profiles o f Outpatient Speech-Language Therapy and A udiology Clients at a Tertiary Hospital in the Western Cape 49 PROFILES OF OUTPATIENT SPEECH-LANGUAGE THERAPY AND AUDIOLOGY CLIENTS AT A TERTIARY HOSPITAL IN THE WESTERN CAPE W endy Overett and Harsha Kathard Division o f Communication Sciences and Disorders, University o f Cape Town a b s t r a c t This stu d y d e s c r ib e d trends in the dem ographic, diagn ostic, a n d attendan ce va ria b le s o f first-tim e clien ts who a tten d ed the Speech- L angu age Therapy a n d A u d io lo g y o u tp a tien t d ep a rtm en t (O P D ) a t a te rtia ry h o sp ita l in the W estern C ape o v e r a f iv e -y e a r p e r io d (1999- 2003). A retro sp ective, d e scrip tive su rve y w a s co n d u cted a n d d ata w ere c o lle c te d fro m h o sp ita l records. The d a ta w e re coded, a n a lyse d d es crip tive ly a n d re p rese n ted in tables, fig u r e s a n d graph s. The d ia g n o stic c a teg o ries o f h earin g loss a n d v o ic e d iso rd e r m ade up the h ighest p e r c e n ta g e o f referrals. The la rg e st p e r c e n ta g e s o f clien ts w ere re fe rred fr o m the Ear, N o se a n d Throat (ENT) D ep a rtm en t a t the stu d y hospital, f o llo w e d b y the edu cation sector. D em o g ra p h ic trends in d ica ted th a t the h ig h est p e r c e n ta g e o f clien ts a tten din g the O P D w as in the a g e ca teg o ry o f 7-12 ye a rs, that sim ila r p e r c e n ta g e s o f m a le a n d fe m a le clien ts a tte n d e d the OPD, an d th at English w a s the language th a t a clien t w as m o st likely to speak. G eograph ically, the highest p e r c e n ta g e o f clien ts a tten d in g the O P D w a s fr o m the K lip - fo n tein region. A tten d a n ce d a ta r e v e a le d th a t a p p ro x im a tely 70% o f clien ts a tte n d e d O P D appoin tm ents within a three-m onth tim e p e ­ rio d a n d a tten d ed no m ore than tw o appointm ents. P erc en ta g e o f appoin tm ents a tte n d e d d e c r e a s e d with in creasin g num bers o f sch ed ­ uled appointm ents. Im p lica tio n s f o r research a n d se rv ic e d e liv e ry a re discussed. Key words: Speech-Language Therapy and Audiology services, healthcare, service delivery, client profiles, attendance INTRODUCTION This study aimed to describe the client population profiles of those attending the speech-language therapy and audiology outpatient department (OPD) at a tertiary hospital in the Western Cape in South Africa over a five year period (1999-2003). To achieve this aim, the demographic, diagnostic and attendance data of a study sample were determined. The impetus for this study arose from difficulties the researcher experienced while attempt­ ing to engage with service planning for Speech-Language Ther­ apy services in a post-apartheid era at a tertiary hospital in the absence o f knowledge o f descriptive client data. In the South African public sector, SLT & Audiology ser­ vices have traditionally been located in both the health and educa­ tion sectors. In the health sector these services have been consid­ ered as part o f allied health service delivery with emphasis on rehabilitation (Allied Health Professionals Technical Committee, 2004). Although health services are essential, they fail to reach many people in South Africa due to a lack o f resources. Histori­ cally, health service delivery in! South Africa has been shaped by the medical model and complied with apartheid ideology (Bhagwanjee & Stewart, 1999; Hall, Haynes & McCoy, 2002). Public health services were characterised by racial and geographi­ cal disparities, fragmentation and duplication o f services and were hospital-centred with minimal emphasis on Primary Health Care (PHC). The combined influences o f the medical model and apart­ heid ideology resulted in an inequitable provision o f services in terms o f accessibility, appropriateness, funding and co-ordination across the variables o f race, class, gender and level o f urbanisa­ tion (Bhagwanjee & Stewart, 1999). The healthcare system was divided, inefficient and grossly inequitable (Hall et al., 2002). Speech-Language Therapy (SLT) and Audiology Services in South Africa have been shaped by such socio-political contex­ tual realities and are also grossly inequitable (Pillay, Kathard & Samuel, 1997). Services in South Africa have been biased toward providing a better quality service to a White, middle class, Eng­ lish and Afrikaans first language speaking population, whilst pro­ viding a poorer service to a Black African first language speaking clientele (Pillay, 1996 cited in Pillay et al., 1997). Public sector SLT & Audiology services have historically been based in hospi­ tals and special schools, with minimal service delivery at commu­ nity level. Similar to the national profile, services in the Western Cape have been urban-based with few Speech-Language Thera­ pists and Audiologists working in rural areas beyond the Cape Metropole. Health sector provision o f SLT & Audiology services have been limited to services at tertiary hospitals, with little avail­ able at primary or secondary levels in the Western Cape (Allied Health Professionals Technical Committee, 2004), thus limiting access and availability o f services to the majority o f the popula­ tion. The current service delivery situation is untenable given the prevalence o f disability in the Western Cape. The data from the 2001 Census (Statistics South Africa, 2004) regarding the numbers o f people with communication, hearing or multiple dis­ abilities point to the need for SLT & Audiology services in the City o f Cape Town and in the Western Cape. The need for acces­ sible services, coupled with appropriate planning, and importantly the knowledge to assist such planning, is essential to meet the service delivery needs o f this population. Over the last decade, systemic changes have taken place within the health system which have had a bearing on SLT & Audiology services. Subsequent to South Africa's first democratic elections in 1994, the National Department o f Health set about transforming and restructuring the healthcare system (Hall et al., 2002; Forman, Pillay & Sait, 2004). These changes included a policy shift to a primary health care (PHC) approach within a dis­ trict health system (DHS), with intent to realise a social model of health. The aim o f such transformation has been to improve the quality o f care provided and create a more equitable service. There is a critical need for relevant knowledge to inform such planning processes. In order to ensure cost-effective improvement and development o f existing health services, the efficacy o f health programmes needs to be validated through research showing that such services are necessary, appropriate and accessible, within The South African Journal o f Communication Disorders, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) 50 Wendy Overett and Harsha Kathard specified contexts (Bhagwanjee & Stewart, 1999). Several studies within the SLT & Audiology profession, have examined client profiles to facilitate service planning. Inter­ nationally studies by Broomfield and Dodd (2004); Edwards, Cape and Brown (1989); Enderby and Davies (1989); Enderby and Petheram (2000); Heron (2001); and Petheram and Enderby (2001) have provided critical data to influence service planning. In South Africa a limited number o f studies have examined client data in different contexts (Klop, 1998; Schneider, 1992 and Swanepoel, 2005). Klop (1998) conducted a study in the area o f quality man­ agement in a private healthcare practice in Cape Town. The out­ comes o f the study were intended to help implement quality man­ agement programmes. Client profiles in terms o f disorders, age, geographical location, gender, home language and referral agents were compiled from 197 clients seen by the researcher in her prac­ tice from 1994 to 1996. She found that the majority o f clients at­ tended for language disorders, followed by stuttering, almost half were between three and six years o f age, 63% o f the clients were nale, almost three quarters o f her clients were Afrikaans-speaking and most o f the clients were drawn from an area within a 10 km radius o f the practice. Her clients were referred from other health­ care professionals, educators and former clients. From a smaller group o f clients she found that only two out o f 64 clients withdrew from therapy. Schneider (1992) collected data from records, reports and case files to determine the nature and prevalence o f communica­ tion disorders seen in six hospitals in Gazankulu. Community- based speech and hearing workers were then interviewed about their work situation, organisation of their time and intervention strategies used with communicatively disordered people in order to evaluate the efficacy o f their work. The most common disorders seen at the hospitals in Gazankulu by these speech and hearing workers were hearing disorders. Swanepoel (2005) conducted an exploratory descriptive study which critically described an infant hearing screening pro­ gramme conducted at two maternal and child health clinics in Hammanskraal. Quantitative and qualitative methods for data col- ! lection were used His study showed poor follow-up return rates i to the clinic. | In South Africa, apart from these studies by Klop (1998), f Schneider (1992) and Swanepoel (2005) there is limited data to contribute to service planning. The unique characteristics and challenges o f developing countries demand that contextual and local research be done in conjunction with international .studies (Swanepoel, 2005). Speech-Language Therapy research in the United Kingdom has emphasised the importance of ongoing gathering information on services and client populations for Speech-Language Therapy services. As with South Africa, inequalities in services for the speech and language impaired in the United Kingdom’s national health service have been documented (Enderby & Davies, 1989). If there is to be efficient planning in healthcare it is important that this process be informed with regard to the size and needs o f the population to be served (Enderby & Davies, 1989). The collation of client data profiles may serve in questioning some o f the basic premises regarding provision o f services and should lead to con­ sideration o f alternative forms of provision which meet the needs o f the speech and/or language disabled and hearing impaired popu­ lation (Enderby, 1989). To monitor equity concerns in South Africa, comparative data are necessary to understand the multifaceted nature o f client profiles which include race, age, gender, urban/rural location and socio-economic status (Ntuli & Day, 2004). The first steps how­ ever, are to collect data from current service sites, as was the inten­ tion o f the present study. The demographic, diagnostic and atten­ dance data o f clients receiving services at a tertiary level o f health­ care could be valuable in planning equitable and appropriate ser­ vices. Reliable data concerning the types o f speech, language and hearing disorders referred, age and sources o f referral, and the ef­ fect o f cultural and socio-economic profiles o f the population on referral patterns are vital for planning services (Broomfield & Dodd, 2004). Comparison o f records may show service trends, admission patterns and familial trends (Lubker & Tomblin, 1998) over time. It was important to collect data gathered over time so that changes in service provision could be examined with the pur­ pose o f informing debate and planning (Petheram & Enderby, 2001). The compilation and analysis o f data, timeous reporting and use o f consistent up-to-date health information, are all key aspects o f healthcare planning and management. The lack o f information regarding the health sector has contributed significantly to the slow process o f transforming the health system (Ijumba & Day, 2004). Thus the results o f this study, with its focus on demographic, diag­ nostic and attendance data, has potential to influence service deliv­ ery changes with regard to SLT & Audiology services. METHODOLOGY Aim This study aimed to describe trends in the demographic, diagnostic, and attendance variables of first-time clients who at­ tended the SLT & Audiology outpatient department (OPD) at the tertiary hospital being studied over a five year time period (1999- 2003). Study design A retrospective descriptive survey was conducted, to collect demographic, diagnostic and attendance data o f a sample o f clients. Sample i The study population included all the hospital records o f new clients who had attended the speech-language therapy and audiology OPD o f the tertiary hospital under study during a 5 year period from January 1, 1999 to December 31, 2003. This period of time was selected as data were readily available and would give a sufficiently large number o f records for trends over the years to be examined. Due to the large number o f clients in the population (2,819), a sample o f one-third o f the population data were drawn, using a stratified random sampling procedure (Katzenellenbogen, Joubert & Abdool Karim, 1997), stratified according to the year in which the client was first seen. The sample consisted of 929 cli­ ents, on which the analysis was conducted. Data collection and analysis The clients' names were retrieved from the client registers and record cards. The data collection form, devised by the re­ searcher, was then utilized to capture the data from the hospital records (Appendix A). Data were electronically captured onto a spreadsheet as raw data and then entries were coded by the re­ searcher. In instances where data were missing on the form (where it was not indicated as missing in the records), the records were Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) Profiles o f Outpatient Speech-Language Therapy and A udiology Clients at a Tertiary Hospital in the Western Cape 51 reviewed again by the researcher to retrieve this information. After the data had been entered into the computer and checked, client names and folder numbers were removed to ensure anonymity o f the clients. Attendance data were then converted to number o f appointments attended, time frame over which these appointments were attended and the percentage o f appointments attended. The co d ed data were transferred from the spreadsheet into a computer- driven statistical package (Statistical Package for the Social Sci­ ences) (SPSS Inc, 1995) and frequency and percentage distribu­ tions as well as contingency tables were generated. In instances where a data collection form had missing data, after being re-checked by the researcher, information which was unavailable, was categorised as such. If a record for a client had missing data for two or three o f the three diagnostic variables, the record was excluded from analysis o f diagnostic variables and at­ tendance variables, but was still included in the analysis o f demo­ graphic variables. In instances where there was no clear atten­ dance data for two or more attendance variables, that client was excluded from the analysis o f attendance information. However, if only one o f these variables was missing, the data were still in­ cluded in the overall attendance analysis. Due to the descriptive nature o f this study, analysis of variables was conducted via descriptive statistics (Hite, 2001), as used in other similar studies (Enderby & Petheram, 2000; Petheram & Enderby, 2001). Frequency and percentage distributions were used to describe the demographic, diagnostic and attendance data. Frequency data were converted into percentage data for each year and for the total sample. Contingency tables (cross tabulation) were used to show relationships between variables. Inferential statistics were not used as this form o f data analysis is not appropriate for a descriptive study (Hite, 2001). Reliability and validity Reliability o f the data collection procedure was ensured by defining the exact methods o f measuring and checking of work (Katzenellenbogen, et al., 1997). In this study a standard, reliable data collection form (Appendix A) was used to collect data. Cross­ checks o f information from the hospital record sheet to the SLT & Audiology folder also enhanced J the reliability o f the data collec­ tion process. | Areas o f concern for validity included the reality that hospital records are generally produced for clinical, administrative or monetary ends rather than research purposes (Abramson, 1990) and that different clinicians ma>| have used different terminology when describing diagnoses. Terminologies were therefore exam­ ined and then grouped in broad categories. Data collection was verified by the researcher as it was entered into the computer. Instrument, observer and client variations can be evaluated by repeating measures o f a sub-sample o f the study sample (Katzenellenbogen, et al., 1997). In this study a random sample of ten percent o f the clients from each year was selected for re­ collection o f data (n=93) by an independent researcher. The data were then coded and the codes were compared to those found for the same clients by the researcher. There was 95% agreement across all the variables, indicating good inter-observer reliability. A large sample was chosen to enhance the validity o f the study as confidence intervals become narrower as sample size in­ creases (Katzenellenbogen, et al., 1997). The data were analysed quantitatively using SPSS to ensure the data were analysed in a consistent manner thereby ensuring valid and reliable results. The results were interpreted by the researcher who also engaged with a process o f peer review to enhance the quality o f the interpretation. Ethical considerations The head o f the speech-language therapy and audiology department, the medical superintendent of the tertiary hospital be­ ing studied, and the ethics committee o f the University o f Cape Town were consulted with regard to gaining access to the hospital files. It was not, however, possible to gain consent from the cli­ ents, due to potential difficulties locating clients and the number of records being reviewed. However, confidentiality was strictly maintained by removing any identifying information after the data had been checked and coded. Access to the files may be consid­ ered ethical on the grounds that there was no risk o f harm to indi­ viduals, there was potential public benefit, and investigators' pro­ tected the confidentiality o f the individuals whose data they stud­ ied (Council for International Organisations o f Medical Sciences, 1991). The community will stand to benefit from this research if changes, taking into account the findings o f this study, are made within the healthcare setting with regard to equity in service provi­ sion and aligning the services to the needs o f the population. RESULTS AND DISCUSSION The number o f clients varied each year ranging from 178 to 197 clients, with a total sample size o f 929 clients on which these results are based. The results and discussion are presented in rela­ tion to the aims o f the study. The total number of clients varied across the aims because o f missing information as explained in the methodology. The quantitative results are represented in tables and graphs and the main trends are described and then discussed. Diagnostic data Speech-Language Therapy and Audiology Diagnosis ; In this study recorded reported medical diagnoses have been managed as inter-related diagnostic categories with SLT & Audiology diagnoses. The percentage of clients within each SLT & Audiology diagnostic category is presented in Figure 1. j Speech-Language Therapy and Audiology diagnostic categories o f j those attending the OPD appeared to remain fairly consistent over the five-year period, with minor variations across the years. ! j The common diagnoses o f those attending the SLT & Audi­ ology OPD included hearing loss (n=255; 30%), voice disorders (n=l 77; 21%) and neurogenic communication disorders. The ; types and percentages o f diagnoses remained relatively similar across the five years. There are several significant issues surrounding the types o f disorders seen at the SLT & Audiology OPD and the percentage of clients attending the OPD for the management o f each disorder (Figure 1). The reason for the high percentages o f clients attend­ ing the OPD as a result o f a hearing loss or voice disorders, may be due to the fact that this SLT & Audiology OPD is situated in a tertiary hospital, with specialized equipment and facilities suitable for assessing and treating these disorders. Due to the fact that hearing loss and voice disorders, as well as neurogenic communication disorders (for which the third high- j est percentage of clients attended the OPD) are medically based and are treated by the medical profession in conjunction with Speech-Language Therapists and Audiologists, clients may be likely to attend this hospital which offers both services. Hearing loss, voice and neurogenic communication disorders are often ac­ quired and therefore there is a ‘loss’ o f function, making the disor­ der noticeable and igniting a desire or need to restore lost function. The South African Journal o f Communication Disorders, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) 52 Wendy Overett and Harsha Kathard V S p e e c h a n d A u d i o l o g y D i a g n o s is Figure 1: Percentage of clients per Speech-Language Therapy and Audiology diagnostic category who attended the Speech-Language Therapy and Audiology OPD at a tertiary hospital in the Western Cape from 1999-2003 (n=859). The proximity and connections to the ENT department, who made the largest percent­ age of referrals to the SLT & Audiology OPD, may also account for the high per­ centages of clients who attended the OPD as a result of a hearing loss or voice disor­ der. The highest percentages of clients were diagnosed with hearing losses, voice disorders, neurogenic communication dis­ orders or fluency disorders, which are ‘noticeable’ disorders and thus easier to detect than less ‘visible’ disorders (McLaren, Solarsh & Saloojee, 2004) and are likely to impact on everyday life. Less ‘visible’ disorders, such as a language im­ pairment, may not be as easily noticeable in everyday situations and thus not as eas­ ily detected. These less ‘visible’ disorders are then not as likely to be referred to SLT & Audiology services. It is also possible that because the Department is actually referred to as a “speech therapy” rather than “speech-language therapy”, it may not be obviously associated with managing language disorders, a reality that the pro­ fession has experienced internationally. Referral Sources The results for referral sources ap­ pear in Figure 2. From the year 2000 on­ wards there was an increase in referrals from community clinics and from wards at the study hospital. When examining individual cate­ gories of clients with a specific disorder or from a specific referral source, particu­ lar trends were found. These results are based on the clients within a specific cate­ gory only and thus the percentages and numbers are based on these individual categories and not on the full sample. The majority of clients who attended the SLT & Audiology OPD as a result of a voice disorders (n=137; 76%) were re­ ferred from the ENT department. Fifty percent (n=41) of referrals from commu­ nity clinics, 80.5% (n=33) o f referrals from occupational health centres and 83% (n= 10) of referrals from old age homes or residential care were referred to the SLT & Audiology OPD as a result of a hearing loss. The majority o f the referrals to the OPD from wards were for dysphagia, neurogenic communication disorders or a combination of these (n=31; 97%). The education sector referred 50% (n=28) of paediatric clients with multiple difficulties to the OPD. Referral sources (Figure 2) would also have shaped the client diagnostic pro­ files discussed above. As mentioned, the ENT department made a high percentage of referrals to the SLT & Audiology OPD. This trend is understandable in light of the discussion around the types of disorders seen most frequently at the OPD. The second major referral agent to the OPD was the Education Sector. This situation may be attributed to the limited SLT & Audiology services within mainstream schools (F. Lewis, personal communica­ tion, February 18, 2005), resulting in re­ ferrals to the Health sector. j I Demographic data | I Age Groups Age group results, presented in Table 1, illustrate that the largest percent­ age (n=l 65; 18%) of clients who attended the OPD were within the age group of 7 - 12 years. The following results are based on sub-categories of clients. Clients attend­ ing the OPD with a hearing loss or tinni­ tus covered the full range of ages, al­ though the majority of these clients were between 30 and 79 years o f age (n= 181; 72%). The majority of clients who at­ tended the SLT & Audiology OPD as a result of a voice disorder were between 30 T T& CS. " \\\% X v X R e f e r r a l S o u r c e <> '■v Figure 2: Percentage of clients per referral source who attended the Speech-Language Therapy and Audiology OPD at a tertiary hospital in the Western Cape from 1999- 2003 (n=859). A bbreviations used: C T : C a p e T ow n OA H : O ld A ge H om es EN T: E ar, N ose, T hroat Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) profiles o f Outpatient Speech-Language Therapy and A udiology Clients at a Tertiary Hospital in the Western Cape 53 ancj 49 years o f age (n=98; 54%). Clients with a neurogenic com­ munication disorder spanned a wide range o f ages, although the highest percentage fell within the age group o f 50-59 years (n=27; 24%). The majority o f clients who attended the OPD as a result of dysphagia were between 50 and 69 years of age (n=10; 67%), while clients with both dysphagia and a neurogenic communica­ tion disorder were slightly older, between 60 and 79 years (n=23; 62%). The majority of clients presenting with fluency disorders, however, were under 18 years o f age (n=64; 90%). A similar trend occurred for clients attending as a result o f a phonology/ articulation/oral motor disorder, language disorder, language and learning disorder or multiple difficulties although the majority were under the age o f 12 (n=20; 87%). While the highest percent­ age o f clients attending as a result o f language disorders was in the under six year age group (n=15; 65%), children attending the SLT & Audiology OPD with language and learning disorders or multi­ ple difficulties had a greater percentage in the 7-12 year old cate­ gory (n=25; 83% and n=35; 62.5% respectively). Despite the high number o f clients with a hearing loss or voice disorder attending the OPD (which in this study were found predominantly in the adult population), the majority o f the caseload attending the SLT & Audiology OPD was found to be between 7 and 12 years o f age (Table 1). O f this age group only a minority attended the OPD for a hearing loss or voice disorder. However, this age group had the majority o f the clients with flu­ ency disorders, phonology/articulation/oral motor disorders, lan­ guage and learning disorders, as well as those with multiple diffi­ culties. A reason for this high percentage o f 7 to 12 year olds at­ tending the OPD under study in relation to the under six popula­ tion, may be due to the close proximity o f another tertiary hospital, which specializes in paediatric intervention. The high percentage of 7 to 12 year olds attending the OPD (who are primary school age children) alludes to the lack o f services within the education system, who were also the second highest referral agent. Despite the inclusive education policy intention regarding inclusive educa­ tion (Department of Education, 2001), there seems to have been minimal support for learners with communication difficulties in mainstream schools in the Western Cape. The researcher has also perceived a general lack o f knowl- Table 1: Number and percentage of clients per age group who attended the Speech-Language Therapy and Audiology OPD at a tertiary hospital in the Western Cape from 1999-2003 (n=910) j Age Number Percent 0 - 6 years 69 : 7.58 7-12 years 165 18.13 13-18 years 39 4.29 19-29 years 79 8 .6 8 30-39 years 118 12.97 40-49 years 115 12.64, 50-59 years 107 11.76 60-69 years 101 1 1 .1 0 70-79 years 87 9.56 80+ years 30 3.30 Total 910 ' 100 edge amongst educators, many health professionals and the public, o f SLT & Audiology services, resulting in ‘late’ referrals o f indi­ viduals. Anecdotal parent reports have indicated that parents who had voiced their concerns regarding their child’s delayed language development have been told by health professionals ‘not to worry’ or that their child will ‘grow out o f it’. Thus, instead o f the child receiving early intervention, intervention was only available upon entering school where there are high demands on communication skills and the child’s difficulties begin to impact on academic per­ formance. This scenario again relates to the ‘visibility’ o f certain disorders (McLaren et al., 2004), as these language and learning disorders are often only detected in an academic environment and are not immediately obvious in everyday situations (Das, 2001). Examination o f the results pertaining to the adult popula­ tion attending the Speech-Language Therapy and Audiology OPD showed that there was a slight decrease in percentage o f clients attending the OPD within each 10 year category from 30 to 69 years, with a slightly larger decrease in therapy attendance at 70 to79 years and a large decrease in therapy attendance in the over 80 year old category. An explanation for the greatest number o f adults attending the OPD being between 30 and 49 years o f age may be due to the large number o f clients attended the OPD as a result o f a voice disorder and the fact that the majority o f clients with voice disorders were in this age group. This finding o f a decrease in therapy attendance amongst clients with increasing age, however, seems to follow a general trend in rehabilitation, where services are less accessible and avail­ able to the older population. Although disability is more prevalent in the older population, it seems that older adults are unable to access hospital based outpatient services. Blake (1981) in the United States o f America, claims that in terms o f age group, par­ ticipation in the rehabilitation service seems to be inversely related to the need for such service. Rehabilitation may be more o f a pri­ ority for younger people, or services may be more accessible to them, than for the older population. Rehabilitation has previously been driven both philosophically and financially by the goal o f restoring individuals to productive employment, resulting in better opportunities for younger clients, although this is now changing to include a focus on older clients (Raia, 1992). The motivation to attend rehabilitation may be greater for the younger adults due to their need to regain employment, as well as to pursue social goals. A study at Groote Schuur Hospital in the Western Cape, South Africa (Whitelaw, Meyer, Bawa & Jennings, 1994) confirmed this trend and reported that greater numbers o f stroke clients under the age o f 65 years old, who had been inpatients, were referred (as outpatients) to Physiotherapy and Occupational Therapy services, while fewer clients above the age o f 65 were referred. Further­ more, a greater number o f the younger adults presented for and received therapy than older adults. Another study in the Western Cape, examining rehabilitation services at Bishop Lavis Rehabili­ tation Centre, documented that 50% o f the population attending these services were 60 years old or younger (Rhoda, 2001). In light o f the above discussion regarding services for dif­ ferent age groups o f clients, the current study revealed that a large percentage (n=71; 64%) o f clients with a neurogenic communica­ tion disorder (without dysphagia) were under the age o f 60 years. However, 70% (n=26) o f those with both dysphagia and a neuro­ genic communication disorder were over the age of 60. This pos­ sibly indicates a greater degree o f disability in the older age groups, where multiple disabilities are perhaps more likely. This trend o f multiple disabilities in the older population may also ex­ plain the reduction in the number of these older clients attending outpatient rehabilitation. Elderly clients may not only be more The South African Journal o f Communication Disorders, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) 54 Wendy Overett and Harsha Kathard affected by a stroke, but may also have more problems reaching therapists than younger clients (Whitelaw et al., 1994). There is also greater attrition of older clients than younger clients due to stroke (Whitelaw et al., 1994). Gender Slightly more than half of the sample who attended the OPD was male (n=470; 52%). More females than males presented with voice disorders, language disorders or no specific Speech-Language &/or Audiology diagnosis. It was unexpected to find similar percentages of male and female clients attending the OPD, as the belief was that there would be many more males than females as found in other studies (for ex­ ample Broomfield & Dodd, 2004; Enderby & Petheram, 2000; Klop, 1998), although direct comparisons could not be drawn as some studies did not include Audiology clients and some were based only on paediatric populations. This trend, however, be­ comes clearer when one considers gender in relation to the different disorders. As found in the present study, as well as other studies (Coyle, Weinrich & Stemple, 2001), voice disorders are more prevalent amongst females than males. This study found that a large percentage of clients (n=180; 21%) attended the OPD for the management of a voice disorder and because many o f these clients were female the number of females attending the SLT & Audiology OPD was increased. There are two possible explanations as to why there were more female than male language disorders found in this study. Firstly, more males presented with language disorders coupled with learning disorders and were thus categorised as such. Secondly, it was found that more of the language disorders fell into the 0-6 year old category. There is a perception that ‘boys develop more slowly’ or ‘boys are slower to talk’ (Phillips, 2004:500) and they might therefore be brought later for therapy, when they would more likely be diagnosed as having a language and learning difficulty. Of all the other disorders (apart from language disorders) found mostly in children, all had higher percentages of males than females. Many studies have commented on the greater likelihood of reading difficulties or dyslexia in males than in females (Owens, 1999) and that children with dyslexia have delayed language devel­ opment. Also, as expected, more males than females attended the OPD for the intervention of fluency disorders (Guitar, 1998). Home Language The majority of clients attending the OPD were classified as having English or Afrikaans as their home language, with a minor­ ity speaking Xhosa or another language (Table 2). Table 2: Number and percentage of clients per Language group who attended the Speech-Language Therapy and Audiology OPD at a tertiary hospital in the Western Cape from 1999-2003 (n=910) This is interesting considering that 55% of the population in the Western Cape speak Afrikaans as a home language, 24% speak Xhosa as a home language and 19% speak English as a home lan­ guage (South Africa.info reporter, 2002). There are several possi­ ble reasons for the mismatch between the population profile and the profile of clients attending the SLT & Audiology OPD. Firstly, English may be the preferred language of interven­ tion for several reasons. The majority of Speech-Language Thera­ pists and Audiologists in the SLT & Audiology OPD at this tertiary hospital in the Western Cape were English first language speaking with Afrikaans as a second language. Also, many children were being schooled in English, as English was the language most com­ monly used as the medium of instruction (Alant, 1989). Thus they may choose to receive therapy in English. Thirdly, there were no Xhosa-speaking Speech-Language Therapists or Audiologists at the study hospital and no formal access to interpreters, resulting in lim­ ited provision of services to the Xhosa-peaking population. This situation is of grave concern given the multilingual nature of the population in the region. Another possible reason for Xhosa-speaking clients not ac­ cessing services in the OPD clinic may be due to cultural reasons. Cultural groups vary in their view of disability and therapeutic in­ terventions and such differences may impact who is likely to attend the hospital (Swartz, 1998; Swanepoel, 2005). Furthermore, the hospital in the present study has historically been a ‘white’ hospital, and there may still be misconceptions about who can access ser­ vices at this hospital. In many communities in South Africa there is little awareness of SLT & Audiology services, due to lack of re­ sources and facilities, and therefore people are unaware that ser­ vices are available. Access to services is also influenced by socioeconomic status of people. Although poverty is not confined to one racial group in South Africa, it is most prevalent amongst the black popu­ lation (Swanepoel, 2005). Many of the Xhosa-speaking population in the Western Cape, the majority of whom would be black, may have a limited income. The costs of travel to the hospital as well as multiple treatment fees may be prohibitive. Geographical Location The Health Districts in Cape Town were used to categorise the areas from where the clients who attended the OPDlcame. i Table 3: Number and percentage of clients per Geographical location who attended the Speech-Language Therapy and Audiology OPD at a tertiary hospital in the Western Cape from 1999-2003 (n=910) Geographical Location Number Percent Central 209 22.97 Eastern 2 2 2.42 Khayelitsha 39 4.29 Klipfontein 258 28.35 Mitchells Plain 117 1 2 .8 6 Northern Panorama 46 5.05 Southern 150 16.48 Tygerberg 39 4.29 Outside Cape Town . 21 2.31 M issing data 9 0.99 Total 910 10 0 Language for Therapy Number Percent English 501 55.05 Afrikaans 298 32.75 Xhosa 82 9.01 Other 18 1.98 M issing data 11 1.21 Total 910 1 0 0 .0 Die Suid-Afrikaanse Tydskrifvir Kommunikasieafwykings, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) profiles o f Outpatient Speech-Language Therapy and Audiology Clients at a Tertiary Hospital in the Western Cape 55 Table 3 shows the number and percentage of clients from each area. It can be seen that clients attended from many different areas. This is not sur­ prising given the lack of SLT & Audiol­ ogy services in the community or even at a secondary level of care (Allied Health Professionals Technical Commit­ tee, 2004). Some of the areas, however, would have been covered by SLT & Audiology services at another tertiary hospital in Cape Town. Attendance The majority of clients attended the OPD over a very short period of time, for example many attended within a three month period (n=513; 71%) or attended two appointments (n=506; 70%). Number of appointments and time frame results showed very similar trends, with a drop-off with increasing number of scheduled appointments or longer period of time over which these appointments were scheduled. Almost half of all the clients (n=353; 49%) at­ tended only one appointment. Only 9% (n=67) of clients attended more than five appointments. Given that long-term therapy was often indicated, these find­ ings were noteworthy in relation to ser­ vice planning. The high number of clients who only had one booked appointment may be due to the fact that certain clients would have been placed on a waiting list for therapy and therefore not been given further scheduled appointments immedi­ ately. They may then not have wanted therapy when it was offered, due to changes in circumstances between the time of the assessment and the date when therapy was offered. Additionally, there are some cases for which one attendance may be all that is indicated. Some clients may have needed an initial assessment with no necessary follow-up. It is likely that once their concerns had been ad­ dressed, they no longer felt the need for further intervention. Enderby and Da­ vies (1989) reported that 60% of newly referred children required assessment and advice only. While this explanation might be applicable to some cases, the data in case files, the nature of the disor­ ders and personal experience suggest that many required additional intervention. The lack of understanding of the nature of interventions offered by the profession of SLT & Audiology by the community, as well as the location of the services within a tertiary hospital envi­ ronment, may have contributed to poor attendance rates. Many clients have the expectation that a hospital is a place which one attends when ill and that it is a once-off attendance, possibly with a fol­ low-up appointment. Many expect treat­ ment that is tangible, such as medication or surgery. Clients arrive with the ex­ pectation that they will be given some­ thing to ‘cure’ them in a once-off ap­ pointment. Therefore, they may not have been prepared for the active role that is required of them in the therapeutic proc­ ess. Also, they may have been unwilling or unable to commit themselves to fur­ ther intervention as recommended. The high rate of non-attendance may also reflect the economically disadvantaged nature of the population served, and the low priority given to SLT & Audiology services given other life circumstances (Broomfield & Dodd, 2004). A further explanation for low at­ tendance rates could relate to different perceptions of a disorder by a therapist and a client, or the client having a differ­ ent understanding of the nature of a dis­ order. Negotiating between explana­ tions of illness increases the possibilities of compliance or adherence to treatment (Swartz, 1998). Thus, explaining the nature of the diagnosis in ways that the client can understand and relate to their understanding of the world, may im­ prove attendance and compliance to therapy. Also, discussions prior to com­ mencing therapy about the nature of therapy and the respective roles of the parent and the therapist may well in­ crease parent satisfaction (Roulstone, Glogowska, Peters & Enderby, 2004), which may improve attendance rates for children. The same principle could be applied to adults. With an increasing number of scheduled appointments, percentage of appointments attended dropped. The only diagnostic categories which had more than 10% of clients attending in excess of five appointments were for the categories o f fluency disorders (n=15; 28%), paediatrics with multiple difficul­ ties (n=12; 25%), language disorders (n=5; 24%) and phonology/ articulation/ oral motor disorders (n=3; 13%). It is possible that the motivation for treat­ ment of these disorders may have been greater than for other disorders. Data presented by Enderby and Davies (1989), which included many but not all types of communication disorders included in this study, indicated that the children who received regular therapy, attended once a week for an average of 16 weeks. Roulstone et al. (2004) found that of the 71 children allocated to Speech-Language Therapy in their study, 68 attended sessions offered, al­ though nearly 18% of appointments were either cancelled (by the therapist or clinician) or not attended. Klop (1998) in her private practice found that only two out of 64 clients dropped out of therapy. The differences in findings be­ tween these studies confirm the impor­ tance of understanding how contextual realities influence service provision. 4 0 - T im e p eriod Figure 3: Percentage of clients who attended their scheduled appointments at the Speech-Language Therapy and Audiology OPD at a tertiary hospital in the Western Cape from 1999-2003 across different time periods (n=719). The South African Journal o f Communication Disorders, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) 56 Wendy Overett and Harsha Kathard LIMITATIONS There are several limitations of this study which need to be considered. There has been minimal research into client profiles attending SLT & Audiology services in South Africa. Therefore, the researcher had to rely on the methodology and literature from other countries and other healthcare disciplines to conduct this study. While such literature was useful, it was not directly appli­ cable to the SLT & Audiology contexts in South Africa. The study was also limited to the data from one tertiary hospital examined over a five year time period. The conclusions therefore are only applicable to the tertiary hospital being studied during the speci­ fied time period. Due to the nature of the study, records used were not de­ vised specifically for research purposes and thus may not have been maintained with the care that would be expected in a planned investigation. Notably, as diagnostic labels vary in use across SLT & Audiology services and medical categories, specific diagnoses are open to different interpretations. For example, a patient’s pri­ mary medical diagnoses may be a “cerebral-vascular accident” with SLT & Audiology services referring to “neurogenic acquired communication disorders” . This resulted in difficulties during the data collection phase which included missing records, incomplete records, and information recorded in an inconsistent manner within and between records. This is a common limitation of retrospective studies such as those by Farmer (1990) and Schneider (1992). A further problem associated with the description of communication disorders is that many disorders (for example learning difficulties) are not clearly defined (Lubker, 1997). Limitations in the interpretation of the results included lack of comparison data from other sites, limited ability to generalize the findings of this research to other service sites, and that the in­ terpretation was speculative in nature. Due to the descriptive na­ ture of the study, no causal or correlational assertions could be drawn (Hite, 2001). Despite such limitations, the findings can in­ form the restructuring of services in the region. The difficulties encountered with the use of records points to the need for good record keeping, which is essential for plan­ ning of healthcare services (Rhoda, 2001). Inadequate records can distort research results, prevent clients from being involved in re­ search and negate the quality of research (Farmer, 1990). There­ fore, methods of recording client information and treatments used need to be reviewed (Farmer, 1990). This information is not only useful for research, but also when assessing cost-efficiency of a service (Rhoda, 2001). The limited access to SLT & Audiology services in the Western Cape, as reflected in the poor attendance rates obtained in this study, point to the need for SLT & Audiology services at all levels, and particularly at a primary level, of care (Rhoda, 2001). Services need to be provided in line with the Primary Health Care Approach within the District Health System (Hall et al., 2002; For­ man, et al., 2004). Ideally, the services should be integrated at all levels of care and should strive towards community based rehabili­ tation. As a starting point, therapists’ participation in community outreach programmes would be advantageous. CONCLUSION This study found that the highest percentages o f clients at­ tending the SLT & Audiology OPD at a tertiary hospital in the Western Cape attended for a hearing loss (n=250; 29%) or voice disorder (N=180; 21%) and that the ENT department at the study hospital (n=203; 24%) and the education sector (n=l 11; 13%) re­ ferred the highest percentages of clients. In terms of age, the high- est percentage of clients attending the OPD were between 7 and 12 years old (n=165; 18%). Overall there were similar percentages of male and female clients who attended the OPD. English speaking clients predominated (n=501; 55%), followed by Afrikaans speak­ ing clients (n=298; 33%). Only a small percentage of clients were Xhosa speaking (n=82; 9%). Patterns of attendance showed that almost half of all the clients who attended the OPD attended only one appointment (n=353; 49%). In total just over 70% of clients attended either no more than two appointments (n=506; 70%) or attended within a three month period (n=513; 71%). With an in­ creasing number of scheduled appointments, percentage of ap­ pointments attended decreased. Given the poor attendance rates and the high number of cli­ ents in the 7 to 12 year age group seen at the SLT & Audiology OPD, there is a definite need for more adequate service provision in schools. The Department of Education in the Western Cape has very limited SLT & Audiology services (F. Lewis, personal com­ munication, February 18, 2005). However, the Department of Education (2001) emphasises the need to optimize the expertise of specialist support personnel, such as therapists, psychologists, re­ medial educators and health professionals within the school set­ ting. In the long term therefore, the service provision for learners in inclusive settings must be given urgent consideration. Cur­ rently, the Education sector in the Western Cape does not have the capacity for individual intervention in ordinary classrooms, but plans to provide preventative services and services to educators (F. Lewis, personal communication, February 18, 2005). One of the major challenges facing the SLT & Audiology profession is to provide equitable services for the multilingual populations. The scarcity of Xhosa-speaking therapists in the Western Cape is a source of concern. In the long term it would be advantageous to train and employ professionals speaking African languages. However, given the language diversity in the country, it is critical that practitioners become skilled to manage multilin­ gual and multicultural populations (Swanepoel, 2005). For exam­ ple, the inclusion of interpreters to support clinical practice is im­ portant. 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The South African Journal o f Communication Disorders, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. ) http://www.southafrica.info/ http://www.info.gov.za/ 58 Wendy Overett and Harsha Kathard APPENDIX A Data Collection Form Demographic Information - Date in file_ Client's N a m e:________________________ Date o f Birth: Folder number:_____________ Gender: Male Female Home language:_____________ Full Residential Address: Monthly Family Income: N o o f dependants: Hospital category: Free HO HI H2 H3 Private Marital Status: Single W idowed Married Divorced N ot Given N A Occupation: Pensioner Grant Other:________________________________ Diagnostic information Medical D iagn osis:__________________________________________________ Speech/Audio Diagnosis: Referral source: Date assessed: Attendance information (write every date) Dates attended therapy sessions: Dates cancelled therapy sessions: Dates o f appointments missed: D ie Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 53, 2006 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 2. )