An Exploratory Survey of Priorities in Establishing Telepractice System for SLPs and Caregivers in Korea

Abstract

This study investigated factors prioritized by speech-language pathologists (SLPs) and caregivers for telehealth services involving speech-language assessments and interventions and determined whether the priorities differed between SLPs and caregivers in Korea. The survey data obtained from 23 SLPs and 50 caregivers were analyzed using analytic hierarchical process (AHP) methodology. The results showed that the “SLP” category was the most important high-level category and “building rapport with the child client” in the “SLP” category was of the highest priorities for both SLPs and caregivers across all factors. Furthermore, the rank-order of a few categories and the global priority between SLPs and caregivers varied slightly. These findings suggest that, in addition to important factors associated with SLPs and caregivers, the different expectations of service providers and clients using telepractice in Korea should be addressed.

Keywords

qualitative research designs research survey technology

According to the American Speech-Language-Hearing Association (ASHA), telepractice (or telehealth) is defined as “the application of telecommunications technology to the delivery of speech-language pathology and audiology professional services at a distance by linking clinician to client or clinician to clinician for assessment, intervention, and/or consultation” (ASHA, n.d.). With the rapid growth in telecommunication technology, telepractice has been utilized in interventions for various communication disorders, including childhood speech and language disorders, as well as fluency, voice, and neurogenetic disorders (Machima & Doarn, 2008; Waite et al., 2006, 2010). Furthermore, telepractice is as effective as on-site service in the field of communication sciences and disorders (Grogan-Johnson et al., 2010; Keck & Doarn, 2014; McCullough, 2001). According to a survey conducted by the ASHA in 2002, around 11% of the 1,667 speech-language pathologists (SLPs) and audiologists who responded to the survey questionnaire reported that they had used telepractice in their therapy sessions. Although the percentage of users decreased to 2.3% of 1,455 SLPs in 2011, excluding the audiologists, telepractice remains a valid option for delivering speech-language services.

The infrastructure for information and communication technology in Korea is highly developed (National ICT Industry Promotion Agency of Korea [NIPA], 2015). However, the general telepractice system and related software or webware programs for telepractice services have received little attention, and research into telepractice in speech-language pathology has rarely been conducted except for a few studies exploring the effects of speech and language interventions delivered via computer-based programs or virtual reality technology (Y. J. Chung et al., 2003; H. J. Kim & Kwon, 2018). S. J. Kim (2008) examined the therapeutic needs of children enrolled in the voucher program in a survey study. The voucher program provides around 200 dollars a month to children under the age of 18 who need to receive rehabilitative therapy in Korea. The results showed that 1,142 caregivers responded that speech-language therapy was not only the most frequently used therapeutic intervention but also the most needed type of therapy regardless of children’s ages or disabilities. The findings suggest the importance of speech-language therapy for children with disabilities (S. J. Kim, 2008). Another survey investigating the status and desire of parents whose children were enrolled in a rehabilitation service program reported that the parents’ answers to questions regarding improvements needed in rehabilitation services included increases in financial subsidy, the expansion of treatment facilities for rehabilitation services for children, and transportation to the therapy centers (M.-J. Chung & Seo, 2010). However, due to the limited number of SLPs or speech-language therapy facilities in rural areas, parents transport children to and from the therapy centers across long distances, bearing the burdens of cost and time.

Given the limited number of qualified SLPs in remote areas in Korea, delivering speech-language therapy services via telepractice is effective and comparable to that of on-site sessions (Grogan-Johnson et al., 2013). Since telepractice in Korea is in its early stages of development, it is necessary to investigate the factors required to develop and establish a successful system.

Barriers preventing routine implementation in a clinical setting exist despite the advantages associated with the delivery of speech-language therapy services via telepractice that include prompt and easy access, as well as cost-effectiveness, compared to on-site sessions (Molini-Avejonas et al., 2015; Tucker, 2012). In a qualitative study examining the benefits and barriers of telepractice from the perspective of school-based SLPs (Tucker, 2012), the most frequently encountered barriers (disadvantages) involved technological challenges, such as low internet speed, lack of audio, frozen video connections, and delayed sound transmission. In addition, ethical issues involving confidentiality and the protection of clients’ privacy are other barriers to consider when delivering SLP services via telepractice.

A few barriers are related to telepractice systems and programs. Although a variety of means may be employed for telepractice, including email, telephone, and videoconferencing, and various custom software programs for assessment and speech-language therapy intervention via telepractice have been developed (Glykas & Chytas, 2004), no standardized procedures or protocols to guide telepractice are available. In a previous study, the need for prior technological expertise and training was mentioned by SLPs before they used telepractice to deliver services because their personal training with computers and telepractice-related technology were at different levels (Tucker, 2012). Also, studies supporting the efficacy of software or other approaches to deliver telepractice are limited (Marble-Flint et al., 2019). For instance, the efficiency of different modes (e.g., synchronous, asynchronous, and mixed modes) for the delivery of telepractice services depends on the client’s status.

In addition, long distances and limited physical contact are other barriers. It is well documented that building rapport with a client is critical for successful therapeutic outcomes (Akamoglu et al., 2018; Dobransky & Frymier, 2004). Akamoglu et al. (2018) analyzed the SLP practices that facilitate the development of rapport and the effect of rapport-building on clients’ outcomes in telepractice in a qualitative study. SLPs reported the advantages of building rapport with clients via phone calls, emails, and text messaging, using an online session note to parents to foster communication, and the degree of flexibility and accessibility in providing services via telepractice, which enabled SLPs to communicate extensively with children. However, a few disadvantages in building rapport with clients via telepractice were also reported by the SLPs. They reported that support (e.g., an e-helper) was required to build rapport with a client and that the lack of physical proximity to children and parents may be a barrier separating them from clients and that the client’s disability may influence the extent of the rapport. Thus, assistants or e-helpers may play an important role in telepractice, especially if the clients are young children or if the clients have difficulty in positioning or operating the equipment needed for telepractice therapy. Therefore, as suggested in the previous study, appropriate training for e-helpers or assistants should be conducted before starting telepractice therapy because untrained personnel can be a challenge in delivering the service (Tucker, 2012). In addition, the types of disabilities should be considered by SLPs in selecting the appropriate clients for telepractice. For instance, it may be a challenge for an SLP to closely monitor the articulation of a child with phonological disorders or to demonstrate clear articulatory movement. Children with severe cognitive impairments or psychological problems may not be the best candidates for telepractice (Akamoglu et al., 2018; Tucker, 2012). Thus, it is necessary for SLPs to display adequate knowledge about various disabilities to select appropriate candidates for telepractice sessions and deliver speech-language services effectively over long distances and static environments (Overby & Baft-Neff, 2017).

The client’s acceptance of telepractice services is also an important factor to consider. Although school-aged children appear to be amenable to telepractice therapy using computers and similar technologies, it may be inconvenient for the elderly or clients who are not familiar with such technological advances (Tucker, 2012). Also, the caregiver’s acceptance of telepractice also should be considered in establishing the telepractice system because in many cases, caregivers may act as assistants during telepractice service sessions. The ability of a client, especially if they are very young, to receive therapy mostly depends on the caregiver’s decision.

Together, the factors mentioned above represent major challenges to telepractice involving patients with communication disorders. This study, contributing to basic research for establishing a telepractice system in speech-language pathology, investigated the key factors underlying speech-language assessment and intervention via telepractice provided by SLPs and caregivers. Specifically, this study analyzed whether the importance of such factors differed between SLPs and caregivers. To this end, we developed a survey to determine the key factors in telepractice service delivery for SLPs and caregivers based on previous studies (Molini-Avejonas et al., 2015; Overby & Baft-Neff, 2017; Tucker, 2012). The survey was specifically constructed for analytic hierarchical process (AHP) methodology analysis (Saaty, 1977). The AHP is a mathematical model frequently used in decision theory to prioritize and select a factor/item and has recently been used to determine priorities between multiple criteria in health care (Pauer et al., 2016; Schmidt et al., 2016).

Method

Participants

A total of 60 responses from SLPs and 175 responses from caregivers were obtained, and incomplete responses or those with a consistency ratio (CR) greater than 0.2 were excluded based on AHP analysis methodology (Dolan, 2008; Saaty, 2000). The final analyses incorporated 23 responses completed by SLPs and 50 responses provided by caregivers.

SLPs

All 23 SLPs were female and employed at various speech and language clinics. Nine of the SLPs (39.1%) reported that they had heard about telepractice and only one SLP reported the experience of delivering a one-time telepractice service for a client with a cochlear implant. The mean age of the SLPs was 29.65 years (SD = 7.26) and ranged from 23 to 55 years. The mean duration of employment as an SLP was 27.18 months (SD = 23.67) and ranged from two to 79 months.

Caregivers

Only one out of 50 caregivers had heard about telepractice before, and none of the caregivers had experienced telepractice services. The mean age of the caregivers’ children was 4.66 years (SD = 1.08) and ranged from 3 to 6 years. The mean age of the caregivers was 37.20 years (SD = 3.75) and ranged from 30 to 48 years. The 50 caregiver respondents included six males and the rest were females. In terms of education, 22% of the caregivers were high-school graduates, 66% were college graduates, 10% completed graduate school, and 2% failed to respond.

Survey Development and Procedures

The survey seeking the priority factors for delivering telepractice services in speech and language was created in two stages.

First, to determine the factors required to deliver telepractice services for speech and language, pre-survey items were prepared for SLPs and caregivers based on a review of the literature (Molini-Avejonas et al., 2015; Overby & Baft-Neff, 2017; Tucker, 2012). A total of 20 factors related to barriers and disadvantages, which were discussed in previous studies, were developed. After a panel of experts reviewed the appropriateness and elucidated the factors, the pre-survey was administered to five SLPs and 40 caregivers of children between the ages of 3 and 6 years at several speech-language clinics. The survey respondents were asked to mark any factor that they considered important to telepractice services. The return rate was 100% because student researchers went to the speech and language clinic sites with the survey materials to distribute them to caregivers while they waited for the children’s therapy sessions. A cutoff threshold for inclusion in the next stage of development for each factor was set at over 20% of all participants, marking the factor as important to telepractice. The SLPs and caregivers marked all 20 factors as important to the delivery of telepractice services involving speech and language.

In the second stage, the 20 factors were classified into four high-level categories of five factors each. The high-level categories were as follows: (a) telepractice system, (b) telepractice program, (c) SLP, and (d) client. The operational definitions of high-level categories and factors under each high-level category are presented in Supplemental Appendix A. At the beginning of the survey, the operational definitions of each high-level category and each factor, as well as the definition of telepractice, were presented to facilitate the respondents’ understanding of the topic. The appropriateness of the terms and definitions was tested by the expert panel. The expert panel comprised five professors who were also certified SLPs who worked in the Department of Communication Sciences and Disorders for over 10 years. The ratings of appropriateness judged by the expert panel ranged from 80% to 100%. In addition, two open questions seeking the participant’s response to the potential advantages and disadvantages of telepractice were included in the final survey.

The final survey, intended to determine the priority of factors involved in delivering speech and language services via telepractice, was distributed to SLPs and caregivers at several speech and language clinics. The survey is presented in Supplemental Appendix A, which was constructed for AHP pairwise comparisons. The SLPs and caregivers were asked to evaluate the comparative importance of each set of matched factors (e.g., SLP vs. client) on a scale from 9 to 1 and from 1 to 9, where 1 indicated equal importance and 9 indicated extreme importance of that factor compared to the opposing factor. The responses were acquired by three student researchers.

Analyses

The completed surveys were coded for analyses using Expert Choice 2000, which is a widely used software program for AHP pairwise comparisons. In AHP pairwise comparisons, the hierarchical structure of the criteria was established, and multiple criteria were categorized with sub-components/items. A series of pairwise comparisons for every two items was conducted, in which a participant was asked to judge the relative importance of two items rating from 9 (extreme importance) to 1 (equal importance) for one item in the pair and from 1 (equal importance) to 9 (extreme importance) for the other item (Schmidt et al., 2016). Finally, a CR based on consistency and random indices were used to confirm the internal consistency of the participant’s judgments for a series of pairwise comparisons. An acceptable level of CR is less than 0.2 (Dolan, 2008; Saaty, 2000). Thus, a CR of 0.2 was set as the data inclusion criterion for analyses in this study.

Results

High-Level Category

AHP analyses of factors in the high-level category for the delivery of telepractice services in speech and language indicated that the first priority was “SLP” for SLPs (37.1%) and caregivers (35.1%). The second priority was “telepractice program (25.8%)” followed by “client (24.6%),” and “telepractice system (12.5%)” for the SLPs. Among the caregivers, the second priority was “client (29.4%)” followed by “telepractice program (22.8%)” and “telepractice system (12.7%).”

Local Priority in Each Category

Within the telepractice system, the first priority was “link between face-to-face session and telepractice session” for both the SLPs and the caregivers. The second priority was “policy related to telepractice service” for the SLPs and “exchange of information among other professionals” for the caregivers. Within the telepractice program category, the first priority was “quality of telepractice program” followed by “parental consultation” for the SLPs. The first priority was “parental consultation,” followed by “quality of telepractice program” for the caregivers. Within the SLP category, “building rapport with a child client” was the first priority for both the SLPs and the caregivers. “Ability to identify suitable clients” was ranked second by the SLPs, whereas “using nonverbal communication skills” was a second priority among the caregivers. Within the client category, “acceptance of telepractice service by a caregiver” was the first priority and “acceptance of telepractice service by a child client” was ranked second by the SLPs. Among the caregivers, “acceptance of telepractice service by a child client” was the top priority, followed by the “client’s accessibility to telepractice service.” The extensive, local priority of the factors in each category for the SLPs and caregivers is listed in Table 1.

Table 1.

Prioritization of Key Factors for Telepractice Services Provided by SLPs and Caregivers.

High-level category	Factor	SLP		Caregiver
High-level category	Factor	Weight	Rank	Weight	Rank
Telepractice system	Technical problems	0.143	5	0.156	4
	Facility and equipment	0.153	4	0.154	5
	Exchange of information among other professionals	0.168	3	0.239	2
	Policy related to telepractice service	0.250	2	0.196	3
	Link between face-to-face session and telepractice session	0.286	1	0.254	1
Telepractice program	Telepractice training for SLPs	0.170	5	0.173	4
	Telepractice training for service assistants	0.196	3	0.160	5
	Ease of use of telepractice program	0.181	4	0.180	3
	Parental consultation	0.199	2	0.253	1
	Quality of telepractice program	0.253	1	0.234	2
SLP	Ability to use telepractice-related equipment	0.152	4	0.117	5
	Ability to identify suitable client	0.189	2	0.160	3
	Understanding of telepractice service	0.148	5	0.133	4
	Using nonverbal communication skills	0.177	3	0.205	2
	Building rapport with a child client	0.334	1	0.385	1
Client	Role of caregiver as a telepractice service assistant	0.166	3	0.191	4
	Client’s access to telepractice service	0.157	4	0.200	2
	Caregiver’s competence for assistance	0.157	4	0.151	5
	Acceptance of telepractice service by a child client	0.255	2	0.262	1
	Acceptance of telepractice service by caregiver	0.264	1	0.196	3

Note. First priority is indicated in bold font in each category. SLP = speech-language pathologists.

Global Priority of Factors Across Categories

AHP analyses for the global priority of factors across the categories for delivering/receiving telepractice service in speech and language revealed that among the SLPs, “building rapport with a child client” was the top priority with a weight of 10.6%, followed by “quality of telepractice program (7.4%),” “acceptance of telepractice service by a caregiver (7.0%),” “acceptance of telepractice service by a child client (6.8%),” and “ability to identify suitable client (6.0%)” in order (see Figure 1 for the full priority of factors by the SLPs). Among caregivers, “building rapport with a child client” was the top priority with a weight of 10.2%, followed by “acceptance of telepractice service by a child client (8.6%),” “parental consultation (6.6%),” “client’s access to telepractice service” (6.5%), and “acceptance of telepractice service by a caregiver (6.4%)” in order (see Figure 2 for the full priority of factors by the caregivers).

Figure 1.

Full priority of factors and corresponding weights based on responses from SLPs.

Figure 2.

Full priority of factors and corresponding weights based on responses from caregivers.

Open Question: Potential Advantages and Disadvantages of Telepractice

Responses to questions regarding the potential advantages and disadvantages of telepractice service were received from 21 SLPs. The potential advantages of telepractice service most frequently specified by the SLPs were “service availability to the rural or remote areas” (14 SLPs) and “time and space effectiveness” (six SLPs). The frequently answered potential disadvantages of telepractice service included “limited attention to therapy” (five SLPs) and “basic start-up cost of the system” (four SLPs). In response to questions regarding the potential advantages and disadvantages of telepractice service, 19 caregivers responded to the open question of advantages and 17 caregivers responded to the open question of disadvantages. The most frequently answered potential advantages of telepractice service specified by the caregivers were “time and space effectiveness” (10 caregivers) and “service availability to rural or remote areas” (four caregivers). The frequently answered potential disadvantages of telepractice service were “lack of physical contact compared to a face-to-face session” (five caregivers) and “difficulty of building rapport between an SLP and a client” (four caregivers).

Discussion

This study analyzed the factors appropriate for telepractice for speech and language services based on the judgment of SLPs and caregivers in Korea. Specifically, the factors were ordered according to weighted priorities to determine the differential perception of SLPs and caregivers regarding the importance of factors in telepractice service. The most important factor was “SLP,” especially in the high-level category and the least important factor was “telepractice system” among both the SLPs and the caregivers, which may generally reflect the caregivers’ strong dependence on SLPs for speech and language treatment for their children. Also, the SLPs and caregivers perceived the important factors in telepractice service similarly with the highest priority of factors remaining the same within each category, as well as among the global rank-orders of both groups, except for the two high-level categories, “telepractice program” and “client.”

“SLP” in the high-level category was the most important factor for the SLPs and the caregivers. The relative importance of “SLP” was reflected in the high weight of the first-ranked factor “building rapport with a child client” for both SLPs and caregivers compared to the weights of the top-ranked factors in other categories. In addition, “building rapport with a child client” within the “SLP” category was the highest priority of all factors for the SLPs, as well as for the caregivers. As reported by previous studies, building rapport with a client is critical for successful therapeutic outcomes. A lack of physical contact with a client, especially in online communication, may lead to difficulties in establishing clinician–client relationships (Akamoglu et al., 2018; Tucker, 2012). Within the “SLP” category of caregivers, the second-ranked factor, “using nonverbal communication skills” is linked to “building rapport with a child client.” Due to limited physical proximity, the use of nonverbal communication skills by an SLP to determine a client’s feelings or mood and respond accordingly may facilitate rapport-building with a child. Thus, it is important to ensure that SLPs are equipped with strategies needed to build rapport with children and families via various communication methods in telepractice to obtain optimal therapeutic outcomes. Approaches used to build rapport with children and families include getting to know each other, fostering open communication, and making personal connections with clients and parents (Akamoglu et al., 2018). In addition, some children, such as those with difficulty paying attention to a specific task, children with severe cognitive impairment, and children with limited motor abilities are contraindicated for speech-language therapy via telepractice (Duffy et al., 1997). Thus, awareness of client competence to receive services via telepractice was an important prerequisite for the SLPs. The “ability to identify suitable client” was the second most important factor within the SLP category for the SLPs.

“Telepractice system” in the high-level category was the least important priority for the SLPs, as well as for the caregivers, which may also reflect the unfamiliarity with telepractice among both groups. In other countries that routinely utilize telehealth services, the most frequently mentioned barriers were technological issues. In contrast, both the SLPs and the caregivers perceived the “link between face-to-face session and telepractice session” as an important factor under the telepractice system category. This perception may be attributed to the lack of experience with telepractice in both groups, which prevented an appreciation of the importance of a technical set-up with high internet speed and bandwidth required for data transmission. Instead, both groups perceived that the traditional on-site therapy session is still an important treatment modality even in the telepractice service model, suggesting the need to combine face-to-face sessions with telepractice to effectively establish a telepractice system in the future.

In the “telepractice program” category, “quality of telepractice program” was an important factor for the SLPs. It reflected the SLPs’ need for qualified therapy content, such as guidelines for assessment and effective intervention programs in telepractice services. As the effectiveness of assessment and treatment protocols, as well as the validity of standardized procedures for carrying out telepractice services, has yet to be extensively examined, further study of telepractice protocols and standardized procedures in telepractice may be required (Molini-Avejonas et al., 2015). However, among caregivers, “parental consultation” was an important factor in the “telepractice program” category. “Parental consultation” enhances the relationship between SLPs and clients. In addition to providing useful information, such as the child’s daily activities, performance, and progress to the parent, SLPs also train parents with the practical skills and strategies required to stimulate and facilitate the child’s target skills during the consultation. Parental consultation is highly ranked, and this may reflect their need to actively engage in their child’s treatment. Thus, there is a need to provide a parent consultation channel to address the caregivers’ needs in telepractice programs.

In the “client” category, “acceptance of telepractice service by a caregiver” and “acceptance of telepractice service by a child client” are considered important factors. It is important for SLPs to determine whether clients or caregivers are familiar with computers and technology, which are necessary for telepractice implementation. In addition, as telepractice is in the developing stages and little is known about its effectiveness in Korea, it is not strange that these factors are ranked highly. Therefore, along with various studies investigating the effectiveness of telepractice services, efforts are required to popularize telepractice by professional organizations, such as the Korean Association of Speech-Language Pathologists. Caregivers also believed that “child’s access to telepractice service” was an important factor. This factor can be linked to the “ability to identify suitable clients” in the SLP category. Whether child clients can use equipment related to telepractice services and whether their cognitive function or motor ability is adequate to receive speech and language therapy via telepractice seem to be critical prerequisites to consider by both SLPs and caregivers.

Finally, the potential advantages specified by most SLPs and caregivers were consistent with previous studies, which indicated that the strengths of telepractice services include cost- and time-effectiveness, as well as therapy across long distances (Molini-Avejonas et al., 2015). The findings suggest the need for a telepractice system in Korea. The potential disadvantages suggested by the caregivers and SLPs were mostly reflected by their priorities under the “SLP” category. Thus, further education involving clinical techniques and strategies and appropriate technical training is essential for effective telepractice by SLPs and audiologists in Korea.

In summary, this study analyzed the priority of factors allocated to telehealth services and possible differences in the perception of SLPs and caregivers in Korea. To establish a successful telepractice system in Korea, appropriate pre-training/instruction programs for SLPs envisaging the use of telepractice to deliver speech-language therapy should be considered, along with evidence-based treatment programs for caregivers and SLPs. It is also necessary to address the needs of both SLPs and caregivers in setting up telepractice systems based on the differences in priorities.

To our knowledge, this is the first qualitative study investigating the key factors related to telepractice services provided by SLPs and caregivers in Korea, where telepractice is in a developing stage in the field of speech and language pathology. We believe that these preliminary findings can serve as the foundation for developing a telepractice system in Korea and for further studies exploring strategies to successfully establish telepractice systems in general.

Supplemental Material

Appendix_The_survey_final – Supplemental material for An Exploratory Survey of Priorities in Establishing Telepractice System for SLPs and Caregivers in Korea

Supplemental material, Appendix_The_survey_final for An Exploratory Survey of Priorities in Establishing Telepractice System for SLPs and Caregivers in Korea by Jeewon Yoo, Mi-sun Yoon, Chi Kyou Lee, Gyung-Hun Hong and Seong Jun Choi in Communication Disorders Quarterly

Footnotes

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a grant of the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI); the Ministry of Health & Welfare, Republic of Korea (grant number: HI18C0744); and the Soonchunhyang University Research Fund.

ORCID iD

Jeewon Yoo

Supplemental Material

Supplementary material for this article is available on the Communication Disorders Quarterly website along with the online version of this article.

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