production and Hands-
Communicative modalities and practice techniques
on-Articulators featured in partnership types A and B.
Table 7 summarizes the communicative modality usage. The teachers execution of an instructional, speech
Partnership type A dyads employed English as the spoken training approach with the children produced pat-
medium during a session, whereas partnership type B terns that were resonant of the transmissional forms of
Practices to support communication needs in Kenya 699
teaching identified by Abd-Kadir and Hardman (2007) Pennington 2008, Pennington and McConachie 1999).
and Ackers and Hardman (2001). This may explain the This might explain how the recorded Acknowledgements
fairly even distribution of turns between adult and child emitted by C4 in response to Initiation-Query were not
playing out an initiation-response sequence. The inter- recognized by the occupational therapist (OT1). This
actional discourse in these dyads followed a recurring suggests inadequate knowledge and understanding of
sequence of Model/Prompt or Instruct to Action, similar communication development, in particular at the earli-
to the teacher-led recitation patterns found by Ponte- est stages, underpinned by a lack of specialist training
fract and Hardman (2005). The teachers limited use associated with the new responsibilities. In addition, the
of Feedback moves at lag 2, echoed findings reported given moves at lag 0, i.e. Inform/Comment/Explain or
by Hardman et al. (2009). It appears that the teaching Instruct were mainly rhetorical and required no response
frames of the classroom were imported into the therapy of the child, thereby indicating therapist control of the
session in Partnership type A. dyads. The similarities discourse, which affected a reduction in communication
seen in dyad OT1/C4 (partnership type B.) may have opportunities for the child similar to that observed by
been affected by the therapists personal experience and Abd-Kadir and Hardman (2007). Whether this was a bi-
cultural knowledge of the teachinglearning process as product of therapy that was about doing something to
summarized by Hardman and Abd-Kadir (2010). the child, e.g. manipulation of oral-musculature, which
A quite different theoretical orientation was in- was not conducive to two-way interaction, or a lack
dicated by the interactional discourse involving the of sensitivity to early, non speech communication be-
younger children (C5 and C6). Although the two-event haviours as described by Marfo et al. (1998) is debatable.
sequences were still adult-led, therapist initiation moves The similar control exerted by the mothers in part-
were linked to No Response Expected (NRE). This may nership type C raises the question of contextual influ-
be explained by the therapy activity of wiping ice blocks ences at work. Both partnership types C. and B. were
and warm cloths around the childs face, which effec- enacted in the hospital department where the mothers
tively cast the child in a passive role with the discourse were exposed to occupational therapy practice applied to
proceeding as a therapist-delivered commentary. The their children. What is notable is that the mothers relied
medical model in the hospital setting may have influ- more on Instruct moves and less on Model/Prompt, com-
enced the use of special techniques and equipment and pared with partnership type B dyads. This was borne
could be seen to support the dominance of the health out by the absence of the modalities/practice techniques
professional (Sherry 2010). No formal label was used of Speech Production, Oral-motor Practice and Hands-on-
by the occupational therapists to describe these activ- Articulators, although there was a greater concentration
ities; however, there appears to be parallels with two of Motor Responses from the child during physical exer-
particular intervention approaches. The first is a branch cises under the mothers instructions. However, Gesture
of proprioceptive neuromuscular facilitation, which is was used by both mother and child in dyads M1/C4
used by occupational therapists and physiotherapists to and M2/C5, which may reflect greater maternal sensi-
promote muscle flexibility. Called pseudo neuromuscu- tivity to a child who has difficulties in the area of speech.
lar facilitation, it was developed in the 1970s for the Alternatively, it could be that the mothers viewed ma-
treatment of acquired motor speech disorders (Langley nipulation and icing as a specialist activity requiring
and Darvill 1979) and involved applying ice to the neu- the particular expertise of the therapists. Of course it
ral pathways of the oral musculature. The second is a would most certainly have been the case that ice blocks
collection of exercises designed to increase strength, tone would not have been available at the homesteads.
and control of the oral musculature termed non-speech In addition to activity selection, the setting cul-
oral motor treatments (Powell 2008). Both approaches ture appears to have influenced the choice of language.
have been largely discredited due to a lack of evidence Speech was the dominant communication modality
supporting their efficacy (Ruscello 2008). used by adults across all the partnerships, consistent with
In addition to the underlying pedagogies of prac- its valued status in educational discourse (Abd-Kadir
tice, factors concerning the childs age, condition and and Hardman 2007) and the oral traditions associated
developmental stage may have influenced the discourse with African culture (Hartley et al. 1998). English as
structure. The dyads OT2/C5 and OT2/C6 (partner- the language of education also featured in the schools
ship type B.) featured younger children, for whom the therapy sessions (Pontefract and Hardman 2005). As the
early stage communication behaviours seen in typically school was residential the children were effectively de-
developing children were compromised by the primary nied development opportunities in their mother tongue.
condition of cerebral palsy. This affected their motor In addition, the school for the deaf followed an oral ap-
skills for verbal and non-verbal representations of mean- proach to communication, which likely governed the
ing (Pennington 2008). Thus the likelihood of the adults goal of speech production. In contrast, the language of
overlooking small or idiosyncratic, seemingly insignifi- the childs home was used in the occupational therapy
cant behaviours was a possibility (Bunning et al. 2013, department, which indirectly acknowledged the role
700 Karen Bunning et al.
of the home and the family in supporting the childs the observational methodology meant that practitioner
development. Typical practice with children with de- confidence outweighed such considerations. During the
velopmental disorders affecting communication would study period it was noted that one of the occupational
usually involve some combination of augmentative therapists changed her practice by ceasing the use
and alternative communication strategies (Pennington of icing and related techniques with the particular
2008); however, partnership types A and B were charac- participant, but was informally observed to continue
terized by speech sound production and manipulation their use at other times. Capacity-building workshops
of the oral musculature. carried out as part of the large scale project may have
The extent to which the practitioners were prepared influenced the therapist in question to try out new
for the additional responsibilities associated with the practices or to conceal usual practice due to raised
missing profession, i.e. speech and language therapy, awareness. Inclusion of motherchild interaction was
must be questioned. Training in phonetics, phonology originally planned as an informal comparator to the
and associated therapy techniques has likely influenced practice in partnership types A and B. Video capture
the teachers use of multi-sensory techniques for mod- during attendance of the occupational therapy depart-
elling sound production targets, which is resonant of ment was not ideal and likely influenced the choice of
practice described by Beazley et al. (2001). However, physical activities carried out. The homestead, whilst
the lack of feedback following the instructional two- less convenient, would have been a more natural setting
event sequences reflected the learning by rote reported for observing motherchild interactions; however, this
by Pontefract and Hardman (2005), with a lack of spe- was not possible due to resource limitations.
cific techniques to facilitate target accuracy. Continu-
ing professional development recorded for the occupa-
tional therapists seemed to be about raising awareness
Conclusions
via knowledge exchange on matters such as HIV and
AIDS, and skills training in areas relevant to the profes- In the absence of a speech and language therapy service
sion, with no specialist training recorded for the extra in this rural part of Kenya, there has been the assign-
duties associated with speech, language and communica- ment of duties to teachers of the deaf and occupational
tion needs. It is possible that the occupational therapists therapists. However, practice appears to be determined
practice, with its focus on oral-motor skills and mo- by the pedagogies associated with the original profes-
tor production of speech, stemmed from their original sional training. The teachers had received some pre-
diploma studies, where undoubtedly human anatomy qualification training in phonetics and phonology, al-
and physiology will have featured. The practice in both though practice was reminiscent of classroom discourse
partnership types A and B seem to tackle surface level in Kenya. The occupational therapists had not un-
processes affecting speech production, with apparently dertaken any specific training relevant to the support
limited attention to pre-requisite competencies, such as of communication development. They used techniques
symbolic development, or indeed communication by that demonstrated inadequate knowledge of communi-
means other than speech. Thus it may be that staff prac- cation. However, the mothers were present and therapy
tised what they had been trained for and not for the was conducted in the language of the home. Speech
additional responsibilities assumed. and sound production was emphasized with limited re-
course to language acquisition and the development of
concepts. The instrumental benefits of such practice
Limitations
and the capacity for generalization into everyday life are
This was a small-scale study of children with complex questionable.
communication needs associated with either hearing Whilst communication between the mothers and
impairment or cerebral palsy, interacting with adults in their children showed resonances of the communication
three types of communication partnership. The results, seen in occupational therapy sessions, their shared use
therefore, are not representative, but nevertheless of gesture and the spontaneous self-/shared expression
serve to illustrate some of the features of interactional by the children are possibly indicative of a more natural
discourse between teachers, occupational therapists and and participative interaction style. Development of sup-
mothers with such children. Nomination of the child port for children with complex communication needs
participants by the service heads was not ideal and and their families in low-income countries requires con-
introduced bias to the sample, as they may have chosen sideration of the range of augmentative and alternative
children more capable of producing speech. It was orig- communication strategies that might support a more
inally planned to recruit a purposive, stratified sample functional approach; the familys contribution as poten-
covering key age ranges and underlying conditions tial agents for change; and finally the training require-
associated with communication disorders; however, ments for effective expansion of professional roles.
Practices to support communication needs in Kenya 701
Acknowledgements ships to develop a culturally relevant intervention for children
with communication disabilities in Kenya. Disability and Re-
The authors would like to thank the Director of the Kenya Medical habilitation, 31, 490499.
Research Institute for permission to publish the data. Gratitude is HEILMANN, J., NOCKERTS, A. and MILLER, J. F., 2010, Language
expressed to the CP Charitable Trust for its generosity in funding the sampling: does length of the transcript matter? Language,
project. Thanks must also go to the Wellcome Trust at KEMRI and Speech and Hearing Services in Schools, 41, 393404.
the services across the health and educational rehabilitation sectors of International World Federation of Occupational Therapy, 2012,
Kilifi District. Professor Charles Newton is funded by the Wellcome Human Resources Project (available at: http://www.wfot.org/
Trust. Declaration of interest: The authors report no conflicts of ResourceCentre.aspx) (accessed on 12 November 2012).
interest. The authors alone are responsible for the content and writing JOCHMANN, A., 2006, Speech and language treatment in East Africa.
of the paper ASHA Leader, 7 February (available at: http://www.asha.org/
Publications/leader/2006/060207/f060207b.htm#4) (ac-
cessed on 12 November 2012).
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