50th Anniversary Archive Series Image

Published on December 17th, 2014


The Importance of Prevention: “A Challenge for the 90s” and Beyond (1992)

From the SAC Archives: A Year-Long Retrospective Series

Publication: Communiqué, (Pages 11-12)
Original publication date: April 1992
Author: Ruth Krmpotic-Cameron

Introduction by: Maureen Penko, S-LP(C) and Sharon Halldorson, S-LP(C)

Ruth Krmpotic-Cameron provides an articulate and passionate plea for changes to the health-care system in its approach to speech-language pathology and audiology services. As a Public Health Unit speech-language pathologist (S-LP) with the province of Ontario in the 1980s, Krmpotic-Cameron was overwhelmed by caseload demands and the risk of burnout due to the province’s woefully inadequate approach to acute care. She boldly proposed that the Ontario government should legislate speech-language pathology and audiology as mandatory and essential health-care services. She and her colleagues further asserted that prevention, education, preschool screening and parent training would better meet the demands of caseloads. Although the establishment of the Association of Speech-Language Pathologists and Audiologists in Public Health (ASAP) offered further support, training programs at the time still did not prepare new graduates for this non-traditional approach to service provision. As Krmpotic-Cameron aptly states: “We have come a long way in this journey towards establishment of our professional disciplines within public health and yet we have far to go.”

We applaud the innovative and creative work of professionals like Krmpotic-Cameron and agree that, even in 2014, prevention services in health care facilities and schools continue to evolve at a slow pace. It is encouraging that current public health websites in Canada consistently list speech-language pathology on their menu of services. We also share Krmpotic-Cameron’s optimism for the future; she sees “the future for public health speech-language pathology and audiology as a bright and promising one.” 

Ruth Krmpotic-Cameron is the Director of Communication Development Services for the Algoma Health Unit in Sault Ste. Marie, Ontario. Ruth is also an active member of the Association of Speech-Language Pathologists and Audiolo­gists in Public Health (ASAP). Her current focus is on the prevention and early identification of communicative disorders.

A Challenge for the 90’s: Integrating Speech-Language Pathology into Public Health

Graduating in the late 70’s, I was probably no different from most other speech-language pathologists.

Anxious to embark on a promising career, I took up a sole charge clinical position in a small and isolated northern community. In the beginning I was confident that my expertise would be welcomed by a community that, up until my arrival, had limited access to the few available professionals.

I had never expected that the demands of the profession would be able to exceed my enthusiasm, and that, in a short time, I would fall victim to the burnout that we now know plagues the profession.

Looking back years later, I realized that I had not failed the profession or the community. Rather, what had failed was the approach. Traditional clinical models of assessment and treatment simply could not hope to meet the demands of an underserviced area.

After an hiatus from the profession, I returned, this time to a position as a speech-language pathologist at a public health unit. It was 1983 and the Health Protection and Promotion Act had recently been proclaimed. This legislation specified that boards of health would be required to deliver “fundamental public health programs and services targeted at prevention of disease, health promotion and health education”. Previously, several disciplines had been defined as “core” or integral to public health, including nursing, dentistry, nutrition and inspection. Speech-language pathology and audiology had not been included among the “fundamental” or core services. Communicative health, specifically speech, language and hearing ‘wellness”, had not yet achieved status as integral components of public health.

As part of this public health delivery system, I found myself caught in a role conflict. While my public health colleagues were off conducting workshops on prevention, and developing health information displays and curricula, I remained in my clinical world, providing individual assessment and treatment services. My prior experience had confirmed the weakness of this method. In a district spanning some twenty-two thousand square miles, with a population of almost seven thousand preschool aged children, this service model could not hope to work. My position was a poor fit for an agency committed to health promotion and prevention.

The influences of James MacDonald’s work, and the emergence of the Hanen Early Language Parent Program in the late 70’s, reinforced the need to re-examine the traditional role of the speech­ language pathologist. The profession was beginning to pay more attention to early intervention and the success of parent mediation efforts for language delayed children. I found myself spending more time working directly with parents of infants and toddlers- a group I had few experiences with during my clinical internships in university. Fewer hours were being spent in the therapy room, with more time in the classroom, where parents gathered each week to learn about language stimulation strategies. With each day, I further pondered the merits of public education about speech and language issues as a more viable role for the public health speech-language pathologist.

Initially, I did not expect to meet with the resistance that was encountered. When I suggested to my supervisor, (a young, and so­l-thought progressive public health physician) that my clinical skills could be applied to develop programs and services aimed at public education and prevention, I did not draw immediate support. I was reminded of long waiting lists for clinical speech-language services. “Perhaps, when all the client waiting lists for speech therapy are resolved, well, then we might be able to look at doing something in prevention…” I left my supervisors office, frustrated and disappointed.

Little did I know at that time, but other speech-language pathologists practising in public health, were experiencing the same frustrations. Caught in an environment mandated to preserve wellness and prevent disorders, these professionals were still largely engaged in rehabilitative clinical services. All that would begin to change.

In 1984, speech-language pathologists and audiologists working in public health units across Ontario were beginning to identify their peers – not their clinical colleagues in hospitals, but rather their counterparts within public health. Each expressed a need to appeal for recognition of the potential role as advocate for the prevention of communication disorders.

And so, June 22, 1984 stands out in my mind as a particularly important date. For on that date, these speech-language patholo­gists and audiologists came together for the first time, to share their experiences, and to develop a vision for a new role for the professions within public health.

Eleven public health units were represented in Toronto at the inaugural meeting that would eventually lead to the establishment of the Association of Speech-Language Pathologists and Audiologists in Public Health (ASAP). Together they would develop a role to support the public health mandate, a role that would represent a departure from the acute clinical care model.

By 1985, ASAP had formally appealed to the Ontario Ministry of Health for inclusion of speech-language pathology and audiology activities as mandatory services within public health. It would be several years later, countless discussions, letters, proposals and position statements before this would be accomplished.

In the four years that followed, speech-language pathologists and audiologists came and went from public health with a dizzying frequency. It appeared to be a reflection of the uncertain levels of acceptance of the new role, even within the field. Gerald Bonham, identified this in his 1985 editorial for the Canadian Journal of Public Health when he wrote,” … the Public and Health Professionals alike do not have an understanding of the many arenas of prevention…”. The response I was witnessing, was not surprising; training programs had generally failed to prepare clinicians for this departure from clinical practice. For many, the transition from acute clinical care to prevention was difficult.

For those audiologists and speech-language pathologists who did remain in public health, defending the role became a way of life. Applying clinical skills in a public health environment was more than simply a matter of performing different activities. “Prevention of communication disorders requires some adjustment in the traditional focus of professional practice… ” wrote the committee on Prevention for the American Speech-Language-Hearing Association. Practice in public health, meant a commitment to not only a new methodology, but a new attitude towards the profession.

By early 1989, ASAP had developed its position outlining the role of speech-language pathology and audiology in public health. The Association had made its debut presentation at the annual convention for the Ontario Association of Speech-Language Pathologists and Audiologists. ASAP challenged the traditional clinical role of treatment and rehabilitation to expand its vision, and to engage in complimentary preventive programs.

The same year, ASAP formulated its recommendations for implementation of speech and language screening for preschool aged children. These were subsequently submitted to the Minister of Health for Ontario, and following revision, were released in 1991 as the provincial guidelines for speech and language screening under the Healthy Children program for Healthy Growth and Development.

ASAP had been successful in its bid to include speech, language and hearing among the mandatory public health services for children and the elderly population. Early identification and referral of at-risk children, and public education about human communication issues would now be a required activity in public health.

We have come a long way in this journey towards establishment of our professional disciplines within public health and yet we have far to go.

Each of us must, as ASHA suggests, adjust our focus to include prevention efforts among the accepted activities for this profession, and then promote this new understanding among other professionals and the public at large.

We must advocate for representation by audiology and speech­ language pathology within all Public Health Units across Ontario. We must ensure that speech, language and hearing services are implemented under the Healthy Growth and Development programs, and are supervised by appropriate professionals.

Those of us practising in public health must continue to promote our unique role, especially among our clinical colleagues who at times have difficulty understanding our work. We must advocate for development of new services, previously unknown in this profession. (How about a speech-language-hearing health curriculum within our local boards of education?) We must lobby for public health specialization within the professional training programs for speech-lan­guage pathologists and audiologists.

We must encourage expansion of health insurance coverage for speech and language services, as a mechanism to increase access to services.

We must foster an acceptance by employers that audiologists and speech-language pathologists practising within public health are no less skilled and valuable than practitioners working in hospitals schools. As such, their positions deserve competitive salaries order to attract and retain these unique professionals.

I see the future for public health speech-language pathology and audiology as a bright and promising one. No doubt, there will continue to be frustrations and obstacles along the way. I believe that the time for prevention in our field is now, and that public health has the potential to serve as a vehicle to help us meet our greatest challenge of the 90’s –prevention of communication disorders.

American Speech-Language-Hearing Association (1991). The prevention of communication disorders tutorial. ASHA, (33), Supp., 15-41.
American Speech-Language-Hearing Association (1984). Prevention: A challenge for the profession. ASHA, Aug., 35-37.
Bonham, G.H. (1985). The four areas of prevention. Canadian Journal of Public Health, (76), 8010.
Manolson, A. (1985). It Takes Two to Talk: A Hanen Early Language Parent Guide Book. Hanen Early Language Resource Centre, Toronto.
Marge, M. (1984). The prevention of communication disorders. ASHA, Aug., 29-33.
Ontario Ministry of Health (1991). Speech and Language Screening Guide. Public Health Branch, Toronto.
Ontario Ministry of Health (1989). Mandatory Health Programs and Services Guidelines. Queen's Printer for Ontario, Toronto.

About this retrospective series:

To commemorate SAC’s 50th anniversary, we will be republishing articles from SAC’s early newsletters and magazines throughout 2014. We will republish the articles in their entirety and will not be editing them for style or grammar. Sharon Halldorson, S-LP(C); Maureen Penko, S-LP(C); Andrea Richardson-Lipon, AuD, Aud(C) and Jessica Bedford, SAC Director of Communications and Marketing, are the editors of this year-long retrospective series.

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