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Malawi: Speech-language services

15. October 2018
Lisa Bacic from Phonak volunteered at our project in Malawi. As a speech-language pathologist she knows that adapting communication resources is very important for a successful therapy. Because not every child in the world knows who wears a red suit and says “Ho, Ho, Ho”.
The clinicians at the ABC Hearing and Training Center, Hear the World Foundation’s project partner in Malawi, recently made a request for a speech therapist volunteer. Many kids they see for hearing tests have speech and language difficulties, and in a low income country like Malawi, children left untreated have little chance of receiving a school education. Given this reality, their clinicians wanted to add resources to their toolbox so families can leave appointments with some guidance on how to promote speech and language development in their children.
As a speech-language pathologist, I was excited to apply for this position and thrilled to be accepted. Initially, I thought this would be a straightforward task. I worked as a clinician for years so I’m familiar with communication tools and in my role on the pediatric team at Phonak, I am involved with creating resources for families that promote timely speech and language development. Quick and easy, right? Not exactly. Let me tell you about my experience.

First, I did a little research

One of our first activities was to visit the local speech therapists and discuss the current status of speech-language services for children in central Malawi. What we discovered is that there are only 3 local centers that offer speech and language therapy and 2 are privately funded. And, the one center that offers free therapy only has a clinician available to see children one morning or afternoon a week.
This means that there are ~4 hours available per week to meet the speech/language needs of all children in central Malawi who cannot afford private therapy. Wow. The majority of kids who have speech and language difficulties do not have access to any intervention. With such limited therapy options, early intervention resources would definitely need to be optimized.

The reality shouldn’t have surprised me

So, where do we start to improve resources? Well, we started with looking at what speech and language resources are being used in Malawi. Not surprisingly, most material was developed in North America.
Common speech battery assessments use pictures of people, places and things to elicit speech sounds in different positions of words. One of the common pictures to test the /v/ sound in English is a picture of a “vacuum”. Perfect, if you’re a child who has a vacuum in the front hall closet, but what about a boy from Malawi who has never seen a vacuum in his life. And when you want to assess /h/ and show a child a picture of a house, does a child in Malawi identify with a picture of a 2 story brick house with an attached garage? Probably not.
Left: Currently used speech battery assessment with a brick house / Right: A Malawian house

And a picture of Santa Clause to assess the letter /s/ in English just doesn’t make sense for a child growing up in one of the world’s least developed countries. They don’t know ‘Santa’ but they know ‘soccer’ which also starts with /s/. Adaptations were definitely needed, and possible.
Left: ‘Santa Clause’ picture in the currently used speech battery assessment / Right: ‘Soccer’ (‘Mpira’) picture for the new adapted binder

Finding the right words and pictures

This was the most rewarding part of my visit to the clinic. In order to improve the binder, one afternoon, a small group of us sat down to go through a list of words/pictures to put them in the “Keep – Toss – Adapt” pile. Some were easy. Picture of children swimming in the lake…..Keep. But what about the picture of a horse? The clinicians at ABC clinic enlightened me. Children in Malawi are surrounded by donkeys, not horses. If a child sees a picture of a horse, the child would say “donkey”, or “bulu” in Chichewa.
I loved their enthusiasm for ensuring every picture in our “keep” pile was appropriate. We are using pictures of people, places and objects that are found in Malawi. The clinicians then translated all the words into Chichewa so we will have 2 versions, depending on the primary language of the child. The result will be two versions of the adapted binder, one to elicit speech sounds in English and one for Chichewa.
Image of pictures to elicit the words, ‘fishing’ and ‘shoes’ (to assess initial /f/ and /sh/) and (‘Kuwedza’ and “Nsapato” in Chichewa to assess initial /k/ and /ns/) for the new adapted binder.

Beyond the bedtime routine

We decided that another need of the clinic was to create a booklet that could be given to parents of newly diagnosed children to guide them in helping their children develop speech and language. If we could support a language rich environment at home, then hopefully, the kids newly fit with hearing aids wouldn’t need speech therapy later on.
For this, we discussed what activities were typical for a Malawian family, and which activities would not be common. For example, in North America, we might tell families to read their child a book at bedtime and talk about the story together. Well, ‘bedtime’ is not a common concept in Malawi. Most children do not put on their pajamas, have a night time snack and have a book read to them before bed. My colleagues smiled when I described this routine and told me that kids in Malawi go to sleep when it’s time for bed, there is no ‘routine’. But, I learned that there are many other language-rich opportunities for Malawian children. For example, music is a big part of their lives and singing songs can be enjoyed when meals are being prepared. As they described many of the traditional songs (a Malawian version of “Head and Shoulders, Knees and Toes”), I smiled. These widely-known Malawian songs would be perfect examples to give families.
We didn’t get a chance to finish the resources before I left, but we are going to be collaborating remotely. I’m really excited to see how families respond to these new resources once they’re ready. My goal is that no child in Malawi is given a picture of Santa Clause to assess the letter /s/. Thanks to the enthusiastic clinicians at ABC Hearing Center, they won’t have to.