How telehealth overcomes barriers to cleft palate care and speech therapy
Photo: Columbia University
Telemedicine can have long-term health equity benefits, including allowing providers to reach more patients in remote regions without travel requirements and see an increased number of patients in need who have historically avoided care due to stigma.
To discuss virtual care and health equity, Healthcare IT News interviewed Dr. Cate Crowley, professor of practice, Teachers College, at Columbia University in New York City. She works as part of Smile Train's Global Medical Advisory Board developing the Cleft Palate Speech Training Project, which provides workshops in Spanish and English for parents and colleagues who work with children with repaired clefts.
Q: You talk about the long-term health equity benefits of telehealth, including reaching more patients in remote regions without travel requirements. How do distance and equity come together?
A: On a global scale, wealthier countries – those with more dedicated resources and education – hold the keys to quality healthcare. Low- and middle-income countries simply do not have equal access, and one way to address this difference is for professionals from those wealthier countries to fly in to provide services as part of short-term missions.
Smile Train has a very different approach. It provides education, resources, infrastructure and funding so local medical centers have professionals who offer quality surgeries, speech therapy, orthodonture, nutritional care and the other services needed by children born with cleft lip and palate. Smile Train's model takes the keys to great healthcare and shares them so that children born with cleft lip and palate receive quality services by local professionals.
The effectiveness of this approach was especially evident during COVID-19 when there was virtually no international travel, yet the children could still receive the needed services by local professionals with masking and other protective equipment.
Even within individual low- and middle-income countries, urban areas typically have better trained professionals and more access to resources compared to a country's rural areas. When I do my five-day cleft palate speech therapy trainings for Smile Train, we invite professionals from throughout the country who are connected to a Smile Train partner surgeon.
They learn needed content and also acquire clinical skills as we invite children with repaired cleft palates to come each day for therapy to give the participants supervised clinical practice. Then when the training is over, people go back to provide speech therapy to the children that have had the surgeries to close the cleft palates. Some live and work in the urban areas and others are returning to small towns and rural areas, so the children who need help can get it where they live.
Technology is important even for the in-person trainings. While the local professionals acquire content and skills, we learned that ongoing support is needed. Once these professionals return home to treat their local communities, we stay in touch via WhatsApp to provide skill-building support.
Initially the WhatsApp posts are looking for my input, but as long as I hold back, they begin to work with each other, sharing ideas and posting videos looking for insight. We also offer online cleft palate speech therapy trainings that can be accessed by anyone with a mobile device.
By focusing on building capacity in low- and middle-income countries, and always considering those children who live in the more rural areas, the Smile Train model reduces the inequities of distance, education and resources. Children born with cleft palate can receive quality services no matter where they are born.
Q: Also on the subject of long-term health equity benefits of telehealth, you point to the increased number of patients who have accepted care due to lack of stigma using telehealth, versus in-person care. Can you elaborate?
A: Last summer, I developed an all-Spanish cleft palate speech therapy graduate course for my students at Teacher's College, Columbia University. We added a telehealth piece and with my colleague, Diana Acevdeo, treated children from many Spanish-speaking countries as well as New York and Miami.
A mother contacted me hoping that we would give her 16-year-old son speech therapy. He had been born with a cleft lip and palate and had successful surgeries, but did not have speech therapy as the family lives in a rural area on the border of Peru and Chile. In the first session with the mother and teen, we could see how embarrassed he was to have to do this with his mother.
In the next session, he was in his bedroom alone. During that first session, he said he was just fine with the way his speech was and didn't need any help. But then when he was in his own room, he got over his hesitation and worked with us. He could hear the almost immediate change in his speech, which motivated him even more.
While at first he had accepted that his speech would always be noticeably different, once he could hear the improvements in his speech he became extremely motivated. I am sure that without the telehealth option he would not have come to more than one session, if any. Telehealth allowed us to meet the teen where he was most comfortable, removing the stigma and barriers that too often can stop people from reaching for support.
Q: What are some tips for healthcare provider organizations successfully meeting patients where they are – both due to eliminating transportation limitations as well as removing language and technology barriers?
A: Most people today, regardless of where they live, have some sort of mobile device. This is a significant change from just five years ago. This means that people in Africa, Asia and Latin America can access all the cleft palate materials I offer for free at my website, LEADERSproject.org. We have cleft palate speech therapy courses in English and Spanish, with French on the way.
We also have many instructional videos at our LEADERSproject YouTube channel and are always adding more. We use one simple but very effective tool that YouTube offers. Before we put up each video, we make sure that the English subtitles are 100% correct. This allows viewers to choose to read subtitles in more than 150 language choices, making the videos available to virtually everyone – something that wasn't possible even a few years ago.
We also have developed cleft palate speech assessment screeners in many languages, including those local languages for the places we are building capacity. For therapy, we have materials in more than 35 languages. Everything is free including our word games and therapy books. Two of our favorite Spanish therapy books are "Sammy Sosa" and "Pablo el Pulpo," which provide a fun way to engage children and get them excited to practice. Smile Train also has incorporated these therapy materials into a practice app and coloring books for the children.
Our materials are theoretically sound and beautifully illustrated, so their quality is high … As with so much information on the internet, misinformation is rampant. We want our materials to be the ones people are attracted to and enjoy using and sharing with the children. With more than 25,000 visits each month to the website from more than 140 countries, evidently many people are finding our materials and using them.
Q: What do you think telehealth looks like 10 years from now? And where will it fit in healthcare delivery?
A: To answer this question, I think about what telehealth was like 10 years ago when my students and I were providing therapy to children at a school for the deaf in La Paz, Bolivia. We would see the children in person during the summer and offer tele-therapy the rest of the year.
Our option then was Skype, and even though we gave the school cameras and computers, internet access was so unreliable that we found a third of the time, we wouldn't even get through to the school and many other times we ended up typing chats with each other because the sound or camera wasn't working. Virtual training and treatment were almost impossible.
Today, reaching remote regions is so much easier thanks to significant improvements and advancements in tele-therapy – and overall internet access. If the next 10 years see as much improvement as the last 10 years, telehealth will be a seamless and significant tool used virtually everywhere.
I also expect artificial intelligence to make extraordinary contributions to cleft palate speech therapy over the next 10 years. One of the important skills of a cleft palate speech expert is the ability to perceive exactly what sounds the child is making.
In 10 years, AI will possibly be able to accurately analyze the child's speech. While the therapist will still be needed to review the analysis, develop therapy strategies and adjust approaches where needed, AI could provide accurate data on the child's skills, and that data could then be shared with the therapist no matter where the therapist is located.
With the continuing development of internet access worldwide and the tools we now have for quality online learning, there will be many more professionals who know how to provide speech therapy, even those in the most remote areas.
Telehealth will play an even more important role in removing barriers and facilitating connections. This will lead to greater awareness that help is available. Then more children at a young age will receive the quality services they need, so that each one can reach their personal potential.
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