13 Early Communication Intervention within a Community-based Intervention - Model in South Mrica Lisl Fair and Brenda Louw Centre for Early Intervention in Communication Pathology Department of Communication Pathology University of Pretoria ABSTRACT Infants and toddlers with special needs within the developing context in South Africa are not currently receiving adequate early communication intervention services. The development of a model for service delivery to this population is impera· tive for the successful implementation of early communication intervention in the developing context in South Africa. The basic model of early intervention service delivery provides a theoretical basis for early intervention service delivery but has certain limitations when applied to the developing context in South Africa. Community· based intervention is pro- posed as an avenue for the delivery of health care services within primary health care although constraints in the appli- cation of community-based intervention exist. An integrated model of early communication intervention service delivery within community-based intervention is proposed and illustrated by presenting a case example. OPSOMMING Jong kinders binne die ontwikkelende konteks in Suid-Afrika wat 'n risiko toon om 'n kommunikasie-probleem te ontwikkel, of wat reeds 'n probleem toon, ontvang tans nie voldoende vroeekommunikasie-intervensie-dienste nie. Die ontwikkeling van 'n diensleweringsmodel vir die populasie is noodsaaklik vir die suksesvolle implementering van vroeekommunikasie- intervensie in die ontwikkelende konteks in Suid-Afrika. Die basiese model van vroee-intervensie-dienslewering verskaf 'n teoretiese basis vir vroee-intervensie-dienslewering, maar het sekere beperkinge binne die Suid-Afrikaanse konteks. Gemeenskapsgebaseerde intervensie binne die primere gesondheidsorg-model is voorgestel as die wyse waarop gesondheidsdienste in die ontwikkelende konteks ge'implimenteer behoort te word, alhoewel die toepassing van gemeenskapsgebaseerde intervensie sekere probleme kan oplewer. 'nGe'integreerde model van vroeekommunikasie- intervensie-dienslewering binne gemeenskapsgebaseerde intervensie word voorgestel en geiUustreer deur middel van 'n / gevallestudie. ) I KEY WORDS: early comfnunication intervention, developing context, community-based intervention 1 INTRODUCTION Early intervention hasi been established internation- ally as accepted practice for se~ice delivery to infants and toddlers with special needs over the past two decades (Guralnick, 1997). Early intervention constitutes services aimed at the prevention of developmental disorders and the facilitation of age appropriate developmental skills in infants and toddlers with special needs (Thurman & Widerstrom, 1990). In South Africa early communication intervention, as a field within speech-language pathology, developed gradually over the past twenty years to provide infants and toddlers with special needs with communica- tion-based intervention aiming at the prevention of com- munication disorders and the age appropriate facilitation of early communication skills (Louw, 1998). The current context in South Africa in which early com- munication intervention services are delivered is hetero- geneous, since mixed dev;eloped and developing sections are present in South Africa (Schoeman, 1991). Approxi- mately half of the population live in developing rural ar- eas, while the rest live in developed urbanized areas. The 1996 sensus indicated that the population in South Africa is of diverse nature, constituting of indigenous Africans, Asians, people from Caucasian decent and also people with a mixed racial heritage (Pickering, McAllister, Hagler, Whitehill, Penn, Robertson, McCready, 1998). Apart from these demographic indicators influencing early communi- cation intervention service delivery in South Africa, the transformation of the national health system to primary health care, also implies that service delivery by speech- language pathologists must be tailored to fit.into the cri- terion of primary health care (Pickering et al., 1998). The diverse nature of the current context in South Af- rica poses a number of unique challenges to the speech- language therapists delivering early communication in- tervention services in South Africa. Challenges such as the multilingual and multicultural nature of communi- ties, the limited number of speech-language therapists working in South Africa, the geographical distribution of Die Suid·Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 14 young children with special needs, limited literacy skills of caregivers often present in developing communities, as well as environmental risk factors exist in the current South African context (Louw, 1998; Uys & Hugo, 1997). A significant number of young children in South Africa is considered to be at-risk to display developmental diffi- culties (WHO, 1997). Although a body of research has emerged over recent years concerning infants and toddlers in developing communities in South Africa, little is docu- mented about the current status of early communication intervention service delivery in that context and it is gen- erally accepted that the infants and toddlers with special needs in the developing context in South Africa are not receiving adequate services (Louw, 1998). A dire need ex~ ists to expand the early communication intervention serv- ices currently being'delivered in South Africa to include young children in developing communities. In order to deliver effective and accountable early com- munication intervention services to young children and their families in the developing context in South Africa, the development of a model for early communication in- tervention service delivery in disadvantaged communities is imperative. The purpose of this article is to provide an overview of issues pertaining to early communication in- tervention as well as community-based intervention serv- ice delivery models and secondly to propose an integrated model of early communication intervention service deliv- ery within community-based intervention. MODELS OF EARLY COMMUNICATION INTERVEN- TION SERVICE DELIVERY In presenting.a basic model of an early communication intervention service delivery system, discussion of the ter- minology underlying the model, basic tenets of early in- tervention and service delivery issues pertaining to early intervention as well as a critical review of the basic model, is imperative. The discussion will provide a basis from which the basic model can be interpreted and expanded. DEFINITION OF TERMS Since different disciplines have contributed to early intervention literature, and terminology is not always used consistently, it is necessary to define the basic terminol- ogy inherent to early intervention. Early intervention re- fers to both the assessment and treatment of infants and toddlers who are at-risk for or who are displaying a devel- opmental delay (ASHA, 1989). Early communication in- tervention constitutes early intervention from a commu- nication-based perspective and these services are deliv- ered by speech-language therapists (Rossetti, 1996; McDonald & Carroll, 1995). As international early inter- vention literature describes the whole early intervention process and not communication-based intervention per se (for example Guralnick, 1997; Blackman, 1995), the early intervention service delivery system will be described first and communication-based intervention will then be placed within the framework of the comprehensive early inter- vention system. At-risk infants and toddlers refer to those young chil- dren who have the potential to develop a disorder based on biological, environmental or behavioral factors (ASHA, 1991; Rossetti, 1996). In'addition, children with disorders such as syndromes or craniofacial anomalies are consid- Lisl Fair and Brenda Louw ered to have an established risk to have developmental problems since deviant or delayed development are often associated with established disabilities (Rossetti, 1996). The term, infants and toddlers with special needs (Mitchell and Brown (1991), is used in this article as an umbrella term to refer to both at-risk children as well as children with an established risk. BASIC MODEL OF AN EARLY INTERVENTION SERVICE DELIVERY SYSTEM Early intervention evolved from research indicating that infancy is a sensitive period for development, espe- cially to individuals who have special needs arising from risk factors or established disorders (Baird & McConachie, 1995, Mitchell & Brown, 1991). In addition to the impor- tance of early experience, the high-risk population is rap- idly expanding due to advances in medical care, The sub- sequent need to provide services for these children led to a further expansion in early intervention services (Ferguson & Brynelson, 1991). A growing recognition also exists of the rights of infants and toddlers with special needs to have equal opportunities to develop to their full pot~ntial(Mitchell & Brown, 1991). These factors led to legislation in the USA in 1986, Part H of USA Public Law 99-457 (PL 99-457), which mandates early intervention services to infants and toddlers with special needs result- ing in an expansion in early intervention services to in- fants and toddlers with special needs as well as a growing body ofliterature on early intervention (Guralnick, 1997). Early intervention is mainly concerned with the pre- vention of developmental disorders (Mitchell & Brown, 1991). Prevention can take place on thre'e levels, namely on primary level where the occurrence of a disorder is com- pletely prevented, on secondary level where the negative outcome of a present risk or disorder is minimized and on tertiary level where rehabilitation is provided for an es- tablished disorder (WHO, 1995). Early intervention is con- sidered as secondary prevention and aims to identify, evaluate and treat young children with special needs as early as possible in order to minimize the potential ~ega­ tive developmental outcome of the risk or disorder (Mitchell & Brown, 1991). . Figure 1 provides a graphical representation of a basic model of early intervention service delivery and indicates that such a system usually comprises four basic corp-po- nents, namely an early identification programme, an as- sessment facility as well as a treatment programme which is managed and supported by an administrative compo- nent (Rossetti, 1996; Mitchell & Brown, 1991; Baird & McConachie, 1995). As indicated in Figure 1; each component of early in- tervention has distinct goals in order to realize the pri- mary goal of early intervention, which is to prevent devel- opmental disorders and minimize the potential negative effect of risk factors and established disorders by facili- tating development (Mitchell & Brown, 1991). The goal of the identification component is to identify infaI1ts and tod- dlers with special needs as early as possible and to usher them into the assessment component of the early inter- vention system (Rossetti, 1996). The assessment compo- nent serves as a diagnostic facility and provides a profile of strengths and weaknesses by Identifying the develop- mental level of the infants and toddlers served. The infor- mation obtained from the assessment serves as the basis / TheSouth African Journal of Communication Disorders, Vol, 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) Early communications intervention within community·based intervention model in South Mrica 15 from which treatment is planned (Rossetti, 1996). The treatment component consists out of the age appropriate facilitation of developmental skills, within a family centered approach, in order to assist· the high·risk infant or toddler to reach his or her full developmental potential (Mitchell & Brown, 1991). The basic model describing an early intervention serv- ice delivery system is simplified. Certain tenets are fun- damental to the early intervention service delivery sys- tem and a number of service delivery issues arise from the basic model. These tenets and issues are discussed in the following sections. BASIC TENETS OF EARLY INTERVENTION ASHA (1989) emphasizes four basic principles that should be included in an early intervention service deliv- ery system by stating that services should be comprehen- sive, community-based, family-centered and that services should be coordinated adequately. Children who are con- sidered to be at-risk or display an established risk often have complex and diverse developmental and health needs and an early intervention service delivery system should provide a comprehensive array of services to meet the needs of these children within their communities (Guralnick, 1997; ASHA, 1989). The importance of the context in which development takes place is increasingly recognized (Thurman & Widerstrom, 1990). This recognition led to the inclusion of parents and families within the early intervention proc- ess (Guralnick, 1997). The comprehensive nature of early intervention service delivery necessitates the effective co- ordination of the different services that infants and tod- dlers with special needs often need to .receive to prevent the fragmentation and duplication of services (Guralnick, 1997). SERVICE DELIVERY ISSUES PERTAINING TO THE EARLY INTERVENTION SERVICE DELIVERY MODEL Different settings of serVice delivery are discussed in literature, these include centre-based services, home-based services as well as a combination of home- and centre-based services (Rossetti, 1996). Centre-based early intervention services are provided within the context of an early inter- vention centre, whereas home-based services are provided at the home of the family with the infant or toddler with special needs (Rossetti, 1996). Within an centre-based set- ting parents have greater access to professionals and more Early Intervention Primary goal: To prevent the occurrence of developmental delays and disorders and to reduce the severity of existing developmental delays and disorders as early as possible through the faCilitation of development. ' ' Basic Components of an Early Intervention Service Delivery System /' Identification / S,creening Goal: Early identification of infants and toddlers who d i emonstrate or art; at-risk for demonstrating: a delay or disorder in de~elop- ment. Assessment Goal: To determine the high-risk toddler's infant level or of functioning in his or her respecti ve developmental domains, in order to compile a profile of strong and weak points in development from which, treatment can be planned. Administration Component Treatment Goal: To facilitate the acquisition and use of age appropriate developmental skills in young children, including all' their developmental domains, within a family focused treating plan, Goal: To manage, coordinate and support the early intervention service delivery system, and to provide logistic services such as attendance to administrative details. FIGURE 1: Basic modeliof an early intervention service delivery system(conceptualized from Mitchell & Brown, 1991; Baird & McConachie, 1995; Rossetti, 1996). Die Suid-Afrikaanse Tydskrifuir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 16 opportunities to meet other parents with children with special needs, but the home environment utilized by the home-based approach is considered to be a more natural and functional context in which to provide services (Rossetti, 1996) PL-457 made the involvement of a team in early in- tervention mandatory and since teamwork is no longer an option but a necessity in the USA, a renewed focus was placed on ways teams can be organized in effective ways (McGonigel & Garland, 1995). Three models of team in- volvement in· early intervention are described by numer- ous authors, namely multidisciplinary teamwork, inter- disciplinary teamwork and transdisciplinary teamwork (McGonigel & Garland, 1995; Ferguson & Brynelson, 1991; Rossetti, 1996). Multidisciplinary teamwork is considered to be the least collaborative of the teamwork models and the functioning of multidisciplinary teams have been described as similar to parallel play in young children - 'side by side but sepa- rate' (Peterson, 1987 p. 484 in McGonigel & Garland, 1995). The interdisciplinary model of service delivery allows for more interaction and collaboration between team mem- bers by providing a framework for interaction between team members (McGonigel & Garland, 1995). Assessments are carried out by each team member separately and a meeting is scheduled where each professional shares his or her assessment findings and views. The parents are usually considered as team members and the services of a family service coordinator (case manager) are utilised to co-ordinate the process (Ferguson & Brynelson, 1991). The transdisciplinary team model of service delivery is currently viewed as one of the most efficacious ways to provide services to infants and toddlers with special needs and their families (Briggs, 1997). During transdisciplinary team functioning the focus is on the sharing of informa- tion, skills and knowledge while professionals cross tradi- tional disciplinary boundaries and parents are viewed as equal team members (Rossetti, 1996). Clinically, trans disciplinary team work is carried outby conducting a play-based arena assessment where all team members are present but only one team member elicits a sample of behaviour from the child. The team members will then make inferences pertaining to their area of expertise and share it with the team after the assessment (McGonigel & Garland, 1995). Intervention is planned in a collaborative manner and one team member is chosen to provide all the services to the child and family while consulting with the other team me~bers (Rossetti, 1996). The choice of a team: involvement model will depend largely on the orientation of the team members. If the team members arenot prepared to cross disciplinary boundaries and have trouble with role release, the transdisciplinary model is not likely to work. The choice of a team involve- ment model is not always an either or issue since some teams prefer to switch between multi- and transdisciplinary functioning in order to meet specific family needs (Ferguson & Brynelson, 1991). COMMUNICATION-BASED INTERVENTION WITH· IN THE EARLY INTERVENTION SERVICE DELIV- ERYMODEL Communication~based assessment and intervention are described as an early intervention approach focussing on the communication development of infants and toddlers Lisl Fair and Brenda Louw with special needs (Rossetti, 1996; McDonald & Carroll, 1995; ASHA, 1989). Speech-language therapists are quali- fied to provide these services and have traditionally pro- vided communication-based services to infants and tod- dlers with special needs, but in accordance with the trans disciplinary team model it is increasingly advocated C that other team members also adapt comm unication-based intervention as approach to service delivery (Rossetti, 1996; McDonald & Carroll; 1995). The following reasons are cited why communication- based intervention should be incorporated into service delivery by team members other than the speech-language therapist: • communication is often the primary vehicle used by team members for assessment and intervention; • goals would be reached more easily if professionals can communicate more readily with infants and toddlers; • children learn communication during every social con- tact and the right strategies used consistently could assist them in their learning process (Rossetti, 1996; McDonald & Carroll, 1995). As early communication skills are considered to be the best predictor for future school success, it is imperative that early communication skills be facilitated (Capute, Palmer & Shapiro, 1987). The utilisation of communica- tion-based intervention strategies by team members other than the speech-language therapist can assist in the fur- ther facilitation of communication development in infants and toddlers with special needs. CRITICAL REVIEW OF THE BASIC EARLY INTER- VENTION SERVICE DELIVERY MODEL South Africa consists of a unique mixture of developed and developing components, and this fact limits the rei· evance of service delivery models created in developed countries such as the USA, Canada and Britain (Louw, 1998). Whereas legislation played a significant role in the development of early intervention programmes in the USA, the South African government has not yet seen the need to mandate and fund early intervention services to infants and toddlers with special needs. The lack of legislation and funding may be due to limited resources availa~le in South Mrican as issues such as unemployment, lack of housing and inadequate health care facilities are consid- ered priorities for funding (Schoeman, 1991). I Apart from legislative and financial challenges, a lim· ited number of speech·language therapists are currently practicing in South Mrica and Uys (1993) estimates that by the year 2000 there would be a shortage of approxi- mately 5000 communication pathologists in South Africa. The number of speech-language therapists competent to deliver early communication intervention services is fur- ther limited by the fact that not all are trained in ~arly intervention on an undergraduate level. Those who quali- fied before early intervention was part of university cur- ricula and did not attend any continuing education events on the subject, can not be considered as qualified to de- liver early intervention services to infants. and toddlers with special needs (Louw, 1998). Certain linguistic and cultur3l constraints also exist in the diverse South Mrican context (Pickering et aI., 1998). More than eleven languages are spoken in South Africa / The South African Journal of Communication Disorders, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) Early communications intervention within community-based intervention model in South Mrica 17 and each linguistic group has unique cultural practices (Department of National Education, 1996). Assessment and intervention material developed in a western culture like the USA and Canada may not be culturally appropri- ate in South Mrica and needs to be applied with care (Louw, 1998). The shortage of speech-language therapists trained in early intervention is magnified against the background of cultural diversity in South Africa since a further short- age of culturally and linguistically diverse speech-language therapists exists although training institutions have ap- plied policies to alleviate the discrepancies of the past (Uys & Hugo, 1997). Certain elements of the basic model of early interven- tion service delivery have the potential to be applied with success in South Africa. Community-based service de- livery may be a successful strategy in South Africa, since the national health system has been changed to district based primary health care in recent years (Government Gazette, 1997). Health care facilities providing primary health care are placed within communities providing a potential platform from which to launch early interven-, tion services in all communities, both developed and de- veloping. Other elements of the basic early intervention service delivery model which could also be applied successfully within the district based primary health care system in South Africa are home visiting and family centered care. Bryant & Maxwell (1997) indicated by reviewing several early intervention programmes with disadvantaged fami- lies that for very poor families home visiting may be ben- eficial. It is estimated that 61% of children in South Af- rica live in poverty (Government Gazette, 1997), and it is proposed that the home visiting approach to early inter- vention may provide a way to reach these children and their families. The transdisciplinary model ofteam functioning also has the potential to contribute to early intervention serv- ice delivery in South Africa (Louw, 1998). The general shortage of speech-language pathologists can be accounted for in part by empowering other professionals or volun- teers to provide communication-based early intervention services. Speech-language pathologists providing early intervention services can be involved in a consultative I capacity and reach more infants and toddlers with special needs in this way. I From the discussion above it is clear that although the international literature provides a useful framework for early intervention, the speech-language pathologist pro- viding early intervention: services, especially in the devel- oping context in South Mrica, needs to be critical and crea- tive when providing early intervention services in the con- text in which he/she works. COMMUNITY-BASED INTERVENTION MODELS Community-based rehabilitation (CBR) grew out of the need to provide rehabilitation services to people with dis- abilities within the context of their families and greater communities especially in developing countries. It meant a shift away from institutionalized care where people with disabilities often received care in isolation from their fami- lies and greater communities (Chaudhury, Menon-Sen & Zinkin, 1995). A joint position statement issued by the International Labour Organization (ILO), the United Na- tion Educational, Scientific and Cultural Organization (UNESCO) and the World Health Organization (WHO) (1LO, UNESCO & WHO, 1994) provided a formal defini- tion of CBR stating the following: 'Community-based rehabilitation is a strategy within community development for the rehabilitation, equali- zation of opportunities and social integration of all peo- ple with disabilities. Community-based rehabilitation is implemented through the combined efforts of disabled people them- 'selves, their families and communities, and the appro- priate health, education, vocational and social services.' Although this definition serves as a guideline to many CBR programmes around the world, many variations ex- ist amongst CBR programmes and it is generally accepted that, there is no true blueprint for CBR programmes (Chaudhury et al., 1995). WHO advocates the use of tpe Primary Health Care (PHC) system as a platform from which to implement CBR programmes and places specific emphasis on health care issues as goals in CBR (WHO, 1995; Chaudhury et al., 1995; Werner, 1987). As South Africa recently changed its national health care system to PHC, the discussion in this article will fo- cus on CBR as an integrated part of the PHC system. Some comments on the use of the term community- based rehabilitation are warranted. The word rehabilita- tion implies the tertiary form of prevention where reha- bilitation is provided for an established disorder. The term CBR therefore excludes primary and secondary preven- tion activities, and since early intervention is considered as secondary prevention, it would be impossible to inte- grate the two service delivery models if one excludes the other by definition. It is suggested that the term commu- nity-based intervention (CBI) is used to provide a basis from which primary, secondary as well as tertiary preven- tion activities can be executed. Based on the basic definition provided above, the main aim of CBI is to bring about a balance between the needs and the resources of disabled people in a given commu- nity through community mobilization, initiative and par- ticipation (Lombard, 1991; ILO, UNESCO & WHO, 1994). This aim emphasizes community participation and initia- tive in CBI but WHO (1995) as well as Chaudhuryet a1., (1995) acknowledge that CBI seldom starts without a stimulus from outside the community making the com- munity aware ofit's"'needs and resources to deal with those needs. The external stimulus can be PHC PE!rsonnel, non- governmental organizations involved with disabled peo- ple or academic institutions (Chaudhury et al., 1995). ' Two types of goals are used in order to achieve the main aim of CBI namely task goals and process goals (Lombard, 1991). Task goals are considered to be mainly focused on obtaining results in the form of concrete tasks to be done or securing specific resources whereas process goals focus on the development of the people through the process of achieving a specific goal (Lombard, 1991; Swil, 1982). Both task- and process goals are viewed to be essential in CBI but process goals like community participation, empower- ment and responsibility are considered to be more impor- tant than simply the completion of tasks (Swil, 1982). It is postulated that if a community went through a self-devel- opment phase (process goal) while striving for a specific goal (task goal) that the community will show ownership towards the desired goal and will possess the necessary Die Suid-Afrikaanse Tydskrif vir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 18 skills and responsibility to maintain that specific goal (Lombard, 1991). Figure 2 provides a graphical representation of a basic model of a CBI programme within a PRC system. As indi- cated in figure 2, two broad functional groupings are typi- cally involved in CBI in a given community, namely mana- gerial and consultative participants and local (or direct) participants in the CBI process (Werner, 1987; Chaudhury Lisl Fair and Brenda Louw et al., 1995). The managerial and consultative participants consist out of the government institution responsible for health policies (ministry of health), the regional hospital with specialized services as well as the local primary health care clinic. These participants are responsible for mandat- ing, planning and staffing CBI services in communities. In addition to these roles the managerial and consultative participants are also involved in the training and support I BASIC MODEL OF COMMUNITY-BASED INTERVENTION WITHIN PHC I (I MINISTRY OF HEALTH I) ;t • Managerial and Consultative Regional r--..- Participants in Hospital the CBI Process ~ ~~ PHC District Clinic + ~~ ~~ -------- --- ~~ , , , ~ , " , ~ AM " " i i , \ .. ~ .. ~ ...... Local I \ .=::::::::,. I I ";::-;!~:~;'" 4 Participants in \ 1~4'+r4'+ ~4'+ I ................ \ , " " , , " ~ the CBI Process " , ~~ Local PHC "- --' -- --------- I Community Community Volunteer Community Worker i + I : I I I 1. Recognize problem / need ~ 6. Evaluation of process • t r--..-The CBI Process 2. Analyze situation 5. Take action • t 3. Do fact finding .. 4. Planning / FIGURE 2: Basic model of community-based intervention within a primary health care system (Conceptualized from Werner, 1987; Dunham (1970) in Swil, 1982; Chaudhury et a!., 1995; WHO, 1995; Lombard, 1991) / The South African Journal of Communication Disorders, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) Early communications intervention within community-based intervention model in South Africa 19 of primary health care community workers and the regional hospital and primary health care clinic serve as referral facilities offering specialized services and consultation to community workers and communities (WHO, 1995; Werner, 1987). Academic institutions and non-governmental organi- zations can also be managerial and consultative participants in CBI (Chaudhury et aI., 1995), but as these two struc- tures are not typically associated with PHC it was not in- cluded in the basic model of CBI within PHC. The local participants in the CBI process as indicated in figure 2 consist of the community itself, the local community volunteer as well as the PHC community worker (Werner, 1987; WHO, 1995). The PHC community worker can be of any primary discipline like physiotherapy, occupational therapy; PHC nursing and speech-language therapy or the person can be a mid-level health worker with a two year training in basic health issues (WHO, 1995; Government Gazette, 1997). The role of the PHC community worker is to facilitate the CBI process, to serve as a consultant to the community and to make the resources of the PHC system known to the local community (WHO, 1995). The local community volunteer can be any person who is willing to serve the community as a volunteer in con- junction with the PHC community worker. Chaudhury et aI. (1995) as well as Werner (1987) state that a person with a disability may be the ideal candidate to be a local community volunteer since he or she usually has first hand experience with issues relating to disabilities. The local community volunteer may also be a group of people in- stead of an individual (Werner, 1987). The role ofthe local community volunteer (or group of volunteers) is to work in conjunction with the PHC community worker to intro- duce the community to CBI and to assist them through the whole CBI process (Werner, 1987). The community is the key role player in the CBI proc- ess and a community can be defined as a group of people living in the same geographical area and utilizing a mu- tual infrastructure (Lombard, 1991). As community par- ticipation and initiative are key components of CBI, the role of the community in CBI can be described as one of self-development during which the community grows to fecognize needs and resoJrces within its own ranks and utilize actions to bridge those needs with available re- sources (Lombard, 1991; Werner, 1987). The CBI process as desdribed in figure 2 is derived from a problem solving approdch to community work from a social work perspective b~ Dunhum (1970) in Swil (1982). Dunhum's approach to coinmunity work (Dunhum (1970) in Swil, 1982) is executed by the PHC community worker, local community volunteer and the community and starts with step one as the recognition of the problem or need. This step involves the creation of an awareness amongst a community that a certain need (for example, inadequate facilities for disabled people) exists (Lombard, 1991). The next step is described by Dunhum (1970 in Swil, 1982) as situation analyses and involves compiling a pro- file of existing needs and potential resources in a commu- nity. When a profile of the community has been compiled the next step namely, fact finding, is executed (Dunhum (1970) in Swil, 1982). The specific actions during the fact finding phase will largely be determined by what the per- ceived needs and resources of the community are. The next step described by Dunhum (1970 in Swil, 1982) is planning and Wernerl(1987) states that it is essential that the community be fully involved in decision making and the setting of realistic goals in order to ensure that the community possesses a sense of ownership over the project. The next logical step after the planning has been done, is for action to be taken by the community (Dunhum (1970) in Swil, 1982). The last step in Dunhum's approach (Dunhum (1970) in Swil, 1982) is the evaluation of the process and WHO (1995) describes it as a crucial element in CBI in order to ensure that the process has been suc- cessful and to gain understanding of how the process can be enhanced within the community. The description of a basic model of CBI within PHC is a simplified description of a complicated system where considerable variations exist between programmes (Chaudhury et aI., 1995). The PHC approach has also been depicted in a simplified manner in the model in figure 2 since in practice one PHC district clinic will often serve more than one community and a substantial number of PHC district clinics are associated with one regional hos- pital (Government Gazette, 1997). For the scope of this article, the basic model does however supply an adequate point of departure for the integration of early communica- tion intervention into a CBI model if cognizance is taken of the following critical review of the CBI model. CRITICAL REVIEW OF THE COMMUNITY-BASED INTERVENTION (CBI) MODEL WITHIN PRIMARY HEALTH CARE One of the problems identified in CBI is that of col- laboration between the different participants in the CBI process (Chaudhury et aI., 1995). The needs and resources that the community perceives may not be those that the other participants in the CBI process anticipated and dif- ferent sections of the community may have different per- ceptions of the needs, resources and action that needs to be taken (Chaudhury et aI., 1995). Another potential prob- lem in CBI is that of conflicting priorities where issues like extreme poverty, violence, hunger and homelessness in a community may override the PHC community work- er's priority of for example facilitating care for children with disabilities in a community (Chaudhury et aI., 1995). Chaudhury et aI. (1995) warns that CBI cannot be im- plemented within selective PHC where fundamental principles of PHC (for example community participation and comprehensive, integrated health care) are not ad- hered fo. A full implelI}entation of comprehensive and in- tegrated PHC is therefore necessary before CBI can suc- cessfully be integrated into PHC. The PHC system in South Africa is still in its infancy as it was only formally insti- tuted in 1997 (Government Gazette, 1997) and limited personnel, support services, training in CBI and experi- ence may pose a unique challenge to CBI in South Africa. An essential element of CBI, namely the availability of support services like PHC clinics and regional hospitals, is imperative to the success of CBI programmes (Chaudhury et aI., 1995). It will be unethical if a commu- nity is made aware of its" needs but the PHC personnel is unable to provide resources or train local people to pro- vide services. Some obstacles to effective CBI may also lie within the community itself. A presupposition of CBI is that com- munities are eager to be empowered and are willing to take responsibility for their needs but communities are not always able to take responsibility (Chaudhury et aI., 1995). The incapacity to take responsibility for a CBI pro- Die Suid-Afrikaanse Tydskrifvir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) 20 Lisl Fair and Brenda Louw gramme may be due to poverty and lack of infrastructure, lack of confidence in their own abilities or lack of interest in the goals of a specific project (Chaudhury et al., 1995). McConkey (1995) also warns that the cultural percep- tions of a specific community towards disabilities may be a barrier to the successful implementation of CBI and a broad social change in attitude may be necessary as part ofthe CBI process. Another factor potentially influencing the success of a CEI programme is the availability and attitude oflocal community volunteers. They often have their'own issues and problems within the community and it may have a detrimental effect on the CBI process (Chaudhury et al., 1995). CBI should not be viewed as a low cost option for the poor in developing countries as even developed countries like the USA and Britain are implementing community- based care as part of comprehensive health services (Chaudhury et al., 1995). It is clear that the CBI process is not void of challenges, but it still is considered as an excellent way to provide services to people with disabili- ties within the context of their communities (Chaudhury et al., 1995). Implementation of early communication intervention services through CBI Institution, planning and staffing of early communication intervention services within CBlby the managerial and consultative participants in CBI Recruitment of local community volunteer by PHC personnel Execution of CBI process' to establish early intervention services in the community by the PHC community worker, the local community volunteer and the community TASK GOALS 1. Recognize need + 2. Analyze situation t 3. Find facts 4. Plan t t 5. Execute action 6. Evaluate process + 7. Institute change PROCESS GOALS Goal: Create awareness of the importance of early communication de- velopment and the relevance of communication development for school success. Goal: Compile a profile of needs and resources in the community. For example, resources include: birth attendants and a group of primary care givers are willing to participate in project, whereas needs include: no services for infants and toddlers with special needs exists at the moment. Goal: Find facts pertaining to needs and resources. For example, conduct a survey about the number of infants and toddlers with special needs in the community; find out about the possibility of state funding for a local day care centre, Goal: Draw up goals pertaining to the implementation of services for infants and toddlers who are at-risk for communication disorders. For example plan 'how these infants will be identified, how they will be assessed, how intervention will be provided and where support services may be found. Goal: Implement the early communication intervention services in the community by for example training the birth attendants and primary care· givers in principles regarding identification and training the local community worker how to make referrals and provide basic intervention strategies. Goal: Evaluate the process by reflecting on the value of the services and process to the community by for example determining the developmental outcomes of the recipients of the services. Goal: Based upon the evaluation of the implementation of early communication intervention services through the eBI process, make changes to the service" delivery system to be more effective. FIGURE 3: Basic implementation of early intervention services through community-based intervention (Derived from Dunhum, 1970 in Swil, 1982; McConkey, 1995) / The South African Journal of Communication Disorders; Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) Early communications intervention within community-based intervention model in South Mrica 21 INTEGRATED MODEL OF EARLY INTERVENTION SERVICE DELIVERY WITHIN COMMUNITY-BASED INTERVENTION From the discussion of an early intervention service delivery model and a community-based intervention model it is clear that mutual objectives exist between these mod- els of service delivery. Both models emphasize the role of the family in the intervention process, advocate the im- plementation of community-based services and focus on the empowerment and training of others (Louw, 1998). Early communication intervention can make a valuable contribution in the integration of the two models by plac- ing emphasis on prevention whereas CBI can bring a new dimension into early communication intervention service delivery with its focus on community participation. The individual strengths ofthe two models integrated into one model of service delivery may provide a powerful tool for the primary, secondary and tertiary prevention of com- munication disorders through the participation of the com- munity in South Africa. The proposed integration of the two service delivery models is presented in two sections. Firstly, the implemen- tation of early communication intervention services through CBI is discussed as a point of departure for the discussion on the integration of the two models. The inte- gration ofthe two models is then discussed by referring to a case example of the functioning of early communication intervention service delivery within a CBI model. Figure 3 provides a graphical representation of the implementation of early communication intervention serv- ices through a CBI model. As indicated in figure 3, the establishment of early communication intervention serv- ice delivery within a CBI model can start once the mana- gerial and consultative participants in the CBI process (e.g. the Ministry of Health, regional hospitals and the primary health care clinics) have instituted legislation for early communication intervention to be applied through CBI, planned the implementation thereof and provided the necessary personnel to implement the process (Chaudhury et aI., 1995). i The next step in the provision of early communication intervention through the C"· •.. • •• >>:'.>'. .,~ .:~ Level ; ii 8 J;~ ~ 8 J;/~ Local c(lmmunity IMPLEMENT SERVICE IDENTIFIES I v()lun!cc~ and PHC PLAN AND CONSULT AND COlllmllllltv worker WITH PHC SPEECII- Child \."ith cleft lip mul Birlh REFERS TO t LANGUAGE TIIERAPIST Child with cleft lip and palate and his family ~lttendunl t . pnlale and his ramily --. ~ ~ FIGURE 4: Case example of the functioning of early communication intervention service delivery within a CBI model (derived from Werner, 1987; McConkey, 1995; Chaudhury et al., 1995). ,/ The South Afr.ican Journal of Communication Disorders, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 ) .. 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CBR Community-based Rehabilitation For and With People with Disabilities. Joint Position Paper. Geneva: WHO, ILO; Paris: UNESCO. Lombard, A. (1991). Community Work and Community Development. Pretoria: HAUM Tertiary. Louw, B. (1998). Early Communication Intervention in the South African Context. Lecture presented: Master's Degree Course, University of Witwatersrand, Johannesburg. McConkey, R (1995). Early Intervention in developing countries. In Zinkin, P. & McConachie, H. (Eds.). Disabled Children and Developing Countries. London: Mac Kieth Press. McDonald, J.D. & Carroll, J.Y. (1995). A partnership model for communicating with infants at-risk. In Blackman, J.A. Treatment Options in Early Intervention. Maryland: Aspen Publications. McGonigel, M.J. & Garland, C.w. (1995). The Individualized Family Service Plan and the early intervention team: team and family issues and recommended practices. In Blackman, J.A. Working with Families in Early Intervention. Maryland: Aspen Publications. 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Locum & Permanent vacancies for: .:.asa • locums Speech Therapists in the UK • Free personal tax advice • Free indemnity & PA Insurance • UK entry clearance advice • Accomodation often arranged • RCSLT registration refund* *subject to conditions ANGELA SHAW ASSOCIATES Call us free from South Africa on: 0800 990 767 call: +44 (0)20-8554 7691 fax: +44 (0)20-8554 9900 email: locums@asa-Iocums.co.uk Montrose House, 412-416 Eastern Avenue, liford, Essex, IG2 6NQ, UK. Die Suid:Afrikaanse Tydskrifuir Kommunikasieafwykings, Vol. 46, 1999 R ep ro du ce d b y Sa bi ne t G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r ( da te d 20 12 )