The evolution of dysphagia management within health care settings began as recently as the 1970s following increased awareness of the need for systematic management of the condition by health professionals, advances in technology enabling enhanced assessment processes, and the commencement of research in the area. Since then, ongoing improvements in the understanding of dysphagia, its assessment and its management have been witnessed internationally. In a number of countries around the world there are now well established dysphagia services with recognised practice guidelines for training and clinical service delivery which ensure high quality care for patients with dysphagia. However, in countries with less well established speech-language pathology services, such as Malaysia, prior research published in 2006 found that dysphagia management was an emerging area of practice and that clinical practice standards were not comparable to other countries (Sharma, Harun, Mustaffa Kamal, & Noerdin, 2006). In light of this recognised deficit, it was the overall objective of the current thesis to gain greater insight into the nature of dysphagia services in Malaysia and the challenges facing the establishment of the service in the country, in order to inform future health service change.
Models of health service change involve three main stages: (i) understanding current practices, (ii) identifying possible barrier(s) to service development, and (iii) addressing identified barrier(s). Using this theoretical framework, the current study involved four separate investigations which incorporated two large cohort comparison survey studies, a mixed methodology study and an intervention study. Specifically, these investigations were used to identify current dysphagia practices in Malaysia (Phase 1: Chapter 2), explore barriers to future establishment of the service (Phase 2: Chapters 3, 4 and 5), and evaluate the outcomes of an intervention targeting an identified barrier (Phase 3: Chapter 6). Across the series of investigations, a total of 283 speech-language pathologists (SLPs) and other health professionals were recruited from Malaysian and Queensland government hospitals. Clinicians in Queensland health settings, Australia were used in the current thesis as a comparison group. This group was chosen as a reference group as the country is recognised to have established processes for training and clinical services in dysphagia management.
In the first main investigation, both Malaysian (n=30) and Queensland (n=30) SLPs completed a detailed survey regarding their caseload characteristics, and nature of dysphagia assessment and treatment practices to establish a baseline of current dysphagia practice in Malaysia. In the same survey, there were also questions pertaining to formal education and clinical training received in dysphagia management, and the SLPs perceptions of their skills and training in the area to examine potential barriers to services. The subsequent investigation used a mixed method study to explore current infrastructure for dysphagia management. This involved a total of 38 hospitals from Malaysia and Queensland and incorporated a stage 1 survey administered to a senior SLP in each setting, which was then followed by in-depth interviews with eight purposefully selected senior clinicians from both the Malaysian and Queensland settings (n=16). A third and separate study involved a survey conducted with other health professionals (medical, nursing and allied health) in both services (Malaysia n=96, Queensland n=80) to examine their awareness, involvement and training in the area of dysphagia. The design of the final investigation was an intervention study. Its purpose evolved from the findings of the first and second studies which identified deficits in the training and confidence of the Malaysian clinicians in the area of dysphagia management. A cohort of nine Malaysian SLPs underwent a series of four workshops. Dysphagia knowledge and clinical skills were evaluated before and after the workshop in order to determine the effectiveness of the training model for developing clinicians’ knowledge, skills and confidence in dysphagia management.
The data from the series of investigations has demonstrated that dysphagia services in Malaysia have dramatically improved in the six years since service deficits were first identified. There is now greater assimilation with international standards of practice particularly in the utilisation of assessment and treatment procedures. Despite this, there remain a number of ongoing challenges to further establishment of dysphagia service in Malaysia. In particular, the majority of Malaysian SLPs surveyed did not feel capable or confident in providing dysphagia services, largely due to inadequate training and workplace infrastructure available. Another key factor identified was the lack of awareness and involvement of other Malaysian health professionals in managing dysphagia, and a lack of a multidisciplinary team (MDT) approach to dysphagia management. Analysis of current infrastructure highlighted further barriers to dysphagia services in Malaysia, including reduced availability of internet access for Malaysian SLPs, unfilled positions for SLP in most settings, lack of experienced and skilled clinicians in the area available to access for support, insufficient funding available to support dysphagia service, and very few documents or policies available to guide and structure practice. In the final study of the thesis, the outcomes of a professional development training model designed to improve both theoretical and clinical skills in dysphagia management was found to be successful. Both immediately post-training and at four weeks follow up there was documented improvements in SLPs’ knowledge, skills and confidence in dysphagia management.
The current series of studies highlight the need to address numerous barriers to service improvement in order to assist Malaysian SLPs to change practice and become better aligned with international standards in their management of individuals with dysphagia. Specific recommendations generated from the current findings include: (a) improved workplace infrastructure and support, (b) the need for increased numbers of SLPs in Malaysia in order to provide services to patients with dysphagia, (c) increased academic and clinical training in dysphagia management as well as enhanced access to workforce mentoring to support SLPs working in this area, and (d) increased involvement of the MDT and enhanced team member awareness of dysphagia and the SLP’s role. By addressing the barriers that currently exist, this will ultimately lead to enhanced service provision for patients with dysphagia in Malaysia.