1. Prevention of Communication Disorders1

2. ASHA’s Prevention Curriculum Guide for Audiologists and Speech-Language Pathologists
American Speech-Language-Hearing Association’s Curriculum Guide to Prevention of Communication Disorders: A recent ASHA activity to increase membership involvement as providers of prevention related services is the development of the Prevention Curriculum Guide for Audiologists and Speech-Language Pathologists. The Guide is a result of a collaborative effort between the American Speech-Language-Hearing Association and the Communication Disorders Prevention and Epidemiology Study Group (CDPESG). Primary Authors of the Guide are: Stacy Antoniadis, Bobbie Lubker, and Michael Marge. Contributing Authors of the Guide are: Karen Beverly-Ducker, Kathryn Darling, Catherine Clarke, Gail Donahue, Michelle Ferketic, Pauline Flynn, Betty Horowitz, Jeri Logemann, Rosemary Lubinski,, Susan Karr, Hilda Ayola Manolson, Frankie Michaelson, Diane Paul-Brown, Gail Rosenberg, Theresa Schulz, Robet Shprintzen, Shirley Sparks, Woody Starkweather, Maureen Thompson, Evelyn Williams, Mark Ylvisaker, David Yoder, and Louise Zingeser.
This guide provides training modules on prevention principles and practices of speech-language pathologists and audiologists lives and can also function as a source book for establishing a prevention program in your community. The guide covers the foundations of prevention, planning and implementing prevention across the life span, and designing prevention programs. 20

3. Why is Prevention Important to the Audiologist and Speech-Language Pathologist?
Prevention has been part of the audiology and speech-language pathology scopes of practice for many years. It is becoming increasingly important with managed care, medicare changes, and the cost of crisis intervention. As Audiologists and Speech-Language Pathologists involved in prevention activities, we can reduce the incidence of a new disorder or disease, identify disorders at an early stage, and also decrease the severity or impact of a disability associated with an existing disorder or disease.
Effective prevention programs are those that are community-based, and can enable the audiologist and speech-language pathologist to help reduce the incidence of communication disorders as a public health problem through primary, secondary or tertiary prevention.
Transition Point: To understand how audiologists and speech-language pathologists can be involved in prevention initiatives, it is important to understand the foundations of prevention….. 2

4. Foundations of Prevention
Inhibiting or interrupting the progression of disease, disorder, or disability
Health Promotion/Wellness
The combination of educational and environmental supports for actions and conditions of living conducive to health
Foundations of Prevention:
Prevention is generally defined as the inhibition or interruption of the progression of a disease, disorder, or disability. In other words…keeping something from happening (example: wearing ear protection to avoid noise-induced hearing loss).
Health Promotion/Wellness is the combination of educational and environmental supports for actions and conditions of living conducive to health. In other words, it is about supplying something that can increase your health or well-being (example: healthy eating and exercise to reduce risk of stroke).
Transition Point: So what, specifically, is the role of the audiologist and speech-language pathologist in the executing prevention activities?... 3

5. The Professional Role of the Speech-Language Pathologist and Audiologist
Competencies and Responsibilities
Prevention Activities
Assisting with National Initiatives
Healthy People 2000 & 2010 Objectives
Role of Prevention: The American Speech-Language-Hearing Association has long considered the prevention of communication disorders as one of the primary responsibilities of speech-language pathologists and audiologists. In fact, according to ASHA’s mission, one of the purposes of the organization is to “promote investigations and prevention of disorders of human communication.”
Several Prevention Activities are:
1. A community awareness program for hearing conservation
2. School screenings disorders of speech, language, and voice
3. Family or caregiver education programs
Competencies and Responsibilities for Speech-Language Pathologists and Audiologists, according to ASHA’s position statement Prevention of Communication Disorders (1988) outlines 10 competencies that clinicians must have if they are to play a significant role in developing and implementing prevention strategies. These competencies are: (a.) Use prevention terminology appropriately: (b.) Understand conditions that place individuals and populations at risk for various communication disorders: (c.) understand conditions which promote development and maintenance of optimal communication abilities (wellness); (d.), interpret the existing prevention literature in order to apply the information appropriately; (e.) present primary prevention information to groups known to be at risk for communication disorders and other appropriately; (f.) provide individual-, family- and community-focused primary prevention information and services; (g.) provide early identification and early intervention services for communication disorders occurring at any time during the life span; (h.) make appropriate referrals for prevention-related services not provided by speech-language pathologists or audiologists; and (I.) disseminate prevention information to various public sectors including health care professionals, social service professionals, and extended families
Another role is in assisting with national initiatives, such as Healthy People 2010 Objectives. Several ways that SLP’s and A’s can participate are by integrating HP objectives into current programs, incorporating HP initiatives into community programs and joining the consortium.
Transition Point: There are three levels of prevention: primary, secondary, and tertiary….. 4

6. Levels of Prevention Primary Prevention Secondary Prevention
Tertiary Prevention
Definitions–Levels of Prevention:
A. Primary prevention: The focus of primary prevention is to keep a disease, disorder, or disability from occurring. Successful primary prevention efforts reduce the number of new cases of a disorder or disease, that is, incidence (example: prevention of traumatic brain injury through the use of bicycle helmets and seatbelts.)
B. Secondary prevention: Early identification and preventive intervention of a disease, disorder, or disability; decreasing the prevalence of a condition (example: universal newborn hearing screenings identifying hearing loss at an early age).
C. Tertiary prevention: Attempt to decrease the severity or impact of a disability associated with an existing disorder or disease, to restore and improve effective functioning of a disability. This is the traditional domain for audiologists and speech-language pathologists… (example: treating a swallowing disorder to improve the ability to swallow).
Transition: The following slides will provide specific examples of each of these levels of prevention… 5

7. Primary Prevention Health Education Genetic Counselling
Environmental Change
Hearing Conservation
Immunization
Prenatal Care
Vocal Hygiene
Prevention of Secondary Communication Disorders
Examples of Primary Prevention:
A. Health Education: programs to increase public awareness, promoting change in behaviors or attitudes (e.g., danger of alcohol and drug use during pregnancy).
B. Genetic Counseling: education of those individuals at risk for genetic disorders.
C. Environmental Change: alteration of the environment to decrease the risk of occurrence (e.g., decreasing noise exposure).
D. Vocal Hygiene: programs targeting prevention of voice disorders (e.g. activities designed to prevent vocal abuse and nodules or stop the use of smoking and smokeless tobacco products).
E. Hearing Conservation: programs related to the prevention of noise-induced hearing loss (e.g. promoting the use of work-site hearing protection and instituting school- and community-based hearing conservation programs).
F. Immunization: shots that provide antigens to resist various diseases (e.g. Rubella).
G. Prenatal Care: provision of prenatal care to significantly decrease the incidence of birth defects and complications due to problems during pregnancy.
H. Primary Prevention of Secondary Communication Disorders: prevention of a secondary communication disorder due to an existing primary disability (e.g. prevention of speech-language disorder in a low birth weight baby).
Transition Point: As previously defined, secondary prevention refers to early identification and preventive intervention of a disease or disorder…. 6

8. Secondary Prevention Screenings Early Intervention
Speech-Language Disorders
Hearing/Balance Disorders
Early Intervention
Speech-Language-Swallowing Disorders
Examples of Secondary Prevention:
A. Screenings and follow-up across the lifespan for
1. Auditory/Balance Disorders (universal newborn hearing
screening, screening hearing, middle-ear function, and central
auditory processing).
2. Speech-Language Disorders
a. Screening speech, language, voice, and oral mechanism and
related behaviors.
b . Educating parents about dysfluencies in preschool children, and
the value of early intervention.
B. Early Preventive Intervention, that is, using treatments targeting toward developmental issues such as early communication development.
1. Auditory/Balance Disorders(audiologic habilitation, amplification and assistive listening devices, vestibular rehabilitation)
2. Speech-Language Disorders (literacy, augmentative/alternative communication devices).
Transition: As previously defined, tertiary prevention is an attempt to decrease the severity or impact of a disability associated with an existing disorder or disease…. 7

9. Tertiary Prevention Treatment of identified disabilities
Family/caregiver education programs
Patient counseling
Cross-disciplinary consultation
Examples of Tertiary Prevention: Tertiary prevention of communication disorders involves treatment of identified disabilities:
A. Auditory/Balance Disorders (amplification and assistive listening devices, balance medication, vestibular rehabilitation)
B. Speech-Language Disorders (augmentative/alternative communication devices, curriculum modification)
C. Family/Caregiver Education Programs (helping family members/caregivers understand a disorder and treatment options; assisting with intervention; advocacy)
D. Patient Counseling (helping patient understand the disorder or disability and treatment options; advocacy for patient needs).
E. Cross-Disciplinary Consultation (collaborating with other disciplines to develop an integrated treatment approach.
Transition Point: The science of prevention gives credibility to our assertions that we are preventing… 8

10. Prevention Science Epidemiology Risk Data Incidence and prevalence
Relative risk and odds ratio
Population attributable risk ratio
Prevention Science clearly identifies what needs to be changed and validates both the reality and magnitude of that change.
A. Epidemiology is the study of:
1. Distributions (when, where, who, how many, how much) and
2. Determinants (how and why) of
3. Diseases, disorders, disabilities and
Desirable health events in...
5. Populations
B. Risk: A major goal of epidemiology is to identify subgroups in the population that are at high risk for disease.
1. Incidence refers to the number of new cases and is changed by primary prevention.
2. Prevalence refers to the number of existing cases and is reduced by secondary prevention.
3. Risk is the probability that an event (e.g., development of a disease or disorder) will occur
within a specific period of time.
4. Risk Ratio (also called Relative Risk) is the likelihood of a particular disease or disorder
occurring among persons exposed to a given risk factor, divided by the corresponding
likelihood among unexposed persons. Based on incidence data derived from cohort studies.
5. Odds Ratio (also known as Probability) is the odds of a particular exposure (risk factor)
among persons with a specific disease or disorder divided by the corresponding odds of
exposure among persons without the health condition of interest.
6. Population Attributable Risk Ratio is the percentage of the overall occurrence of a disease
or disorder as an outcome within exposed persons that is related to the targeted exposure.
Transition Point: There are several models of health care delivery that can assist the Speech-Language Pathologist or Audiologist in carrying out prevention activities... 9

11. Models of Health Behavior and Health Education
Individual Health Behavior Models
Group Intervention Models
Applying Health Education Models to Communication Disorders
Models of Health Behavior and Health Education
A. Individual Health Behavior Model, the desire to avoid illness, disorder, or disability (or to get well), is based on the individual’s belief that a specific health action will prevent or ameliorate illness, disorder, or disability (e.g., not yelling to avoid development of a voice disorder). Three components of this model are:
1. Subjective perception of health threat
2. Subjective perception of net benefits of action
3. Cues to action, or the trigger that stimulate an individual to act.
B. Group Intervention Models: Social Marketing refers to the design, implementation, and control of programs seeking to increase the acceptability of a social idea or health practice in a target group; promoting ideas, not products (e.g., advertising to targets a specific behavior to avoid).
C. Health Education Models: When planning prevention and promotion programs, health education models can assist in the identification of attitudes, values, and beliefs that affect on an individual’s decision making or a population’s trends of behaviors (e.g., Why do physicians refer, or not refer, children for speech and language evaluations?)
Transition Point: Understanding genetic predisposition for various communication disorders is also important in regard to prevention... 10

12. Genetic Influences Genetics Disorders Preventive Approaches 11
A. Genetic Disorders: Though genetic research in communication
disorders has lagged behind that of other health care areas, genetic links to hearing, language, and speech disorders are now being discovered. Identifying children with genetic, chromosomal, or teratogenic disorders is extremely important.
B. Preventive Approaches: A first step in prevention is the proper delivery of genetic counseling (e.g., informing individuals about recurrence risk associated with a history of anomalies within a family, such as mental retardation).
Transition Point: Various factors in the environment can cause individuals to become more susceptible to various diseases or disorders... 11

13. Environmental Influences
Physical
Toxins
Nutrition
Sick buildings
Noise pollution
Second-hand smoke
Lead
Social
Violence
Substance abuse
Child rearing practices
Poverty
Environmental Influences: Whether it is through active behaviors or passive activity, humans are exposed to environmental risks affecting health and safety through a variety of interactions with their environment in everyday situations.
A. Physical influences include toxins, nutrition, sick buildings, noise pollution, second-hand smoke, and lead.
B. Social influences include violence, substance abuse, child-rearing practices, and poverty. A prevention activity to decrease aggression or violent behavior is teaching school-age children how to use appropriate social or pragmatic communication skills.
C. Nutrition and Health. Nutrition’s contributions to primary conditions leading to communication disorders among adults are numerous. Diet accounts for one third of cancer risk. Prenatally, nutrition greatly effects the fetus.
Transition Point: It is very important to consider the role that an individual’s culture plays in their involvement in any prevention efforts... 12

14. Multicultural Influences
Culture
Influences on health, social, and educational behaviors and practices
Planning Prevention Targets
Multicultural Influences
A. Culture: The term “culture” refers to the customary beliefs, social forms, and material traits of a race, or religious or social group. It is manifested in family roles and relationships, child-rearing practices, child-disciplinary practices, and expectations of individuals at different stages in the life cycle. It influences methods of teaching and learning, the role of education, work and leisure behaviors, religion, traditions, health beliefs and attitudes, as well as time and space concepts, food preferences, dress and personal appearance, and interpersonal relationships.
B. Influences On Health, Social and Educational Behaviors, and Practices: People of all cultural, ethnic, and linguistic backgrounds value good health. However, the ways in which various cultures view, react to, and treat disabilities vary. Cross-cultural beliefs about disabilities will influence individual and family participation in prevention programs. Cultural elements such as language, family roles, gender roles, and religious beliefs can and do influence beliefs about causation of illness, the conditions that qualify as “sickness,” expected treatment outcomes, treatment programs, and how to “prevent” or if “preventive” measures should taken.
C. On Planning Prevention Targets: In planning a prevention target, the following are some considerations:
1. Describe the ethnic group with which the family identifies (e.g. language).
2. Identify the social organization of the ethnic community.
3. Describe the prevailing belief system within the ethnic community.
4. Learn about the history of the ethnic group and current events that affect the family.
5. Determine how members of the community gain access to and use social services.
6. Identify the attitudes of the ethnic community toward seeking help.
Transition Point: Based on the communication disorder, various means of prevention can be implemented... 13

15. Prevention Across the Life Span (Specific Disorders)
Dysphagia
Literacy and Learning Problems
Oral Problems/Cancer
Ototoxicity/Noice- Induced Hearing Loss
Stroke
Stuttering
Traumatic Brain Injury
Voice Disorders
Resources for Specific Disorder Categories: In each of the following disorders, there are primary, secondary, and tertiary means of prevention the audiologist or speech-language pathologist can implement.
A. Dysphagia: (Secondary) Dysphagia screenings of high-risk patients on admission to a health-care facility.
B. Literacy and Learning Problems: (Primary) Providing young children with the necessary environmental stimuli to enhance communication skills and literacy.
C. Oral Cancer: (Secondary) Oral cancers account for more that 5% of all cancers in the United States. Early detection and diagnosis of oral cancer to coordinate efforts and referrals for diagnosis and treatment is a preventive measure.
D. Ototoxicity: (Primary) Medications used to treat cancer have potential to cause damage to the structures of the inner ear. Patient counseling regarding potential effects on the auditory system prior to drug prescription is a primary or secondary means of prevention. Noice-Induced Hearing Loss: (Secondary) Routine hearing screenings for individuals at risk for NIHL (e.g. musicians, construction workers)
E. Stroke: (Tertiary) Stroke is the number one cause of adult disability in the United States, often resulting in communication disorders. Treatment of aphasia, apraxia, dysarthria, cognitive-communication impairments, and dysphagia are examples of tertiary prevention treated by a speech-language pathologist.
F. Stuttering: (Secondary) Prevention begins with a thorough evaluation of communication demands in a child’s motor, linguistic, emotional, and cognitive capacities.
G. Traumatic Brain Injury: (Primary) Prevention programs targeted at decreasing the incidence of onset in high-risk population is an example of primary prevention (e.g., high-risk parents for child abuse, roadway safety).
H. Voice Disorders: (Primary) Encouragement of healthy voice production through vocal hygiene programs.
Transition Point: At certain ages, individuals are at higher risk for specific disorders... 14

16. Prevention Across the Life Span (Distinct Age Categories)
Prenatal/Antenatal
Infancy
Early Childhood
School-Age
Adulthood
Maturity
Resources for Distinct Age Categories:
A. Prenatal/Antenatal (Primary) Good health care and nutrition, and avoidance of toxic substances during the pre-conceptual time prepares a woman for a healthier pregnancy when she is ready to conceive.
B. Infancy: Infant Hearing Screening (Secondary): Universal newborn hearing screening is an example of secondary prevention efforts.
C. Early Childhood/School-Age: (Secondary): Preschool and kindergarten speech-language and hearing screening programs are examples of secondary prevention. Primary prevention for injuries includes seat belts, helmets, and fire safety.
D. School-Age (Tertiary): With school-age children with hearing impairments, an example of tertiary prevention would be provision of habilitative activities (e.g., auditory training, speech reading, speech conservation).
E. Adulthood (Secondary, Tertiary): Less common illnesses leading to communication disorders may begin to show signs and symptoms during adulthood (e.g., Parkinson’s, ALS, multiple sclerosis) calling for secondary and tertiary prevention efforts.
F. Maturity (Secondary): The ultimate goal of a communication prevention program designed for elderly individuals is to improve or sustain their ability to communicate effectively in as many contexts of choice as possible. This includes early identification of symptoms that might be indicative of a communication problem or of factors that might contribute to deterioration of communication skills
Transition Point: Health education prevention models can assist the audiologist and speech-language pathologist in establishing a prevention program... 15

17. Models of Prevention Program Design
Public Health PRECEDE-PROCEED
Comprehensive Health Education Model (CHEM)
Models of Prevention Program Design: Prevention programs require attention to the communication outcomes that the speech-language pathologist or audiologist wishes to change. Two models of prevention from health education are:
A. Public Health Model PRECEDE-PROCEED: PRECEDE and PROCEED are acronyms for public health models that describe a health promotion-planning framework. PRECEDE stands for attitudes or actions which are predisposing (Doctors make you well, go to one when you are sick), reinforcing (all your friends smoke marijuana, you smoke marijuana), and enabling (access of health resources) constructs in educational/environmental diagnosis and evaluation. PROCEED stands for policy (What current policies would support a prevention effort?) , regulatory, and organizational constructs in educational and environmental development (Do your children believe they can change behaviors that contribute to their disorder?).
B. Comprehensive health education model (CHEM): Consists of six steps with specified procedures. 1) Involve people (ID target population and persons required to carry out the program), 2) Set goals (appropriate for the program), 3) Define problems (What are the health gaps and what will be the focus of the program), 4) Design plans (creation of activities, program objectives, resources needed and evaluation plan), 5) Conduct activities; 6) Evaluate results.
Transition Point: It is important to have clear program objectives and initiatives when designing a prevention program... 16

18. Prevention Program Objectives and Initiatives
Stating Prevention Outcomes
Implementing the Prevention Program
Program Objectives and Implementation:
A. Program Objectives: A program of prevention should be based on sets of essential information about the magnitude of the problem, specific characteristics of the population at risk, current effort directed toward reduction of risk, and pertinent resources needed for an effective program.
B. Stating Prevention Outcomes: State anticipated outcomes in measurable terms (e.g., Primary prevention: Confine annual incidence of diagnosing AIDS cases to no more than 98,000 cases: e.g., Secondary prevention: Reduce significant hearing impairment to a prevalence of no more than 82 per 1,000 people.
C. Implementing the prevention program: For prevention programs to occur, one must secure appropriate sites, resource personnel, community stakeholders, and an adequate level of funding. Some potential ideas are parent education at day care centers, school staff development days, and hospital wellness programs.
Transition Point: An evaluation mechanism to determine the effectiveness of a prevention program is the next step... 17

19. Determining the Success of Prevention Efforts
Determining Success of Prevention Efforts: Evaluation is the systematic collection and analysis of data needed to make decisions. There are several reasons why one should include evaluation as part of a prevention program. These reasons include:
1. To determine program effectiveness/efficiency.
2. To document objectives and demonstrate accountability.
3. To provide information.
Dimensions of evaluation include the process, the impact, and the outcome.
Transition Point: Various prevention initiatives are in place nationally and within ASHA... 18

20. Public Policy and Public Health
ASHA Public Policy Agenda for Prevention
Public Health and Professions of Speech- Language Pathology and Audiology
Public Policy and Public Health:
A. American Speech-Language-Hearing Association Public Policy Agenda for Prevention is developed by ASHA’s Governmental and Social Policy Board and the Government Relations and Public Policy staff. Issues are assigned a category based on: a) importance to the Association’s members and b) immediacy and likelihood of federal or state action.
B. Public Health and the Professions of Speech-Language Pathology and Audiology. With the dramatic changes taking place in health care delivery, all health and health-related professions are re-assessing their role in prevention:
1. Selected Public Health Activities: The speech-language pathology and audiology professionals may participate in public health activities at the local, state, regional, national, and international levels. An example of a national public health activity is Healthy People 2000/2010, a blueprint for disease prevention and health promotion that grew out of a health strategy initiated in 1979 by the U.S. Surgeon General.
2. Politics of Prevention/Creation of Public Health Policy. There are a number of factors that explain why U.S. health policy is still struggling with the role and significance of prevention…1) crisis intervention as primary mode of intervention, 2) long period of time from prevention action to measurable reduction in incidence of disease and disability.
Transition Point: To encourage prevention activities in the practice of the speech-language pathologist and audiologist, ASHA has developed the Curriculum Guide to Prevention of Communication Disorders for Speech-Language Pathologists and Audiologists...
Review this Lecture 19