E V I D E N C E BASED P R A C T I C E IN SPEECH L A N G U A G E P A T H O L O G Y / A U D I O L O G Y IN I N D I A i G e e ta M u k u n d a n R ead er & H ead , D e p t, o f S p eech -L a n g u a g e P athology, A.Y.J. N a tio n a l In s titu te fo r t h e H e a rin g H a n d ic a p p e d , M u m b a i, India A b s tra c t i T h is o p in io n a rtic le a d d re s s e s th e is s u e o fE B P in a c a d e m ic , re s e a rc h a n d c lin ic a ls e ttin g s in In d ia . E B P is n o ta n a lie n c o n c e p t fo rS p e e c h -L a n g u a g e P a th o lo g is ts /A u d io lo g is ts in th e c o u n try .M o s tp r o fe s s io n a ls in p ra c tic e a r e a c q u a in te d w ith th e id e a o f in te g ra tin g c u rre n t research e v id e n c e w ith clinical e x p e rtis e in th e c o n te x t o f th e client's o w n life s itu a tio n . W ith th e a im o fe lim in a tin g n o n s ta n d a rd p ractice p a tte rn s in b o th a s s e s s m e n ta n d in te r v e n tio n ,e x p e r ts in th e fie ld h a v e d e v e lo p e d g u id e lin e s fo r w o rk in g w ith a w id e r a n g e o f clinical p o p u la tio n s in In d ia . M o n o g ra p h s a n d jo u rn a ls a re b e in g p u b lis h e d p e ­ rio d ically b y a c a d e m ic in s titu tio n s a n d profession al b o d ie s in an e ffo r tto b r id g e th e r e s e a r c h -to -p r a c tic e g a p . This o p in io n a r tic le re v ie w s th e E B P im p le m e n ta tio n p r o b le m s u n iq u e to th e s u b c o n tin e n tin c lu d in g d iv e r s e la n g u a g e s a n d d ia le c ts ,la c k o fs ta n d a rd to o ls fo ra s s e s s m e n tin d iffe re n tla n g u a g e s ,fin a n c ia lc o n s tra in ts ,illite ra c y ,n o n a v a ila b ility o fs p e c ia liz e d c e n te rs a n d th e lack o f a m e c h a n is m to m o n ito r clinical practices in In d ia . The disciplines o f Speech-Language Pathology and Audiology have been in existence in India from the early 60s (Nikam, 2003). The first speech and hear­ ing centre was established at Mumbai and soon after a di­ ploma course in speech and hearing was started. This was followed by the establishment o f an Institute at Mysore in 1966 and commencement o f undergraduate and postgradu­ ate degrees in both Speech-Language Pathology and Audi­ ology. Thus began a slow but steady increase in the number o f Speech-Language Pathologists and Audiologists in the country. The Indian Speech and Hearing Association (ISH A ) was formed in 1967 (Rathna, 1993). Its inception marked the growth and interest in services rendered by the profes­ sion. I t has both regular members as well as associate mem­ bers. However, it is not mandatory for all professionals to be members o f IS H A ' I t neither has powers to grant licenses nor to place strictures on professionals who indulge in mal­ practices. The Indian perspective on evidence based practices Evidence based !health care is a concept that is gaining ground steadily in India. The notion has found acceptance in the medical institutions and is being promoted by the professional bodies! The movement is currently catching on with a number o f training and awareness programs being conducted to improve skills and facilities fo r making such practice widespread among the medical fraternity. The term Evidence Based Practice (E B P ) is used in Speech-Language Pathology and Audiology to refer to per­ spective on clinical decision making (A SH A , 2 0 04). It refers to the integration o f current best research evidence, clini­ cal expertise, and the client’s perspectives in making de­ cisions about the care o f individual patients (Schlosser 8c Raghavendra, 2 0 04). I t is acknowledged amongst academ­ ic Speech-Language Pathologists and Audiologists in In ­ dia that empirical evidence is crucial for decision making in routine clinical practice. There is a need to look to empirical evidence to support the assessments and interventions and determine the most efficacious, effective and efficient ways o f providing services (Frattali 8c Golper, 2 0 06). W ith the aim o f eliminating nonstandard practice pat­ terns in assessment, experts in the field have developed a set o f standard tests and procedures, known as the IS H A B a t­ tery, for professionals working with different clinical pop­ ulations (Kacker 8c Basavaraj, 1990). Additionally, mono­ graphs on topics o f interest as well as journals have been published periodically by IS H A as well as other institutes. These are aimed towards bridging the research-to-practice gap in India. The framework o f E B P is not new to clinicians in In ­ dia except, perhaps, for those in non-academic work settings who graduated in the 1960s. M ost professionals in practice are acquainted with the idea o f integrating current research evidence with clinical expertise in the context o f the clients own life situation. The International Classification o f Func­ tioning, Disability and Health (W orld H ealth Organization, 2001) is currently used by academic institutes and individual practitioners for profiling clients to determine the impact o f disability in the real world. W h ile there is the tendency to rely on old ways and rules o f thumb, this is giving way to application o f new and better information today. Clinicians acknowledge their need for research database and hands-on training especially in areas that have assumed importance in the current scenario. In recognition o f the relevance o f EBP, the curriculum o f the M aster’s training program in Speech-Language Pa­ thology and Audiology includes topics on the subject. The IS H A also encourages presentations to be made on the top­ ic at its annual conferences. As the domain o f Speech-Lan- guage Pathology has expanded to include dsyphagia and other upper aerodigestive disorders, practitioners constantly feel the need to acquaint themselves with new information and best possible assessments and interventions. Author Contact: Dept, o f Speech Language Pathology Bandra Reclamation(W) Mumbai 400050 India E-mail: gmuk5@yahoo.com TH E S O U T H A FR IC A N J O U R N A L OF C O M M U N IC A T IO N D ISO RD ER S, V O L 5 5 2 0 0 8 13 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. ) mailto:gmuk5@yahoo.com GEETA M U K U N D A N Opportunities offered via E B P for development of SLP/Audiology practices, professional education and/or research Professionals in India are increasingly becoming aware o f the need to make decisions by identifying such evidence that there may be for a practice and rating /evaluating it ac­ cording to how scientifically sound it may be. This is done with an aim to eliminate unsound or risky practices in fa­ vor o f those that have better outcomes. A good number o f Speech-Language Pathologists/Audiologists do adopt the principles o f E B P in their work lives, although the term is not widely used. G reater emphasis on such an approach would encourage more professionals to search for best evi­ dences by reviewing the literature, thus inculcating the habit o f keeping in touch with libraries, subscribing to relevant publications or engaging in literature search on the internet. They perforce would need to hone their skills o f critical ap­ praisal and technical writing as well. The offshoot is that the professional life o f Speech-Language Pathologists/Audiol­ ogists would evolve which, in turn, would contribute to bet­ ter care for their clients. The professional body would also be in a position to bring out policy documents on E B P and also implement guidelines for clinical practice. However, unlike the W est, the demand for accountability is not often voiced as insurance companies and other payers do not play a large role in this sector. The majority o f research papers that are submitted for presentation at the annual conferences o f IS H A and for publication in its journal, demonstrate that Indian profes­ sionals do apply the E B P framework as a routine. However, most o f these authors are attached to academic or research institutions. Such institutions provide good library facilities, access to internet resources and opportunities for attending seminars/ workshops. Moreover, as a procedure, research proposals are screened by academic and ethics committees for approval, thus ensuring that they meet the standards. Continued education programs for speech and hearing professionals have been a fervent endeavor o f IS H A as well as lead institutions in the country. As E B P comes to center stage in India, it would mandate that the themes for such programs focus on the relevance o f summarizing research as well as guiding professionals on how to understand and apply research findings. For instance, as research outcomes encourage the use o f cochlear implants in young children, more clinicians sign in for such training programs to im ­ prove their knowledge o f research based evidence for appro­ priate decision making. Speech Language Pathologists/Audiologists working in India are required to be registered under the Rehabilitation Council o f India (R C I). For renewal o f their licenses every seven years, it is mandatory that they attend continued edu­ cation programmes (C E P ) so that they update themselves. Such opportunities could be used to educate professionals on applying research data to clinical practices. Also it serves as a platform for exchanging information on outcome meas­ ures, test selection considerations, and measures o f disabil­ ity. The weakest link in the process o f addressing E B P has been the non-availability o f standard assessment tools in the various Indian languages. W ith 18 official languages and many hundreds o f dialects, the scenario is daunting even to the most diehard proponent o f EBP. However, while a be­ ginning has been made in some main languages, there is a need to develop similar tools for the others. Lead institu­ tions have also made efforts to develop indigenous software and assessment kits to enable clinicians to measure out­ comes in clinical practice. As E B P becomes the approach o f choice, certainly greater priority would need to be given to this issue. Researchers and administrators would then ad­ dress the problem with greater urgency. However, it is also important that the limitations o f the E B P framework be realized by the professionals. It would seem appropriate to use the E B P orientation mainly where there is uncertainty. W h en a condition is quite apparent and can be diagnosed quite accurately, the use o f elaborate testing would be unwarranted. In my opinion, most clini­ cians in India, by virtue o f their exposure to a large variety o f cases during training as well as in their work lives, have developed the skills o f making accurate diagnoses without resorting to extensive testing. Potential problems/threats to professional develop­ ment in the country India is a vast country with a teeming population o f over one billion. The bulk o f its people live in the villages where basic facilities are far from adequate. Its large and diverse population is a melting pot o f various beliefs and practices. Superstitions and quackery are rife in certain areas o f the country especially where illiteracy predominates. N ot sur­ prisingly, clients/caregivers generally consult a Speech-L an- guage Pathologist/Audiologist long after the crucial years have been lost to such endeavours. A myriad o f problems are encountered by the Speech- Language Pathologists/Audiologists in clinical practice. They grapple with large caseloads and frequently do not have the time for detailed record keeping and documenta­ tion. Financial and time considerations may constrain oth­ ers in applying standard procedures and tests. O ftentim es, their decisions are made keeping in view the resources o f the clients or their parents, their location, availability o f profes­ sional/educational services, and ability to attend follow-up appointments. Assessments are short circuited i f the client/caregiver is unable or unwilling to spend time or funds for detailed test­ ing or to make another visit to the centre. For instance, for a case with hoarse voice who cannot afford an endoscopy, the clinician may decide to make do with a perceptual assess­ ment and refer the client to an Otolaryngologist. Interven­ tion plans, too, may hinge on factors such as distance from the centre, availability o f transport as well as an escort to ac­ company the client to the session, follow-up o f hom e-pro- grammes, and affordability o f the charges. It may be noted that services provided at Government run hospitals are free or nominal while private establish­ ments levy higher charges. Clients have to be able to meet the expenses involved as there is no insurance cover unless a policy has been purchased. W h ile Government agencies provide hearing aids and some devices free o f cost for the needy, oftentimes clients would have to look out for them­ selves. Professionals thus have to lim it themselves to options that are affordable for their clients. 14 | DIE SU ID -AFR IK A A N SE TY D SK R IF VIR K O M M U N IK A S IE -A FW Y K IN G S , VO L. 55, 2 0 0 8 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. ) E V ID E N C E B A S E D P R A C T IC E IN S P E E C H -L A N G U A G E P A T H O L O G Y /A U D IO L O G Y IN IN D I A I believe that clinicians deal with two main groups o f cli­ ents: the informed, literate and internet savvy on one hand and the uninformed, naive and gullible on the other hand. The former usually is willing to invest time and money in the endeavor to obtain precise and detailed evaluations o f their ward; O n the other hand, the latter would be inclined to give the procedures short shrift and look for quick and easy solutions. Scheduling detailed evaluations would not be in the interest o f their child who would lose out should the caregiver decide that the process was too tedious and give up altogether. Hence the professional would be forced to make compromises. In some settings, only one professional is available to deal with a big client load. T im e constraints dictate that evalu­ ations be cursory so that more clients could be examined and ensure that intervention programs, too, can be carried out. Detailed client documentation would not be possible in such a scenario. However, qualitative and quantitative meas­ ures are frequently used. The effectiveness o f intervention is verified through such means and also through self assess­ ment by the client and his family. For professionals in private settings, attending seminars, conferences or workshops is not frequently encouraged. The management frowns on time lost in such activities and the loss o f revenue on account o f the absence o f the clinician. The practitioner thus has little opportunity for professional development and has to make extra efforts to keep abreast o f research and development in the field. The management, however, has to take cognizance o f the fact that the profes­ sional has to attend at least three C E P s in order to get his/ her license renewed by the R C I. T o their credit, the training programmes for Speech- Language Pathologists/Audiologists in India provide great depth o f insight to students in dealing with a variety o f cli­ ents. Students learn to do a thorough workup using exten­ sive documentation in an institutional setting, for example, but also learn how 'to conduct screening at camps where hundreds o f people gather to have their hearing, language or speech evaluated! They learn to carry out assessments and interventions using the cornerstones o f E B P ; yet they also learn about areas where E B P is not critical. The need to be flexible and to keep the client’s perspective in mind in decision making is encouraged in student training pro­ grams. Reviewing current literature, making critical judg­ ments, weighing options with the concerns o f the clients in mind are emphasized during their clinical training. T o conclude, the E B P orientation is not alien to the In ­ dian system o f perception and thought. Indian professionals generally subscribe to a broader perspective in terms o f re­ search and practice. They are naturally inclined to study hu­ man behavior as a whole rather than to look for specific rules o f behavior. Further, given the time and other demands on practicing professionals, the application o f E B P is not con­ sidered appropriate in all settings, especially for busy clinics. However, there is little doubt that such an orientation has the potential to improve the quality o f evidence supporting clinical practice in Speech—Language Pathology and Audi­ ology and, ultimately, the quality o f services to patients with speech, language and hearing disorders (A SH A , 2 0 04). References American Speech-Language and Hearing Association (2004). Evidence-Based Practice in Communication Disorders (Techni­ cal Report). Retrieved July 16, 2008 from www.asha.org/NR/ rdonlyres. Frattali, C.M. 8tGolper, L.A. (2006). Evidence-based practice and outcome oriented approaches in Speech-Language Pathology. In A.F. Johnson and B.H. Jacobson (Eds.).MedicalSpeech-Lan- guage Pathology: A practitioner's guide (2nd Edition). New York: Ihieme. Kacker, S.A. 8c Basavaraj, V. (1990). (Eds.). Indian Speech, Lan­ guage and Hearing Tests: The ISHA Battery. Mysore: Indian Speech and Hearing Association. Nikam, S. (2003). Hearing Impairment. In C.L.Kundu (Ed.). Dis­ ability Status India. New Delhi: Rehabilitation Council of In­ dia. Rathna, N. (1993). Speech and Hearing in India: Thirty years. My­ sore: Indian Speech and Hearing Association. Schlosser, R.W. 8c Raghavendra, P. (2004) Evidence based practice in Augmentative and Alternative Communication. Augmenta­ tive and Alternative Communication, 2 0 , 1 , 1-21. World Health Organization (2001). International Classification o f Functioning, Disability and Health (ICF). Geneva: WHO. TH E S O U T H A FR IC A N J O U R N A L OF C O M M U N IC A T IO N D ISO RD ER S, V O L . 55 2 0 0 8 | 15 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.asha.org/NR/