Abstract
Speech language pathologists (SLPs) play a leading role in overall augmentative and alternative communication (AAC) service delivery. Several changes (e.g., the provision of university AAC courses) related to AAC occurred in Taiwan in the past. However, little information of AAC services provided by SLPs in Taiwan is available. The purpose of the article is to review the evolution of AAC service delivery by SLPs in Taiwan. Findings from Australia, New Zealand, and Hong Kong served as a reference. A questionnaire was mailed to 302 participants registered with the Speech-Language-Hearing Association of Taiwan (SLHA) as SLPs. A response rate is 33%. Most SLPs work in a department of rehabilitation in a hospital setting which is in northern Taiwan. Workshops held by the SLHA were the major resources for obtaining professional knowledge in AAC. Collaboration with an AAC team and training in the use of high-tech communication devices were the most desired forms of information and/or training. Implications are discussed.
Keywords
Introduction
Augmentative and alternative communication (AAC) allows people who are temporarily or permanently unable to efficiently use their natural speech to compensate for natural speech–language impairments, to achieve effective and efficient communication, and to actively communicate with family members, peers, colleagues, and communities (Rosenfeld, 2002; American Speech-Language-Hearing Association [ASHA], 2005; Beukelman & Mirenda, 2013; Calculator, 2007). ASHA (2004, 2005) has defined AAC as integrating four primary components: symbol, aid, strategy, and technique. Among these, an “aid” is an electronic or nonelectronic communication device used either to transmit or to receive messages (Beukelman & Mirenda, 2005). High-tech communication devices are computerized with special software to generate digitized and synthesized speech (Church & Glennen, 1992; Johnston, Reichle, Feeley, & Jones, 2012; Quist & Lloyd, 1997), whereas in contrast low-tech communication devices are simple electronic devices without built-in rechargeable batteries or speech generation on which a limited number of messages can be recorded and played back (Binger & Kent-Walsh, 2010; Johnston et al., 2012). Johnston et al. (2012) stated that no-tech communication devices are nonelectronic and might be displayed on a board or a book.
Speech–language pathologists (SLPs) play a leading role in overall AAC services (i.e., assessment and treatment; ASHA, 2016; Balandin & Iacono, 1998a, 1998b; Beukelman & Mirenda, 2013; Russell & McAllister, 1995). SLPs with high clinical self-efficacy, defined as the confidence of an individual to successfully perform clinical services, have greater confidence in their ability to conduct a greater number of clinical services (Pasupathy & Bogschutz, 2013). Accordingly, Beukelman and Mirenda (2013) and Glennen and DeCoste (1997) recommended that SLPs should receive exposure to and training in skills and knowledge related to AAC to effectively provide AAC services. These AAC services include assessment, intervention, access to support, resources, education, and partner training (Balandin & Iacono, 1998a). Due to the special nature of the AAC services, Balandin and Iacono (1998a) and Ratcliff, Koul, and Lloyd (2008) indicated that SLPs require advanced training to appropriately provide AAC services.
Current Practice in Taiwan
Taiwan is classified as a developed country with a population of approximately 23.4 million (Department of Statistics of the Ministry of the Interior, 2015). The Department of Statistics of the Ministry of the Interior (2015) reported that the population with disabilities increased from 860,000 in 2003 to 1.14 million in 2015. The proportion of the population with disabilities over the same period increased from 4.01% to 4.9%, including 550,000 people with different types of communication disorders (Department of Statistics of the Ministry of the Interior, 2015).
Most qualified SLPs in Taiwan complete undergraduate and/or graduate programs in speech–language pathology and audiology, whereas others receive only a 6-month SLP training program provided by the Speech-Language-Hearing Association of Taiwan (SLHA) at present (Yeh, 2015). First, between 1976 and 2005, when no undergraduate/graduate programs in speech–language pathology were available, SLHA provided a 6-month training program for those with a college diploma in nursing, psychology, special education, or a foreign language to qualify as SLPs working in departments of rehabilitation in hospital settings (Lee, 1993). This 6-month training program primarily focused on learning via a clinical practicum with short lectures on a number of specific topics (e.g., articulation disorders), without providing formal courses in diverse areas (Lee, 1993). Second, in 1994, the first 4-year undergraduate program in speech–language pathology and audiology was established, with a total of 95 credits needed to qualify (Lee, 1993). The first three-credit course dedicated to AAC was provided in 1997. At the time that this questionnaire was conducted, two undergraduate programs, two graduate programs, and one graduate curriculum in speech–language pathology had been established, and at least one course related to AAC is provided in each program. Therefore, in the years between 1994 and 2005, the dedicated programs in speech–language pathology and the 6-month training program coexisted. SLPs who completed their undergraduate and/or graduate degrees in the field of speech–language pathology have received AAC dedicated courses, whereas others who only received the 6-month training program gained knowledge of AAC through colleague contact, on-the-job training, or in-service learning from assistive technology engineering lab (ATEL).
A local assistive technology vendor, ATEL, began to expand the market in 1997, and gradually developed four types of low-tech communication devices (e.g., Hummingbird©) and one type of high-tech communication device (AAC好溝通©) (ATEL, 2014). ATEL offers information and support (i.e., demonstrations, sales, repairs, trials, and rentals) related to communication devices but not intervention to practitioners, consumers, caregivers, and family members. Provision of AAC services began immediately afterward. Over a decade later, evaluation and training on the use of AAC was defined in the practice of SLPs in the Speech Therapists Act, and AAC services in medical settings are now supported by the National Health Insurance Program administered by the Ministry of Health and Welfare (Speech Therapists Act, 2008). Consequently, AAC services are assumed mainly to be provided by SLPs in medical settings, with a small proportion in nonhospital settings.
In the past two decades, several changes related to AAC have occurred in Taiwan. These include the following: (a) the provision of university courses devoted to AAC; (b) the founding of two assistive technology vendors (e.g., ATEL); (c) the promulgation of the Speech Therapists Act (Speech Therapists Act, 2008); (d) the initiation of Type B assistive technology evaluators (i.e., SLPs) in 2012 (Ministry of Health and Welfare, 2012); (e) the initiation of a local chapter of the International Society of Augmentative and Alternative Communication (ISAAC)-Taiwan, in 2013 (The Taiwan Society for Augmentative and Alternative Communication, 2013); (f) an increase in the number of workshops with invited international speakers (e.g., Lyle L. Lloyd) on AAC-related topics; (g) a decrease in the period for paid intervention in hospital settings by SLPs (e.g., AAC service) by the National Health Insurance Program (National Health Insurance Administration, 2016); and (h) increased funding for AAC services in nonhospital settings provided by the Ministry of Education, Ministry of Health and Welfare, and private donors (Ministry of Health and Welfare, 2015). Furthermore, the Long-Term Care Services Act, initially proposed in 2007, integrates assistive technology services (Ministry of Health and Welfare, 2007). It was promulgated in 2015 and went into effect in 2017 (Long-Term Care Services Act, 2015). Yang and Chung (2009) estimated there to be approximately 300,000 people with complex communication needs who may benefit from AAC. However, there is little information available related to AAC services provided by SLPs in Taiwan.
Over the past two decades, AAC services provided by SLPs have been examined in only two countries, Australia (Balandin & Iacono, 1998a) and New Zealand (Sutherland, Gillon, & Yoder, 2005), and the AAC services provided by diverse professionals (e.g., SLPs, occupational therapists) have been examined in the Hong Kong Special Administrative Region of the People’s Republic of China (Siu et al., 2010). In Australia, Balandin and Iacono (1998a) investigated AAC knowledge, practices, and resources, as well as the preferred formats for further education. A 20-item survey questionnaire was mailed to the 1600 Australian SLPs who are members of Speech Pathology Australia, with a 61% response rate. No follow-up was made. Seventy percent of the respondents had completed an undergraduate degree, had practiced for more than 9 years, and resided in the capital city, Canberra. Fifty percent of the respondents reported working exclusively with a pediatric caseload, followed by an adult-only caseload (26%), and a combined adult and pediatric caseload (23%). Thirty-four percent of the respondents reported working in hospitals, followed by community health centers (26%), private practices (23%), and schools (21%); some of the respondents worked in more than one facility. Moreover, 65% of the respondents working in hospitals occasionally recommended AAC, 13% never recommended AAC, and 19% frequently recommended AAC. The authors reported that the negative attitudes of family members, the presence of presymbolic skills, and a lack of resources were factors impeding the provision of AAC. Most of the respondents reported some knowledge of unaided AAC and limited knowledge of aided AAC, particularly of high-tech devices. AAC information resources, centers providing AAC assessment, and device loans were the most accessed. Information on the range of available options and intervention techniques was considered most important. The respondents in the capital city had better access to AAC resources than those in rural areas. The respondents with a pediatric-only caseload tended to have either limited knowledge or extensive knowledge, those with both pediatric and adult caseload tended to have limited knowledge, and those with an adult-only caseload tended to have evenly distributed knowledge. The respondents with more than 9 years of experience had less knowledge than those with only 1 to 2 years of experience.
In New Zealand, Sutherland et al. (2005) investigated the provision of AAC services to children and adults by SLPs and their professional needs in providing AAC services. A survey questionnaire was mailed to 450 SLPs working in New Zealand. A follow-up of nonrespondents through an electronic mail or a standard letter was made 6 weeks after the initial distribution, with a 48% response rate. AAC services were provided by less than 41% of the responding SLPs and were mostly offered to children aged 5 to 10 years, mainly those with cerebral palsy, intellectual disabilities, and autism spectrum disorders. These included low-tech communication devices and sign language, which were mostly introduced to adults and children, and high-tech devices, which were mostly introduced to children with cerebral palsy and adults with ALS. However, the factors for nonprovision of AAC services were not investigated. Most of the respondents had received professional knowledge of AAC from education courses, in-service training, and/or workshops or conferences. Over half of the respondents viewed themselves as low competent in AAC, and most felt a need for training seminars or workshops, printed materials, and training videos.
In Hong Kong, Siu et al. (2010) conducted a survey of the provision of AAC services by diverse professionals (e.g., SLPs, occupational therapists). An 18-item survey questionnaire was mailed out and follow-up phone calls were made. The study found that AAC was mostly provided by SLPs, and thus SLPs working in special preschool training centers (59% response rate), special schools (71% response rate), and adult settings (18% response rate) were investigated. Most of the respondents had received educational courses related to AAC in their undergraduate programs and reported having 3 to 10 years of experience. Most respondents had also received training in AAC from short courses, workshops, and/or seminars, which were considered inadequate. AAC services were provided in school settings more often than in adult settings. Low acceptance, poor availability of home devices, and limited knowledge of device operation impeded the provision of AAC services. The survey found that the basic AAC professional preparation and current level of AAC services were considered unsatisfactory. Siu et al. (2010) proposed that this dissatisfaction affected both the quantity and quality of AAC services in Hong Kong and that there was a need for increased awareness and knowledge of AAC practice in Hong Kong.
However, a number of the AAC services observed in Australia, New Zealand, and Hong Kong have not yet been explored in Taiwan. The broad purpose of this article is to review the evolution of AAC service delivery by SLPs in Taiwan, including demographic information, current practices, and needs for continuing education. In addition, the effects of four demographic factors—type of workplace, geographical location of employment, years of service, and current clinical caseload—on practices and the desire for continuing education in AAC services were analyzed. Furthermore, findings from Australia (Balandin & Iacono, 1998a), New Zealand (Sutherland et al., 2005), and Hong Kong (Siu et al., 2010) served as a reference. The findings of this article are expected to provide a basis for understanding early indicators of unmet needs in AAC service provision, leading to an increased awareness of requirements (i.e., an increase in individuals with potential AAC needs), improved services, and increased potential for AAC services (Johnson & Bloomberg, 1988; Siu et al., 2010; Sutherland et al., 2005), and then to plan further and more diverse resources related to AAC services in Taiwan. Furthermore, this study contributes additional information on the field to the international AAC community.
Information Gathering Procedures
Participants
At the time that the questionnaire was conducted, qualified SLPs working in Taiwan were required to register with SLHA. These qualified SLPs underwent either the 6-month SLP training program provided by SLHA or undergraduate/graduate programs in speech–language pathology and audiology. A total of 302 participants who had registered with SLHA as SLPs were identified and recruited. Although the recruited SLPs may not constitute a homogeneous group (e.g., different educational trainings), they were considered to represent a comprehensive range of SLPs providing AAC services in Taiwan.
Procedures
A comprehensive sampling technique was employed whereby all SLPs in Taiwan were approached for participation. Recruitment was conducted through SLHA, as all SLPs must register with this organization. All 302 SLPs in their registry were invited to participate. SLHA mailed the finalized questionnaire package to all of the identified SLPs, to ensure participant confidentiality. This package included a consent letter detailing the purpose of the clinical exchange and encouraging participation, a self-administered questionnaire, and a self-addressed stamped return envelope. Each questionnaire was coded to faciliate tracking and follow-up. Follow-up was implemented after 3 weeks by an email to recipients who had not yet returned their questionnaires.
Instrumentation
The initial questionnaire was developed in two phases. A preliminary questionnaire was compiled by the author. To ensure clarity and legibility, the author consulted with an expert, a university professor with a research specialization in AAC, during the development of the questionnaire. The questionnaire was revised according to the specific comments received. Second, the questionnaire was written in Mandarin Chinese and reviewed by an expert committee of 10 SLPs who had worked for more than 10 years in hospitals, schools, or centers (e.g., early intervention centers or rehabilitation centers) in Taiwan, and who provided feedback on the question order, content, appropriateness, time taken to complete the questionnaire, phrasing, and potential questions or comments to enhance the validity of the questionnaire. The questionnaire was revised based on the feedback of eight SLPs.
The final questionnaire comprised 19 closed-ended questions in three main sections: background information, current practices, and continuing education needs (see the appendix). The section “Background Information” contained questions to solicit general information concerning respondents’ current occupation, workplace, geographical location of work, years serving as an SLP, and most recent level of education in the field of speech–language pathology. The section “Current Practices” focused on current clinical caseloads, populations currently using AAC, current populations that they work with needing AAC, types of communication device used (e.g., high-tech and low-tech), professional knowledge in the application of AAC, resources for acquiring professional knowledge in AAC (e.g., workshops), total hours spent during the past 2 years exploring these resources, factors preventing the introduction of AAC (e.g., too early to introduce AAC), and factors for introducing AAC (e.g., individuals without speech). In addition, the quality (e.g., if useful in providing AAC service) of the available AAC resources overall was rated, including university courses, workshops, direct contacts with professionals, journals or books, associations, centers, foundations, and/or labs. A 6-point Likert-type scale was used to reduce the tendency of some respondents to select the middle choice, which can occur with a 5-point Likert-type scale (Joshi, Kale, Chandel, & Pal, 2015). Finally, the section “Continuing Education Needs” was designed to collect information about desired further information and/or training in AAC and the most helpful resources for gaining competency in AAC. The completion time was estimated to be 10 to 15 min.
Data Analysis
The number of questionnaires received was counted and compared with the number of questionnaires dispatched to the potential participants. Data from each returned questionnaire were entered and analyzed using SPSS 17 for frequency, tabulation, and cross-tabulation. To avoid underestimation of the data, incomplete questionnaires were included in the data analysis as recommended by Sutherland et al. (2005). Questions with incomplete answers were treated as missing data.
Results
A total of 101 questionnaires were returned, representing a response rate of 33% and less than 3% omission rate across survey questions.
Demographic Information
Work in rehabilitation departments in hospital settings was reported by 65% of the respondents, followed by schools (27%). In addition, 46% of respondents reported working in northern Taiwan, including the capital city (Taipei City), followed by central Taiwan, southern Taiwan (each 27%) and eastern Taiwan (1%). A period of 4 to 8 years serving as an SLP was reported by 49% (n = 49) of the respondents, followed by 1 to 3 years (17%), 9 to 12 years (13%), and 13 to 20 years (13%). Among the respondents, 61% had completed an undergraduate, graduate, or doctoral degree program in the field of speech–language pathology, and 36% had completed the 6-month training program provided by SLHA.
Current Practices
Seventy-six percent of the respondents worked with both adults and children in their current clinical positions, whereas 24% worked only with children. None of the respondents worked only with adults. Figure 1 summarizes the diversity of disorders among the population served. As shown in Figure 2, 67% of the respondents had up to 10% of their individuals currently using AAC, whereas 17% had none of their individuals currently using AAC, while 45% and 32% of the respondents, respectively, reported up to 10% and 30% of the individuals needing AAC. A combination of high- and low-tech communication devices (63%) was mostly provided, followed by low-tech communication devices only (23%) and high-tech communication devices only (7%). The respondents were asked to report on their knowledge levels pertaining to low-tech and high-tech communication devices: 62% and 57% of respondents, respectively, indicated having adequate knowledge levels for low-tech communication devices (i.e., introducing a basic low-tech device) and high-tech communication devices (i.e., introducing a basic high-tech device), and 12% of the respondents indicated having high levels of knowledge for both high-tech and low-tech communication devices.
Proportion of the served populations with disorders.
Proportion of caseload currently using AAC and future needing AAC.
The four major resources for acquiring professional knowledge in AAC were workshops held by SLHA (84%), journals and/or books (58%), associations, centers, foundations, and/or laboratories (e.g., ATEL; 57%), and university courses in Taiwan (54%; see Figure 3). The most explored specific information before providing AAC services includes (a) programming of high-tech communication devices (76%), (b) programming of low-tech communication devices (76%), (c) available communication devices (75%), and (d) assessment protocols and strategies for introducing AAC (n = 71, 72%), as shown in Figure 4. During the past 2 years, 27 (28%) of the respondents reported receiving approximately 4 to 8 hr of training in exploring the AAC resources (e.g., types of communication devices), followed by those receiving more than 20 hr (25%), as reported in Figure 5. Figures 6 and 7 report that the lack of necessary prerequisites (67%); for example, adequate cognition, was the most reported factor for not introducing AAC, whereas the lack of natural speech (88%) and current language disability (84%) were the most reported factors for introducing AAC.
Proportion of the resources for acquiring professional knowledge in AAC.
Proportion of the explored specific information in AAC service provision.
Proportion of the hours in the past 2 years exploring AAC resources.
Proportion of the factors preventing introduction of AAC.
Proportion of the factors for introducing AAC.
For the most part, the quality of university courses devoted to AAC was rated as moderate (33%), followed by low to moderate (26%), and moderate to high (17%), whereas 16 respondents (17%) reported no experience with this type of resource. Similarly, the quality of direct contacts with professionals was generally indicated as moderate (31%), followed by low to moderate (27%), and low (15%), with no experience in this type of resource indicated by 14 respondents (14%). Conversely, the quality of workshops held by SLHA were generally rated as moderate (40%), followed by low to moderate (30%), and moderate to high (22%). The qualities of workshops not held by SLHA, journals or books, and associations, centers, foundations, and/or labs indicated similar results. The details are displayed in Figure 8.
Quality of overall AAC resources.
Continuing Education Needs
Figure 9 reports the proportion of respondents desiring further information and/or training. Collaboration with an AAC team (e.g., physical therapists [PT] or occupation therapists [OT]; 65%) and training in the use of high-tech communication devices (60%) were most frequently indicated. The workshops provided by professionals (73%) were reported as the most helpful resources, followed by suggested readings in journals and books (26%); continuing education courses provided in university (12%); and others (5%).
Proportion of the desired further information and/or training.
Cross-Tabulations
A number of cross-tabulations were conducted to determine the effects of demographic factors on AAC practices and the desire for continuing education in AAC services. A chi-square test of independence addressed the relationships between certain variables. Independent variables included (a) workplace, (b) geographical location of employment in relation to the capital city, (c) most recent education, and (d) current clinical caseload, whereas dependent variables included (a) explored resources, (b) individuals currently using AAC, (c) individuals possibly needing AAC, (d) types of communication devices, (e) level of knowledge about communication devices, and (f) types of desired AAC information.
First, the type of workplace was recoded into a new variable. Hospital in the department of rehabilitation, hospital in the department of ENT, and hospital in the craniofacial center were combined into a single category—hospital and organization, center, or foundation; school systems; university/university clinic; and others were combined into the single category—nonhospital. A significant interaction was found, χ2(4, N = 101) = 9.955, p < .05, when comparing the percentages of types of workplace and the individuals currently using AAC. The respondents working in hospital settings were more likely to have individuals currently using AAC than respondents working in nonhospital settings. A significant interaction was also found, χ2(4, N = 101) = 19.045, p = .001, when comparing the percentages of the types of workplace and the individuals possibly needing AAC. The respondents working in nonhospital settings were more likely to have individuals possibly needing AAC than respondents working in hospital settings. No significant relationship was found, χ2(3, N = 101) = 3.548, p > .005, when comparing the percentages of the types of workplace and the types of communication device provided. The types of communication device provided appeared to be independent of types of workplace.
Second, the geographical location of employment was recoded into a new variable as follows. Northern Taiwan was categorized as capital, whereas central Taiwan, southern Taiwan, and eastern Taiwan were combined into a single category of noncapital. No significant relationship was found, χ2(7, N = 101) = 2.947, p > .005, when comparing the percentages of geographical location of employment in relation to the capital city and types of explored resources. The types of explored resources were independent of geographical location of employment in relation to the capital city. Third, a chi-square test of independence was conducted to compare the level of knowledge of communication devices among SLPs who had completed programs in the field of speech–language pathology or the 6-month training program provided by SLHA. No significant relationship was found, χ2(4, N = 101) = 2.155, p > .05, indicating that the level of knowledge of communication devices appeared to be independent of the most recent education. Fourth, a chi-square test of independence was conducted to examine the relationship between types of current clinical caseload and types of communication device provided. No significant relationship was found, χ2(3, N = 99) = 3.766, p > .05, indicating that the types of communication device provided appear to be independent of the types of clinical caseload.
Finally, a chi-square test of independence was conducted to compare current clinical caseloads (i.e., children; both children and adults) and, first, individuals currently using AAC, and, second, individuals who may need AAC. Based on the recommendations of Huck (2004), the current clinical caseloads with adults only were omitted due to being reported by none of the respondent group. The percentages of individuals currently using AAC and possibly needing AAC were recoded: Categories of 0% and up to 10% were recoded as low percentage, whereas categories of up to 30%, up to 50%, up to 70%, and 100% were recoded as high percentage. A significant interaction was found, χ2(4, N = 98) = 10.675, p < .05, between current clinical caseloads and individuals currently using AAC. The respondents working with both adults and children were more likely to have a low percentage of individuals currently using AAC than respondents working with children only. No significant relationship was found, χ2(5, N = 98) = 9.756, p > .05, between current clinical caseload and individuals who may need AAC, indicating that the percentages of individuals possibly needing AAC appear to be independent of the current clinical caseload. Similarly, a chi-square test of independence was conducted to compare the percentages of individuals currently using AAC and individuals who may need AAC. A significant interaction was found, χ2(1, N = 99) = 6.247, p < .05. The respondents with a higher percentage of individuals currently using AAC were more likely to report a higher percentage of individuals possibly needing AAC. Furthermore, a Pearson correlation coefficient was calculated for the relationship between individuals currently using AAC and those possibly needing AAC. A strong positive correlation was found, r(4) = .834, p < .05, indicating a significant linear relationship between the two variables. The respondents with a higher percentage of individuals currently using AAC tended to report a higher percentage of those possibly needing AAC.
Discussion
The current survey was the first to review the evolution of AAC service delivery by SLPs in Taiwan, including factors such as demographics, current practices, and need for continuing education. The effects of four factors—(a) workplace, (b) geographical location of employment in relation to the capital city, (c) most recent education, and (d) current clinical caseload—on AAC practices and desire for continuing education in AAC services were also investigated. As some recruited SLPs received undergraduate and/or graduate degrees in the field of speech–language pathology, others received only a 6-month SLP training program provided by SLHA, they were considered a heterogeneous group representing an inclusive range of certificated SLPs providing AAC services in Taiwan. The overall response rate was lower than in the studies conducted in Australia by Balandin and Iacono (1998a), in New Zealand by Sutherland et al. (2005), and in Hong Kong by Siu et al. (2010). This might be due to the fact that all of the mailings were made by SLHA to protect the privacy of their members (i.e., SLPs), which appears to be a different method from that of other studies. Possible additional factors are that only one follow-up electronic mail was sent out by SLHA and that some mailing addresses might have been incorrect.
The demographic information demonstrates that almost half of the SLPs reside in northern Taiwan, including the capital city, Taipei City, with some living in central Taiwan, southern Taiwan, and remote rural areas of Taiwan. This is similar to the findings of Balandin and Iacono (1998a) in Australia. The finding that more than half of the SLPs work in departments of rehabilitation in hospital settings in Taiwan is different from the near-equal distributions found among workplace types in Australia. Unlike Australian SLPs, who mostly work only with children, most SLPs working in hospital settings in Taiwan provide services to both adults and children, with only a few providing services to adults only or children only. This is because the 6-month training program that began in 1976 trained qualified SLPs working in departments of rehabilitation in hospital settings.
Almost half of the responding SLPs have practiced for 4 to 8 years, similar to the findings of Siu et al. (2010) in Hong Kong but different from those (i.e., more than 9 years) of Balandin and Iacono (1998a) in Australia. The findings in Taiwan suggest that current SLPs, mostly in the new to middle generation, are supported and supervised by experienced practitioners and provide AAC services with some clinical experience and little AAC practice. Two thirds of the responding SLPs have received undergraduate, graduate, or doctoral degrees in the field of speech–language pathology and one third have completed a 6-month training program provided by SLHA. These figures may reflect the fact that (a) the 6-month training program was not available after 2005 and (b) there have been increases in undergraduate and graduate programs devoted to SLPs over the past two decades.
The presentation of individuals without natural speech and their current language disabilities appeared to be the primary factors for introducing AAC, which might affect more than two thirds of the SLPs currently introducing AAC to up to 10% of their caseloads, with two fifths of the SLPs foreseeing that up to 10% of their caseloads might benefit from AAC. Conversely, the individuals without the necessary prerequisites, which was also noted in the work of Balandin and Iacono (1998a) in Australia, was a powerful factor in Taiwan in preventing the introduction of AAC, which may have caused approximately one sixth of the respondents to never recommend AAC to their served individuals. This is one of the factors causing a discrepancy between the potential need and actual use of communication devices. A combination of high- and low-tech communication devices was generally provided, unlike New Zealand, where mostly low-tech communication devices were provided. This is because both high-tech and low-tech communication devices were introduced to SLPs in Taiwan by ATEL very early on. However, it needs to be acknowledged that with recent developments in technology, the situation may well have changed in New Zealand in recent years, and thus that the differences reported between New Zealand and the current findings may be a function of time elapsed rather than context.
Although the current findings show that the types of communication devices provided were not significantly influenced by current clinical caseloads, communication devices were more frequently introduced by SLPs working only with children than those working with both adults and children. There are two possible explanations for these findings. One is that SLPs expect better outcomes from the use of communication devices in children than in adults. The other is that the family members of children may have a more positive attitude than those of adults. Furthermore, the types of communication device provided were not significantly affected by type of workplace (i.e., hospital settings and nonhospital settings). We might expect that both high-tech and low-tech communication devices are gradually being increasingly recommended in nonhospital settings (e.g., centers, foundations, and schools) in addition to hospital settings. One of the potential factors is the increased funding for the AAC services in nonhospital settings provided by the Ministry of Education, Ministry of Health and Welfare, and private donors (Ministry of Health and Welfare, 2015) and the inclusion of assistive technology services in Long-Term Care Services Act (Ministry of Health and Welfare, 2007). Another potential factor is that limited options of communication devices from the vendors (e.g., ATEL) are available across hospital settings and nonhospital settings. The current findings also found that SLPs working in hospital settings were more likely to have their individuals currently using AAC than SLPs working in nonhospital settings. The assumption that AAC services are mainly provided in hospital settings with a small proportion provided in nonhospital settings is supported by these findings and was consistent with those of Balandin and Iacono (1998a) but contrary to those of Siu et al. (2010). SLPs working in nonhospital settings are more likely to have individuals benefiting from AAC than SLPs working in hospital settings. This, first, reflects the fact that SLPs working in nonhospital settings have come to increasingly consider recommending AAC, as the Taiwanese government has taken the initiative to increase the number of Type B assistive technology evaluators (i.e., SLPs) regulated by the Ministry of Health and Welfare (2012), as well as the number of courses devoted to the field of AAC in undergraduate and graduate programs. Second, SLPs working in hospitals have reduced AAC services due to a decrease in the period of paid intervention by the National Health Insurance Program (National Health Insurance Administration, 2016). Third, funding for AAC services in nonhospital settings that is primarily provided by the Ministry of Education, Ministry of Health and Welfare, and some private donors has increased (Ministry of Health and Welfare, 2015), in contrast to the gradually decreasing subsidy from the National Health Insurance Program in hospital settings.
In view of the strong positive correlation found between SLPs who have a higher percentage of individuals currently using AAC and those reporting a higher percentage of individuals possibly benefiting from AAC, it may also be that SLPs who have experience in AAC services tend to be more enthusiastic in applying AAC to potential needs, whereas SLPs who do not have experience in AAC services tend to feel hesitant about doing so. This finding supports the idea that the provision of AAC services by SLPs can also be addressed using the construct of self-efficacy proposed by Pasupathy and Bogschutz (2013). As AAC service is one of the service delivery domains of SLPs and is led by SLPs (ASHA, 2016; Balandin & Iacono, 1998a, 1998b; Beukelman & Mirenda, 2013; Russell & McAllister, 1995), SLPs who have this special practice have higher self-efficacy to provide more AAC services than those without this practice.
More than half of the SLPs in Taiwan who responded in this study reported adequate knowledge levels in low-tech, because many low-tech communication devices and one high-tech communication device were initially introduced by ATEL. Their level of knowledge of communication devices was not affected by different types of training programs (i.e., programs in speech–language pathology or the 6-month training program provided by SLHA). This reflects the findings that SLPs with different levels of education spend either 4 hr to 8 hr or more than 20 hr acquiring AAC-related knowledge from the most helpful resources, such as workshops provided by professionals (e.g., SLHA). Journals and/or books, associations, centers, foundations, and/or laboratories (e.g., ATEL), and university courses devoted to AAC were additional resources, consistent with the results of Sutherland et al. (2005).
The most explored resources included programming of high-tech communication devices, programming of low-tech communication devices, available communication devices, and assessment protocols and strategies for introducing AAC. Among these, issues in assessment were also indicated in the study by Balandin and Iacono (1998a), who further reported that discrepancies in access to resources and information were dependent on the distance from the capital city. However, this was not an issue in Taiwan, according to the current findings, as traveling from northern to southern Taiwan takes approximately 1 hr 30 min by high-speed railway, which reduces the effect of geographical location of employment.
The quality of the available AAC resources overall (e.g., university courses) was mostly ranked as moderate, followed by low to moderate. This implies that the available AAC resources in Taiwan still have room for improvement. In addition to rating the quality as moderate and low to moderate, around one fourth of the respondents rated the quality of workshops held by SLHA; workshops held not by SLHA; journals or books; and associations, centers, foundations, and/or laboratories as low to moderate and moderate to high. This may be because these resources provide a great deal of reliable information on AAC from international scholars and/or practitioners. Remarkably, approximately one seventh of the SLPs did not have opportunities for access university courses devoted to AAC or direct contacts with professionals. This may be because these SLPs completed the 6 month training program provided by SLHA. The quality of AAC resources in Taiwan must be improved, as was also indicated in the study by Siu et al. (2010) in Hong Kong.
Many SLPs indicated the need for further information on collaboration with an AAC team (e.g., PT or OT) and training in the use of high-tech communication devices. These needs were also highlighted by Sutherland et al. (2005) in New Zealand and Balandin and Iacono (1998a) in Australia. However, one of the preferred resources reported by Balandin and Iacono (1998a) in Australia was information on the range of available options of communication devices, which was not indicated in the current findings. One possible explanation is that ATEL in Taiwan has continually provided information and courses on different ranges of available communication devices.
Conclusion
The AAC services provided by SLPs in Taiwan began from the launch of ATEL in 1997 and the first three-credit course dedicated to AAC provided in the same year in the first 4-year undergraduate program. These AAC services are mostly provided in northern Taiwan, including the capital city, Taipei City, and are mainly provided in hospital settings to diverse populations with SLPs introducing a combination of high-tech and low-tech communication devices. Most SLPs have completed programs in speech–language pathology and have practiced for 4 to 8 years with adequate knowledge levels of low-tech communication devices. Individuals without natural speech and their current language disability are the primary factors for introducing AAC, whereas an absence of prerequisites is the primary reason for not recommending AAC. The quality of AAC resources overall was rated as moderate and various continuing education needs were identified. Furthermore, four relationships among factors were identified: (a) SLPs working in hospital settings have more individuals currently using AAC than those in nonhospital settings, (b) SLPs working in nonhospital settings have more individuals possibly needing AAC than those in hospital settings, (c) SLPs working with both adults and children have a lower percentage of individuals currently using AAC than those working with children only, and (d) SLPs with a higher percentage of individuals currently using AAC have a higher percentage of individuals possibly needing AAC.
This article reviewed the evolution of AAC service delivery by SLPs in Taiwan. The studies on AAC service delivery have been investigated in other nations and provided additional pieces of information to the international AAC community. Several changes (e.g., initiation of Type B assistive technology evaluators; the Long-Term Care Services Act) related to AAC practice might have made AAC services more inclusive, as evidenced by their expansion into hospitals and nonhospital settings (e.g., centers, foundations, and schools). With adequate support, the AAC services in Taiwan in the next 5 to 10 years might change in several ways. First, the Type B assistive technology evaluators that have been initiated (i.e., SLPs) might compel SLPs to earn certificates and then provide more services in AAC assessment. Second, decreased paid intervention (e.g., AAC services) by the National Health Insurance Program and increased funding for AAC services by the Ministry of Education, Ministry of Health and Welfare, and private donors might greatly increase the availability of AAC services in nonhospital settings. Third, the Long-Term Care Services Act will extend AAC services into home services, community-based services, institutional services, and family caregiver supportive services with individuals who need AAC. Fourth, more international scholars and practitioners are invited by ISAAC-Taiwan and SLHA to hold workshops and/or conferences related to AAC practice. Fifth, accordingly, advocacy work is needed to increase public awareness of AAC services provided by SLPs.
The findings have several implications. First, the reported information on AAC services by SLPs in Taiwan contributes to the global AAC literature and can improve knowledge of the field internationally. A comprehensive picture of the provision of AAC services by SLPs can motivate further reports on the AAC services provided by other multidisciplinary team members. Second, the reported information on current practices and continuing education needs provides a basis for the Ministry of Health and Welfare and programs of speech–language pathology to modify current training courses to better meet the needs of SLPs when providing AAC services. The specific knowledge related to AAC services in these training courses includes evidence-based AAC practice, collaboration models with AAC service teams, and intervention strategies for high-tech communication devices from international perspectives. These might alleviate many issues reported in the current findings and also promote an interest in searching for greater breadth and depth of knowledge related to AAC services (Balandin & Iacono, 1998a), which might result in improved AAC services to potential candidates.
There are several limitations to the current findings. First, certain methodological issues related to survey delivery might have resulted in the low response rate of 33%. Information from nonrespondents may differ from what was reported in many ways (Sutherland et al., 2005). Second, SLPs play a leading role in overall AAC services (i.e., assessment and treatment; ASHA, 2016; Balandin & Iacono, 1998a, 1998b; Beukelman & Mirenda, 2013; Russell & McAllister, 1995) provided by a multidisciplinary team (e.g., individuals, family members, SLPs, PTs, and occupational therapists). The information presented in this article focused on AAC services solely provided by SLPs; AAC services provided by other professionals (e.g., PTs and occupational therapists) have not been explored. The whole puzzle of the AAC services in Taiwan was not closely examined in drawing the picture that emerges from the data reported in this article. Third, the 6-point scale was used to rate the qualitative information regarding the overall quality of the available resources of AAC. However, the qualitative information was not be explored.
Information on AAC services provided by different stakeholders, including people who use AAC, family members, primary caregivers, professional practitioners (e.g., special educators), and the communication device industry, is needed for future studies. Different perspectives on AAC services in Taiwan can be fully pictured. A deeper understanding is warranted of the issues surrounding the service delivery of AAC, as well as potential recommendations for further development of AAC practices. These issues include quality indicators of AAC services, perceptions of introducing AAC to good candidates and their families, and recommended training and/or education courses for professionals to become more competent AAC service providers.
Footnotes
Appendix
Acknowledgements
The author wishes to thank Dr. Julie Scherz from Wichita State University, Wichita, Kansas, USA; Dr. Kuo-You Huang from Chung Shan Medical University, Taichung, Taiwan; Yi-Jen Chen from National Cheng Kung University Medical College and Hospital, Tainan, Taiwan; and Hsiu-Ching Lee from Maria Social Welfare Foundation, Taichung, Taiwan for their expertise contributed to this article.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
