Perceptions of rural primary healthcare personnel

Perceptions of rural primary healthcare personnel
Page 1 of 11
Original Research
Perceptions of rural primary healthcare personnel
about expansion of early communication intervention
Jeannie van der Linde1
Alta Kritzinger1
Department of
Communication Pathology,
University of Pretoria,
South Africa
Correspondence to:
Jeannie van der Linde
[email protected]
Postal address:
University of Pretoria,
Department of
Communication Pathology,
Private Bag X20, Hatfield,
Received: 17 May 2013
Accepted: 17 August 2013
Published: 25 Oct. 2013
How to cite this article:
van der Linde J, Kritzinger A.
Perceptions of rural primary
healthcare personnel
about expansion of early
communication intervention.
Afr J Prm Health Care Fam
Med. 2013;5(1), Art. #553,
11 pages. http://dx.doi.
© 2013. The Authors.
Licensee: AOSIS
OpenJournals. This work
is licensed under the
Creative Commons
Attribution License.
Background: Early communication intervention services rendered by speech-language therapists
and audiologists to families of infants and young children with feeding difficulties, hearing
loss or emerging communication disorders should be implemented throughout South Africa.
Early intervention can ameliorate risks, enhance development and may prevent further delays.
Based on research initiated during a community-service year experience in a rural subdistrict,
an incremental process of establishing accessible early communication intervention services was
deemed feasible. Such a process cannot be successful if the collaboration of primary healthcare
personnel and managers is not ensured.
Objectives: The aim of the article was to describe the perceptions of primary healthcare
personnel with regard to expansion of early communication intervention services to infants at
risk of developmental delay.
Method: A qualitative descriptive survey design was followed. Semi-structured interviews
were conducted with 20 primary healthcare nurses and sisters and eight primary healthcare
programme managers in Ditsobotla subdistrict in the North West province of South Africa.
Results: The participants indicated that by improving team work, developing training
programmes and evaluating identification methods and resources, the step-by-step rollout of
early communication intervention functions on four organisational levels may be a realistic goal
for sustainable services in the resource-limited district.
Conclusion: The positive perceptions and contributions by participants promise a rich
human-resource basis for transdisciplinary collaboration between speech-language therapists,
audiologists and primary healthcare personnel in order to reduce the burden of early
communication disorders in a rural district.
Les opinions du personnel de soins de santé primaires sur le développement des interventions
en troubles précoces de la communication
Contexte: Les services d’intervention en troubles précoces de la communication fournis par les
orthophonistes et audiologistes aux familles de nourrissons et jeunes enfants présentant des
difficultés d’alimentation, une perte auditive ou des débuts de troubles de la communication
devraient être mis en place dans toute l’Afrique du Sud. L’intervention précoce peut limiter les
risques, améliorer le développement et contrer des retards supplémentaires. Sur la base d’un
travail de recherche entrepris pendant une expérience d’un an de service communautaire dans un
sous-district rural, un processus progressif d’établissement de services accessibles d’intervention
en troubles précoces de la communication a été jugé faisable. Un tel processus ne peut réussir si la
collaboration du personnel et des cadres de soins de santé primaires n’est pas assurée.
Objectifs: Le but de l’article était de décrire les opinions du personnel de soins de santé primaires
quant au développement des services d’intervention en troubles précoces de la communication
chez les nourrissons à risque de retard du développement.
Méthode: Un modèle d’étude descriptive quantitative a été suivi. Des entretiens semi-structurés
ont été conduits avec vingt infirmiers/-ières et sœurs et huit responsables de programme de soins
de santé primaires dans le sous-district de Ditsobotla, dans la province sud-africaine du NordOuest.
Résultats: Les participants ont indiqué qu’en améliorant le travail d’équipe, en développant
des programmes de formation et en évaluant des méthodes et ressources d’identification, le
déploiement étape par étape de fonctions d’intervention en troubles précoces de la communication
à quatre niveaux organisationnels pouvait être un objectif réaliste pour des services durables dans
ce district aux ressources limitées.
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Conclusion: Les opinions et contributions positives des participants laissent promettre une base
fournie de ressources humaines pour une collaboration transdisciplinaire entre les orthophonistes,
les audiologistes et le personnel de soins de santé primaires afin de réduire le poids des troubles
précoces de communication dans un district rural.
Page 2 of 11
Early communication intervention, an evidence-based
approach to the comprehensive management of feeding
difficulties, hearing impairment and emerging communication
disorders in infants and young children, is now established
at most tertiary-level public hospitals and private practices in
South Africa. Training in early communication intervention
is included in all undergraduate Speech-Language Pathology
and Audiology programmes.1 Despite the lack of public
policy, early communication intervention as a subject
field and a service is expanding in South Africa. Since the
turn of the millennium local publications have suggested
strategies for community-based implementation of early
communication intervention in Primary Health Care (PHC).2,3
A renewed call for the establishment of early communication
interventions in rural communities was made by the South
African Speech–Language–Hearing Association (SASLHA).4
The implementation of early communication intervention
services in PHC and community-based contexts is limited.5
The lack of clear procedures, evidence-based practice
guidelines and health policy on how to implement early
communication intervention in PHC, as well as the fact that
early communication intervention is an unknown service
amongst most healthcare professionals and the public
in general, may be some of the reasons why few speechlanguage therapists and audiologists respond to the challenge
to establish formal community-based early communication
intervention programmes.
Establishing a comprehensive early communication
intervention programme in a rural area is a large
undertaking, but a step-by-step approach to implementation
may be a feasible option.6 The rationale for an incremental
implementation of early communication intervention
functions is found in resource limitations and the needs of
infants in rural communities in South Africa.
As the main concentration of families living in poverty is found
in rural areas, poverty should be regarded as a key risk factor
influencing infant development in rural communities.7 Of the
18.7 million children in South Africa, the majority are living
in provinces with large rural populations, such as Limpopo,
the Eastern Cape and KwaZulu-Natal.8 It is generally
accepted that children living in poverty are at increased
risk of developing disability.9 Due to the prevalence of risk
conditions such as HIV, foetal alcohol spectrum disorder,
prematurity, low birth weight and cerebral palsy in South
Africa,2 infants and young children are at an even higher
risk of hearing loss, feeding and communication disorders. A
great need for early interventionists to focus on prevention of
communication disorders is therefore indicated.2,10 A careful
look at the evolution of PHC as implemented by trained
personnel and managers in South Africa may provide
strategies for the much-needed implementation of all early
communication intervention services in rural communities.
PHC is one of the five health priorities for South Africa
and the Minister of Health recently called for a renewed
Original Research
emphasis on prevention of disease instead of a curative
approach to healthcare.11 Since the implementation of
PHC in the South African health system, communities and
individuals who previously did not have access to health
services have reaped numerous benefits from the system.
According to the PHC Facilities Surveys of 1998 and 2000,
significant improvements, such as better emergency-vehicle
response times, daily immunisation opportunities for infants
and children and antenatal services, are now evident in
both rural and urban areas.12 Currently, however, due to
a largely hospital-centric healthcare system, epidemics,
poor partnering with communities and poor multisectoral
collaboration, comprehensive and integrative primary care
were not realised to the majority of South Africans.13 These
challenges resulted in passive, poor-quality and sporadic
PHC services, whereas the hospitals were overburdened with
referrals and patients in need of services.13,14 The National
Department of Health15 responded to these challenges with
the ‘Revitalisation of Primary Health Care’ initiative as a
means of re-engineering PHC toward proactive home- and
community-focused interventions. As a result, municipal
ward outreach teams, district specialists’ teams and school
health services13,15 should be integrated into the PHC Package.
Originally, the PHC Package16,17 was designed to adapt
the previous health system through comprehensive and
integrated services and can therefore not be implemented
through separate, vertical programmes by personnel not
collaborating with one another.12 Vertical programmes with
a narrow focus often split services according to disciplines,
thereby hindering teamwork across different professions.
As indicated in Table 1, the PHC Package16,17 is a standardised,
comprehensive ‘basket’ of services, including preventive-,
promotive-, basic curative- and rehabilitative services
delivered at community level. The package stipulates
the common quality norms and standards for each PHC
service and should receive mutual support from healthcare
professionals delivering the services.16 A ‘one-stop’ approach
is facilitated where interventions are delivered in clusters,
congruent with the infrastructure and the model of care at
district level.12 PHC facilities in South Africa had already
been identified by audiologists as viable platforms for the
early identification of hearing loss.18
When viewing the PHC Package with its 10 different
programmes in Table 1, it is clear that early communication
intervention services should be offered when mothers
or caregivers of infants and young children visit a health
facility. An early communication intervention programme
should therefore be integrated into several PHC programmes
and not offered as a vertical programme dependent on one
discipline only, such as Speech-Language Pathology or
The onset and progression of communication disorders may
be reduced or eliminated by changing the susceptibility
or minimising exposure to the risk factors that influence
prenatal- and postnatal development in infants and young
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Original Research
TABLE 1: Components of the Primary Health Care Package.
PHC Programmes
1. Non-personal health services
•Promotion of occupational health
•Promotion of health and disease prevention
•Dissemination of information on environmental health
2. Disease prevention and control
•Prevention of chronic diseases
•Promotion of well-being in geriatric patients
•Rehabilitation of disabilities
•Promotion of oral health and prevention of oral diseases
•Prevention of communicable diseases (including notifiable medical conditions)
3. Maternal, child and women’s health
•Provision of ante-natal and post-natal care
•Provision of contraceptive methods
•Screening for cervical cancer
•Termination of pregnancy
•Provision of genetic services
•Management of childhood illnesses and immunisation
•Intervention in protein-energy malnutrition
•Sustaining the primary-school nutritional programme
4. HIV, sexually-transmitted infections and
•Support and home based care for HIV patients
•Voluntary confidential counselling and testing for HIV
•Prevention of mother-to-child HIV transmission
•Prevention and management of sexually-transmitted diseases
•Diagnosis and treatment of tuberculosis
5. Health monitoring and evaluation
•Obtaining health information from healthcare facilities
•Surveillance of the public-health system
•Coordination of research on health-related topics and current issues influencing healthcare in South Africa
6. Mental health and substance abuse
•Prevention and treatment of mental disability
•Prevention of substance abuse
7. Gender issues
•Referral and counselling of victims of violence and sexual abuse
8. Municipal ward outreach teams
•Collective facilitation of community involvement and participation in identifying health problems and behaviours that place
individuals at risk of disease or injury
•Identify vulnerable individuals and groups
•Implementation of appropriate interventions from the service package to address the behaviours or health problems
9. District-specialist teams
•To promote innovative models of providing specialist healthcare closer to the patients’ homes
•To promote integrated working practices between general practitioners and hospital-based specialists.
•To improve the quality of services rendered at the first level of care by ensuring adherence to treatment guidelines and protocols
•To provide peer support for specialists working in primary healthcare
10. School health teams
•Health promotion, prevention and curative health services that address the health needs of school-going children, including those
children who have missed the opportunity to access services such as child immunisation services during their pre-school years
Source: National Department of Health 2011 15; Department of Health 200117
children.19,20 It is therefore evident that early communication
intervention operates mainly on the primary- and secondary
levels of prevention. Both early communication intervention21
and the PHC approach stipulate that programmes should
address the specific needs of communities, with full
participation of families and community members. Services
should be accessible to all, affordable, culturally acceptable
and implement appropriately-selected evidence-based
procedures. Both PHC and early communication intervention
are comprehensive, should be well coordinated with partners
and should be based on teamwork.4,12,22,23
Based on research initiated during a community-service year
in Ditsobotla subdistrict in the North West province of South
Africa6 and as reported in van der Linde et al.,5 the full-scale
implementation of all early communication intervention
functions at the PHC facilities in the subdistrict was
neither possible nor sustainable. The study found that the
identification methods for infants at risk of communication
delay were limited and unreliable and that the referral
system in the subdistrict was ineffective.5 An incremental
rollout of the different early communication intervention
functions such as promotion of normal development,
developmental surveillance of infants at risk, assessment,
providing intervention and parent training was suggested.
As the implementation of the different functions depends
on the collaboration between a speech-language therapist
or audiologist, as well as the PHC personnel at each health
facility and their managers, it is important to investigate
perceptions and attitudes toward the proposed plans.
The article presents the perceptions of rural healthcare
workers to implement sustainable early communication
intervention programmes in remote PHC facilities so that
accessible and best-practice services can be provided to
infants at risk and their families.
The purpose of this article is to describe the perceptions
of PHC personnel with regard to the expansion of early
communication intervention services to infants at risk in the
rural subdistrict of Ditsobotla in South Africa. The following
objectives were pursued:
• To describe the participants’ perceptions regarding case
finding, identification methods, resources and limitations
in Ditsobotla subdistrict.
• To describe the self-identified training needs amongst
PHC personnel and managers for early communication
intervention in the subdistrict.
• To describe the team approach suggested by the
Research method and design
A qualitative descriptive study was conducted as the
researchers attempted to gain a first-hand and holistic
understanding of the perceptions of participants.24 Semistructured interviews with the PHC personnel and
programme managers of Ditsobotla subdistrict were
conducted. The two data sources, namely those of the PHC
personnel and the programme managers, served as data
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Original Research
triangulation which increased the reliability of the study.
The purpose was therefore to shift the research from an
investigator perspective to that of the participants and to
report on the qualitative data which were collected.6
Research context
The subdistrict forms part of the central district in the
North West province of South Africa and is characterised
by small communities, mostly Setswana speaking. The
subdistrict covers an area of 6465 square kilometres (2496.2
square miles), with a population density of 59.1 people per
square mile. The largest town in the area is Lichtenburg.
Income is generated by the agricultural activities of private
landowners, mining and tourism, but many families rely on
subsistence farming on ancestral land allocated by the tribal
chief.25 The first researcher was stationed at the Lichtenberg
hospital as a community-service speech-language therapist
and audiologist. Public-health services in the subdistrict
were organised according to the PHC model, with 17 clinics
and three small hospitals. The travelling distances between
Lichtenburg and the different clinics range from 3 km to
35 km, allowing a clinician to visit two clinics per day. A map
highlighting the research setting can be seen in Figure 1.
The PHC clinics and hospitals in Ditsobotla subdistrict
were selected randomly from two strata. The clinics were
subdivided in the strata according to the size of the clinic:
small clinics such as eight-hour clinics and mobile clinics
were placed in stratum 1 and large clinics such as 24-hour
PHC centres and district hospitals were placed in stratum
2. Twenty participants were recruited from the randomlyselected facilities, simply by asking the PHC personnel (with
support from the PHC facility manager) who would like to
participate as the participants in Group 1. The only exclusion
criterion was little or no verbal competence in English or
Afrikaans, which were the researchers’ primary languages,
meaning that all prospective participants were competent
in either Afrikaans or English. In Group 2, all 12 PHC
programme managers of Ditsobotla subdistrict were invited
to participate in the research.
All the participants (PHC personnel and programme
managers) had to be employed in Ditsobotla subdistrict and
proficient in English in order to participate in the study.
Approximately one-third (20) of the PHC personnel
(Group 1) in the entire subdistrict were included in the study,
with each stratum represented equally. The characteristics of
the participants in Group 1 are summarised in Table 2. The
majority of the participants had nursing diplomas and all
were working on a full-time basis, with an average of eight to
12 years’ work experience. Although three participants had
no formal training, their work experience rendered them as
informed research participants.
Participants in Group 2 represented 67% of the PHC
programme managers in the subdistrict (Table 3). According
FIGURE 1: Area map of the North West province. Ditsobotla subdistrict is
situated at the centre of the province and is represented by the numeral 10.
TABLE 2: Characteristics of the primary healthcare personnel (n = 20).
Stratum 1 (n = 10)
Stratum 2 (n = 10)
B Cur Degree: 2
Nursing Diploma: 6
No formal training: 2
B Cur Degree: 3
Nursing Diploma: 6
No formal training: 1
Years of experience
4 years – 25 years
Average: 12,5 years
1 year –26 years
Average: 8,4 years
First language
Setswana: 10
Setswana: 9
Afrikaans: 1
Employment status
Full-time: 10
Full-time: 10
Type of facility where employed
8-hour clinic: 7
12-hour clinic: 3
PHC hospital: 2
24-hour clinic: 8
to Table 3, most of the programme managers had qualifications
and work experience. A variety of programmes in the PHC
package were represented by the managers, but those who
managed the Maternal, Child and Women’s Health, Mental
Health and HIV programmes could not be included as
participants as they were attending a course during the time
allocated for data collection.
Since face to face interviews have the highest response rate
in survey research,26 semi-structured interviews were used
to collect the data from both groups of participants. The
different open-ended questions explored the following
needs and perceptions of the participants: their information
needs about early communication intervention and how
case finding, the referral system and collaboration can be
improved. The interviews began with an explanation of early
communication intervention, followed by the following
question: ‘Speech-language therapists and audiologists are
experiencing difficulty in finding babies who need speech
and hearing services in the rural areas. How can we work
together to address the problem?’
In order to increase the credibility of the data and to test the two
interview schedules, two pilot studies were conducted. Two
PHC nurses and one PHC programme manager were selected
to be part of the pilot studies. The interview schedules were
adapted according to the results obtained in the pilot studies.
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Original Research
TABLE 3: The characteristics of the primary healthcare programme managers (n = 8).
Masters degree: 1
B Cur degree: 2
Nursing diploma: 4
No formal training: 1
Experience in programme managing
Range: 1–10 years
Average: 4 years
Facilities visited by primary healthcare programme managers
Hospitals, clinics, frail-care centres, prisons, hospices and schools, crèches and business premises
First language
2: Afrikaans
6: Setswana
Employment status
All full-time
Primary healthcare programme managed
•Geriatrics, chronic diseases and rehabilitation
•Communicable diseases
•Occupational therapy
•Health promotion
•School health
•Environmental health
During the visit to each of the randomly-selected facilities
the facility manager explained the reason for the visit and
introduced the researcher to potential participants in Group
1. Informed consent was obtained from the participants
and the interviews were conducted in consultation rooms
at the different PHC facilities. The researcher visited the
participants in Group 2, the programme managers at the
district office of Ditsobotla. Informed consent was obtained
and the semi-structured interviews were conducted in each
participant’s office. The arrangement made the participants
feel comfortable and communication barriers were limited
as a result of the professional environment in which the
interviews were conducted.
Data analysis
The interviews were recorded and the digital voice files
were transcribed. A second reviewer was utilised in
order to verify the interview transcripts of both groups of
participants. The reviewer listened to the recordings whilst
reading the transcriptions. Discrepancies between the
text- and voice recordings were discussed until agreement
was found between the researcher and second reviewer.
The transcripts were read holistically and then re-read
before the corpus was categorised according to themes.
Regularities, or themes, were noted during the data analysis
and categories of meaning emerged that could be presented
as descriptive results. As two data sources were included in
the data collection (data from the PHC personnel and the
programme managers) common themes across the two data
sets confirmed the reliability of the data and highlighted the
categories of meaning that had been identified.
Objective 1: Identification methods and
resources in Ditsobotla subdistrict
Useful findings regarding specific resource needs to identify
infants at risk were obtained and are paraphrased below:
• PHC personnel reported that they were not successful
in identifying infants and young children at risk of
developmental delay in the subdistrict.
• No reliable and valid identification methods and instruments
for hearing loss, feeding difficulties and communication
delay in infants and children were being used.
PHC personnel indicated that parents, grandparents and
other caregivers are either barriers or helpful resources
when the developmental history of infants and young
children has to be collected at clinics.
It is therefore imperative that a standardised screening
instrument for risks of communication delay should be
developed. Apart from the lack of screening instruments,
another limitation is the lack of information on developmental
history of the infant or young child obtained from parents,
grandparents and caregivers during immunisation. As
information on children’s disabilities may not be shared
by parents due to shame or other reasons, grandparents
and caregivers may not know the case histories when
bringing infants for immunisation. Despite these challenges,
caregivers remain a valuable source of information about the
children in their care and should be utilised. Research at the
Clinic for High Risk Babies (CHRIB), University of Pretoria,
found that parents consistently identified their children’s
communication difficulties earlier than professionals even
though they might not act upon their concerns.2 Parents
from all cultures strive to help their children to develop
maximally, but they require knowledge to support their
children’s development.10 Consequently, parents, caregivers
and grandparents need training,27 as they are irreplaceable
members within the early communication intervention team.
It is therefore essential to develop a training package for
families of infants at risk.
Objective 2: Perceptions on training
Subtheme 1: Professional training programmes
The responses of two PHC programme managers, when asked
what information they need regarding early communication
intervention, early identification of delays or disorders and the
referral process, were:
‘[We need] brochures, information booklets on general services,
signs and symptoms and how to go about caring for that person
with the problem’. (Manager, female, 40 – 45 years old)
‘[Training] to indicate problems or signs; what is it that shows
communication problems in children and what steps to take
thereafter’. (Manager, female, 50 – 55 years old)
The information needs expressed by the majority of the
healthcare participants, along with their willingness to
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receive information, imply that an early communication
intervention information package must not only be
developed for families but for professional collaborators as
well. Training is required so that healthcare partners can
assist in the identification and referral of infants and young
children at risk for communication disorders, hearing loss
and feeding difficulties. Training has to be provided to all
PHC personnel, programme managers and managers of the
Subtheme 2: Promotional activities
Two of the PHC programme managers responded with the
following statements, when asked why parent and caregiver
training on communication and literacy development in
young children should be integrated in PHC:
‘To make mothers aware. They are twenty-four hours with
the child and they can detect and refer early, then there is less
damage’. (Manager, female, 40 – 45 years old)
‘Mothers spend most of their time with the child, they know and
can really identify. We only see the child for twenty minutes’.
(Manager, female, 45 – 50 years old)
It is therefore evident that appropriate information should
be provided to the community by means of talks and
workshops to caregivers who attend immunisation clinics,
as well as mass-communication media. Since the aim of
mass media strategies is to educate the public, shape public
behaviour and advocate services,28 posters and pamphlets on
child development and other topics should be developed in
the local languages. Popich et al.10 describe the development
of an educational DVD for caregivers as a strategy for
primary prevention of communication disorders in a specific
community in South Africa. It is suggested that parents,
grandparents and other stakeholders from the community
should be involved in the planning of such an informational
tool in order to ensure that their needs and values are
reflected in the final product.10,27
Objective 3: Team approach for early
communication intervention in Ditsobotla
The team approach suggested by the participants of both
groups is presented according to six subthemes that became
evident during data analysis.
Subtheme 1: Collaborative partnerships amongst
communities and professionals in primary healthcare
In response to a question regarding the advantages of
collaboration for PHC programmes in Ditsobotla subdistrict,
two of the PHC programme managers replied:
‘We will work collaboratively and other programme managers
will know about early communication intervention services. You
will get patients from all angles since all the PHC managers are
aware’. (Manager, female, 40 – 45 years old)
‘We get a well-informed community, personnel and volunteers.
We get a healthy community, because they will be informed’.
(Manager, female, 45 – 50 years old)
The quotes reflect the perception that there is a close
relationship between case finding, effective service delivery
Original Research
and collaboration. According to the participants, a clear
advantage of collaboration would be a greater awareness of
early communication intervention amongst health workers
and the community. The participants also indicated that
collaboration is limited in the subdistrict and the following
suggestions were made to improve team work:
• An information sheet should be made available about
the specialised services offered by early communication
• Trusting relationships between the speech-language
therapist or audiologist and PHC personnel should be
• Positive attitudes toward the newly-established early
communication intervention services should be created.
• The permanent employment of a speech-language
therapist or audiologist within the subdistrict is critical to
the process.
The professions and the concept of early communication
intervention must therefore be introduced to the PHC
facilities and communities. The speech-language therapist
or audiologist should be the leading professional in the
collaborative process of establishing early communication
Subtheme 2: Building a comprehensive team
One of the PHC personnel responded with the following
statement, when asked why team work will influence early
identification and referral of infants positively:
‘As a team it makes work easier – quality nursing care. I can be
taught some things, but the specialist [speech-language therapist]
can do some work [i.e. rendering of early communication intervention
services]. The team will provide better quality care’. (Manager,
female, 45 – 50 years old)
The participants indicated that other healthcare professionals,
such as occupational therapists, physiotherapists and
dieticians should also be involved. Similar to the speechlanguage therapist or audiologist, many of these professionals
are also annual community-service professionals and their
services may be disrupted when clinicians are replaced or
their posts are discontinued after a year.
Further results indicated that the teamwork in Ditsobotla
subdistrict was uncoordinated, although different professionals
are available. The PHC personnel only consulted with doctors
during their visits to the facilities.
Subtheme 3: The role of primary healthcare programme
The PHC programme managers are a resourceful group of
professionals who can assist the speech-language therapist
or audiologist in the implementation of early communication
intervention services in a rural community. When two of
the PHC programme managers were asked to comment on
how they see the future of working in collaboration speechlanguage therapists or audiologists, they responded:
‘Services will be marketed; it will be cost effective because
we are working together, for example with transport. The
PHC programme managers are from the same culture [as the
Page 7 of 11
community members] and they know the language and therefore
they may help the clinician. Services will be well known to the
community’ (Manager, female, 50 – 55 years old)
‘It is easier for the PHC programme manager to reach more
people; fieldworkers get to more people, know the professions
better, managers know what to do in case finding’. (Manager,
female, 50 – 55 years old)
It is therefore evident that the PHC programme managers
can assist speech-language therapists to reach the public,
as they have already established a relationship of trust
with the communities. Language- and cultural barriers
can be overcome with the support of the PHC programme
managers as they often share the same cultural backgrounds
and speak the same languages as the local communities.6
The PHC programme managers’ knowledge and status
in the community should be regarded as an asset and
partnerships should be established in order to formalise
early communication intervention in PHC. Programme
managers are invaluable partners who can support the
clinician in planning and implementing collaborative early
communication intervention activities and integrating the
services into the different PHC programmes. As managers,
they have more authority than PHC personnel and can
therefore exert more influence to assist with case finding.
Subtheme 4: Recruiting volunteers from communities
As speech-language therapists and audiologists are
burdened with large caseloads in SA, it may not be possible
to successfully fulfil all the functions included in the scope
of early communication intervention practice. A PHC
programme manager in Ditsobotla subdistrict recommended
the following:
‘Speech-language therapists should recruit volunteers. They
[volunteers] can play a supportive role and can help [the clinician]
in overcoming language and cultural barriers’ (Manager, female,
45 – 50 years old)
If trained, volunteers can play a supportive role during the
implementation and management of early communication
intervention services in communities.
Subtheme 5: The suggested formalised process
The participants recommended that various aspects be taken
into account in the implementation of early communication
intervention services. The results were summarised as
• The process should commence with meetings and
negotiations with the health managers of the subdistrict.
Starting at entry level, collaboration should therefore be
the vehicle throughout the process of implementation.
• Establish a good relationship with management, namely,
the Assistant Director of Community Health services in
Ditsobotla subdistrict.
• Other community stakeholders, such as churches and
religious communities, crèches and youth centres, could
also be part of the planning and implementation of
collaborative early communication-intervention functions.
• Continued and once-off collaborative activities should
be planned in partnership with the PHC programme
Original Research
managers as these will improve the accessibility and
affordability of services. The speech-language therapist
and audiologist should manage early communication
intervention as a PHC programme and should therefore
play a promotional as well as an educational role in the
developmental phase of early communication intervention
services and thereafter.
Developing amicable relations with PHC management is
vital.12 In addition to PHC management, the community
should be considered as stakeholders in the implementation
of early communication intervention services. The role of
grandmothers in the rural community should be valued as
they act as indigenous gatekeepers of knowledge to younger
generations regarding the development, care giving and
well-being of women and children.27 Involving community
stakeholders serves as an inclusive approach to planning
and implementation and may increase interest, ownership
and support for the early communication intervention
programme. The researchers recommend that a rollout
of functions should commence with primary prevention,
which implies promotion and training activities (Figure 2).
Against the background of poverty in infants’ care-giving
environments, promotional activities for optimal early
communication development may include the following: to
raise parental awareness of the importance and their role in
early communication and emergent literacy development
for school readiness, the importance of first-language
development in infants and young children; to promote
safety to prevent injuries; to raise public awareness of
available early communication intervention services; to
advocate for enriched preschool education; and to facilitate
the implementation of a language- and literacy-based
preschool curriculum in nursery schools.21
Subtheme 6: The referral system in primary healthcare
The existing referral system for health-related cases in
Ditsobotla subdistrict was not effective and involved a
lengthy procedure of three operational organisational
networks, since speech-language therapy and audiology
teams at the secondary- and tertiary levels were located at
facilities outside the subdistrict. The PHC personnel were
uncertain when and to whom they should refer mothers
with concerns regarding their children’s hearing or
communication development. Instead of referring directly
to a speech-language therapist or audiologist, referrals were
made through the doctor, who then had to refer to speechlanguage therapy or audiology services. It is within the
extensive interdepartmental organisational network that a
local referral system has to be adapted for improved service
Strategies suggested by participants for changing the referral
system to improve service delivery included the following:
• Establish an effective interorganisational network to refer
patients for early communication intervention services to
tertiary-level services, such as diagnostic hearing testing.
• Collaborate with the PHC personnel to address the
factors that are negatively influencing the referral system,
such as transport problems and time delays.
Page 8 of 11
Original Research
Promote early child development and train others
•Raise care givers’ awareness and facilitate an interest to stimulate the communication and emergent literacy
development of young children
•Raise PHC personnel’s awareness of early communication intervention services, the importance of early identification
and referral of infants and young children at risk for developmental delay or disorders
•Teach the importance of toys and books in early development
•Advocate for the education of preschool children
•Facilitate the implementation of a language and literacy-based preschool curriculum at community crèches to ensure
school readiness
•Prevent hearing loss and communication disorders through awareness of causes and risks
Early identification and intervention
•Screen for communication and hearing disabilities in young children
•Determine risks for communication delay in young children, assess and provide intervention for children and their
•Facilitate collaborative activities with PHC personnel and other health care professionals, such as screening, referral and
PHC programmes
1. Non-personal health services
2. Disease prevention and control
3. Maternal, child and women’s
4. HIV/AIDS, sexually transmitted
infections and tuberculosis
5. Mental health and substance
6. Health monitoring and
7. Gender issues
•Provide assessment of and intervention for infants and young children with emerging risk or with established risks for
developmental delay and their families
•Implement intervention programmes as early as possible
•Refer the infants and young children to other professionals if necessary
•Establish inter- and transdisciplinary EI services to families with infants and/or children with disabilities or disorders
Source: Department of Health 2001 17; Kritzinger & Louw 2003 21; Feldman 200431
FIGURE 2: Early communication-intervention functions according to the levels of prevention in primary healthcare.
• Develop context-specific referral systems, as unique
needs and resources may be identified in a district.
• Provide in-service training when a referral framework is
implemented in the subdistrict, so that PHC personnel
can use the referral system successfully.
• Plan and manage early communication-intervention
referral systems within the subdistrict.
• Establish effective communication between collaborators.
• Develop a comprehensive referral letter so that backreferral information can be recorded and sent to the
referring healthcare professional.
Therefore, by providing feedback to the referring party,
it helps to establish a relationship of trust and effective
collaboration between the professionals and also helps to
monitor patients on return visits to the clinician.
Ethical considerations
The research study was approved by the Research Ethics and
Proposal Committee of the Faculty of Humanities, University
of Pretoria (Reference number: 21060038). Permission to
conduct the research was granted by the North West Province
Department of Health. All participants gave voluntary
informed consent to participate in the study. Information
obtained from the participants was treated confidentially
and reported anonymously. All efforts were made to conduct
the research according to the ethical principles of no harm or
embarrassment to participants, veracity, non-discrimination
and sensitivity to cultural- and language differences between
participants and the researcher who collected the data.
The researcher aimed to improve the trustworthiness of the
study by improving the dependability, that is to say, the
extent to which the results are reproducible. The researcher
used data triangulation as well as detailed descriptions in
order to get reproducible results.
Strategies that were used to increase the validity of the
instruments are as follows:
• Face validity was ensured as the format of the instruments
corresponded with the aims of the data collection.
• Since the researcher interviewed the participants the
content validity was improved as observations and
conceptualisations were made during the interviews. The
views of the PHC programme managers regarding the
implementation of an early identification programme for
infants at risk for developmental delays or disorders were
explored in the semi-structured interviews.
• The instruments were developed in accordance with the
study aims and relevant research findings in the field and
were designed to be adaptable across cultural diversities,
using constructs that remain the same across cultures,
hence achieving construct validity.
With triangulation the reliability of the instruments is
increased, as the data is collected by means of different
instruments and results can therefore be compared.
Furthermore, two separate groups of participants were used
to investigate the identification methods and referral systems,
whilst the researcher’s own field notes also supported
the data obtained in the interviews. The aim of the pilot
testing of the instruments was to determine the reliability
Page 9 of 11
Original Research
of the instruments. Each pilot testing made significant
contributions, assisting the researcher in enhancing the
reliability of the instruments. A second interpreter analysed
the results obtained from the interviews with the participants
in Group 1 and Group 2, which improved the reliability of
and what it entails, community speech-language therapists
and audiologists have an ideal opportunity to develop and
present in-service training programmes to all PHC personnel
and programme managers.
The results with regard to teamwork indicated that
the participants wanted teamwork through dynamic
collaboration and that they wanted to be consulted.
Apart from the participants’ willingness to be involved in
developing effective early communication intervention in
the subdistrict, programme managers and trained volunteers
are uniquely positioned to play effective roles. Doctors were
identified as crucial role players in the early identification and
referral of infants at risk6 and therefore need to be part of the
early intervention team. The subdistrict may be characterised
by poverty, but proved to be rich in human resources.
Despite limited awareness of the benefits of early
communication intervention, the lack of identification
methods and ineffective referral systems in this impoverished
rural subdistrict, PHC personnel (i.e. nurses in training,
qualified nurses and sisters working in the PHC context)
and PHC programme managers were interested in early
communication intervention and had a positive attitude
toward improving services.
Primary healthcare personnel as valued
The PHC personnel at the different facilities can be
instrumental in the early identification of infants and young
children at risk of developmental delay or disorders. The
level of entry for all patients into the health system is at the
PHC facilities.12 PHC personnel address health problems
directly or make referrals to a doctor or a specialised health
professional. As the PHC personnel act as gatekeepers of the
health care system,28 they need effective support in order to
identify and refer infants and young children with risks as
early as possible.
Despite their heavy workload, the PHC personnel and
the PHC programme managers in Ditsobotla subdistrict
responded positively to the concept of early communication
intervention and wished to be part of the team. They were
also agreeable regarding the implementation of different
early communication intervention functions in increments
at the facilities. They wanted to be consulted when selecting
the functions to be implemented at each facility, as they
are aware of the needs and the capacity of the human- and
physical resources at the different facilities.
Training programme for primary healthcare
Based on results disclosing the information needs of the
participants, components of such a training programme
should include: Strategies to build trust, partnerships and
effectively collaborate with other professionals; information
on typical communication and emergent literacy development
in infants and children; information sharing with parents;
effective use of referral systems and identification methods;
and the role of adults and environmental enrichment in early
child development.
The results on self-identified training needs of the participants
provided very clear suggestions to speech-language therapists
and audiologists. Since the healthcare personnel in this rural
area were unaware of early communication intervention
Collaborative team approach
Much literature exists about building effective teams in early
intervention. According to Rossetti,19 a transdisciplinary early
communication intervention team approach is the preferred
option. Different team members are dependent upon one
another and share the knowledge, roles and responsibilities of
negotiated functions. Shared information and roles between
a speech-language therapist, an audiologist, PHC personnel
and other health workers, if available, could therefore
simplify the process of establishing a transdisciplinary early
intervention team, as all have similar objectives to achieve.
Teams may start small, as speech-language therapists and
audiologists could be an effective transdisciplinary team
of two professionals.4 Assessments and diagnosis may
be discipline-specific professional roles, but screening,
intervention and parent guidance may be shared roles.4
Incremental implementation of early
communication intervention functions
Van der Linde et al.5 already found that each of the PHC
facilities in Ditsobotla subdistrict provided an opportunity
and location to implement some of the early communication
intervention functions as a means to reach infants at risk in
a rural community. According to van der Linde,6 the assets
and needs analysis indicated that all 20 PHC facilities in the
subdistrict had permanent building structures, electricity and
water supply and three clinics had been rebuilt or renovated
recently. The implications were that early communication
intervention services should be brought closer to the
different communities, but that the full extent of preventative
services and training, early identification, assessment and
intervention of young children, parent training and diagnostic
procedures could not be implemented at every PHC facility
in the subdistrict at the time of data collection. Only three
PHC facilities in Ditsobotla subdistrict had the capacity to
support the full implementation of all early communication
intervention functions.
Consistent with the incremental implementation process,
the provision of early communication intervention functions
at the different facilities will vary according to capacity
Page 10 of 11
and needs. The speech-language therapist and audiologist,
in collaboration with the PHC personnel, clinic managers
and PHC programme managers, should determine which
functions should be implemented at the various facilities. The
decisions of implementation should therefore be negotiated
by an early communication intervention task team. If the
speech-language therapist or audiologist cannot visit a
specific clinic regularly, or when certain early communication
intervention functions cannot be implemented at the facility
due to lack of capacity, a referral has to be made to a nearby
PHC facility. This process is known as ‘intradepartmental
The participants indicated that continuous monitoring of the
implementation process is important. A needs assessment
and environmental analysis should be conducted at regular
intervals at each facility as the needs and capacity can change
over time as the PHC facility develops. The needs assessment
would also provide the clinician with insight into recurrent
needs, the improvement of service delivery and the demand
for services.
An incremental rollout of the implementation of collaborative
early communication intervention activities may involve the
• During the planning phase of collaborative activities the
facilities need to be evaluated to determine whether there
is capacity for successful implementation of the activities.
Diverse activities may therefore be implemented at
different facilities, according to capacity and needs.
• The incremental rollout of early communication
intervention functions should not be considered as
the only option, as once-off collaborative activities can
be implemented at facilities with a limited capacity.
The necessary arrangements should be made, such as
allocation of space and training of volunteers to help with
the implementation of the collaborative activities.
• Certain PHC programmes, such as Maternal, Child and
Women’s Health, should be utilised comprehensively, as
many early communication intervention functions can be
integrated in collaboration with these programmes.
• The participants indicated that early communication
intervention should be introduced on four operational
levels as indicated in Figure 3.
In summary, the four-level organisational framework (Figure 3)
to implement early communication intervention services in
increments at PHC facilities in the subdistrict was developed
by the participatory process of the research study.
Establishing sustainable early communication intervention
in rural PHC communities is a challenge, as limitations
influence the implementation of services in these contexts. The
need for comprehensive early communication intervention
in rural communities undoubtedly outweighs the limitations
that may be experienced by clinicians. Implementation of
early communication intervention in increments is a dynamic
Original Research
of speech-language
therapist and audiologist
to integrate
Early Communication
of speech-language
and audiologist
to integrate
in the PHC package
Early Communication Intervention in the PHC package
Level 1
Level 2
Meet with
the the
Assistant Director
Community Health
Health Services
Discuss the plan
of action
Level 3
Meet with PHC
with PHC
personnel andand
their their
PHC programme
In In
of PHC programme
of PHC
and training
with PHC
Joint planning of
of collaborative
Provide information
Provide checklist
checklist for for
identification, referral
and feedback
Level 4
Meet with
with other
Provide information
information and
Distribute posters and
posters and
brochures in clinics to
in clinics to
reach the community
reach the community
Train groups of
groups of
to discussto
plan collaborative
on a continuousactivities
basis and onon
and plan
awareness days
continuous basis and on health awareness days
Implementation of collaborative
activities on
a continuous
and on health awareness
days on
of collaborative
a continuous
basis and
health awareness days
evaluate collaborative
to determineto
and limitations
and limitations
FIGURE 3: The process of integrating early communication intervention services into the Primary Healthcare Package.
FIGURE 3: The process of integrating early communication intervention services
into the Primary Healthcare Package.
process that allows the clinician to monitor, add and adapt
the functions implemented at the facilities, according to the
needs of the specific community living around a PHC clinic
or hospital. Early communication intervention functions
should always be introduced by the collaboration with and
training of partners in order to promote typical development,
prevent disability and illness, screen and identify early, refer
the family, conduct assessment, supply intervention, manage
and evaluate programmes and continue with research.
The results indicated that speech-language therapists,
audiologists and PHC personnel may indeed work together
to address the problem of early case finding and providing
early communication intervention services to infants at
risk. According to Olusanya et al.,29 reducing the burden of
communication disorders should also be on the agenda of the
many health priorities of the developing world.
A limitation of the research study is the exclusion of
the general community in the subdistrict and therefore
their needs, perceptions and suggestions regarding early
communication intervention should be considered in
future research. Collaborative partnerships with caregivers,
professionals, PHC programme managers and volunteers,
effective training programmes, extensive promotional
activities, thoughtful application of methods and resources
and an effective referral system are the building blocks
required to reach the goal of accessible and affordable
early communication intervention services in a community.
Page 11 of 11
Ultimately, an incremental implementation of early
communication intervention may be integrated in the PHC
package as part of a formalised programme. The impetus to
expand early communication intervention services to rural
communities lies in the evidence that ‘early intervention
works’.30 This research should encourage clinicians to
participate in this worthy endeavour to intervene as early as
possible in the lives of all infants at risk.
The researchers would like to acknowledge Aniel
Redelinghuys for her support in the planning of the research.
We would also like to acknowledge Zandre van Zyl who
acted as the second reviewer in the analysis of the data.
Competing interests
The authors declare that they have no financial or personal
relationship(s) which may have inappropriately influenced
them in writing this article.
Authors’ contributions
J.v.d.L. (University of Pretoria) collected the data and
contributed in writing of the article. A.K. (University of
Pretoria) supervised the research and contributed with the
writing of the article.
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