THE IDENTIFICATION PROCESS IN EARLY COMMUNICATION INTERVENTION FOLLOWED BY PRIMARY HEALTH CARE PERSONNEL IN DITSOBOTLA SUB-DISTRICT

Based on clinical observations, case finding for early communication intervention service delivery in rural areas, such as Ditsobotla sub-district, is limited. The study described the identification process used for infants and young children at risk for communication delay and disorders as part of a proposed incremental implementation of early communication intervention services within the existing primary health care package. A descriptive survey design was followed. A rating scale was utilized and interviews were conducted with 20 randomly selected primary health care personnel and eight primary health care programme managers in Ditsobotla sub-district in North West province. The aims were to describe the early identification methods/processes, resources and limitations and provide guidelines to introduce early communication intervention services in a rural community. The results indicated that the identification process was limited. An incremental implementation of the different early communication intervention functions within the primary health care package appears feasible. Implications of the findings may be applied to initiate early communication intervention services, based on integrated teamwork, in a rural district in South Africa.

THE id e n tific a tio n p r o c e s s in The underpinnings for the research study ." mPreed over time in the field of early intervention.
Hence that ei iic s oariv intervention was shown to be linked to the The efficacy or eariy ." at identification (Rossetti, 2001).If under three years child s age the window of opportunity may be enhanced by neurode-° lopmental plasticity (Dennis, 2000).Early identification of risk conditions in infants should therefore be the primary function of I (KritZinger, Louw & Rossetti, 2001).Developing and imple menting effective identification strategies, especially in rural ar eas is one of the biggest challenges in ECI, as a lack of identifica tion will compromise the efficiency of the services (Kritzinger, 2000).Consequently, the efficacy of early identification of an infant at risk of developmental delay depends on a reliable refer ral system so that time delays between the detection of a prob lem and intervention services to the family may be minimised.
Furthermore, the efficacy of a referral system is in direct rela tion to the outcomes that the system achieves (Equity Project, 2000).By means of a smoothly functioning referral system the ECI client and family, for example, receives diagnostic and thera peutic services from a specialised team of medical and rehabilita tive professionals, ensuring that PHC is more unified and finan cially sustainable (Equity Project, 2000;North West Department of Health, 2003).It appears that limited referrals and improper coordination of referral systems are partially responsible for ECI and its benefits being unknown in the South African health care system (Kritzinger, 2000).
Integrating ECI services into PHC in rural communities in South Africa has been recommended in various studies (Fair & Louw, 1999;Kritzinger & Louw, 2003;Moodley, 1999).Formalised by Rossetti in 1996, the concept of communication-based services to the population of children birth to three years of age, is based on the finding that communication delay is the most prevalent characteristic of delayed development in children in this age group (Rossetti, 2001).Enhancing communication development should therefore be the main focus of any effective early interven tion programme (Rossetti, 2001) -hence the term early commu nication intervention.
In the planning and management of ECI services, the focus should be to develop strategies to prevent communication disor ders in all people, including rural and disadvantaged communi ties (Kritzinger, 2000).As prevention of disability and communi cation disorders is the ultimate goal in ECI, primary prevention programmes could be implemented at PHC clinics.
A transdisciplinary framework for ECI public service delivery has been proposed by Kritzinger and Louw (2003), which may be integrated into the PHC package of the Department of Health (2000).The PHC package was designed to provide comprehen sive and integrated health services and not to be implemented through separate, vertical programmes where services are split PRIMARY HEALTH CARE PERSONNEL IN DITSOBOTLA SUB-DISTRICT according to disciplines, resulting in barriers to teamwork (van Rensburg, 2004).Consisting of eight different programmes, the package entails a standardised and comprehensive 'basket' of preventative, promotive, basic curative, rehabilitative and pallia tive services delivered at district level (Department of Health, 2000).Linked together as a service delivery model for health care, there are eight programmes i.e., 1) Non-personal health services (occupational and environmental health); 2) Disease prevention and control; 3) Maternal, child and women's health; 4) HIV/AIDS, sexually transmitted infections and tuberculosis; 5) Health monitoring and evaluation; 6) Mental health and sub stance abuse; 7) Gender issues, and 8) School health services.
These should be mutually supported by the health care profes sionals delivering these services (Department of Health, 2000;Van Rensburg, 2004).Since teamwork is an essential approach in the implementation of the PHC package, the opportunity for collaboration should be utilised by therapists to introduce ECI services in communities.
The transdisciplinary conceptual framework for ECI describes collaborative partnerships with parents and caregivers, commu nity health nurses and doctors, speech-language therapists, audi ologists at PHC clinics, and secondary caregivers at creches and day-care facilities (Kritzinger & Louw, 2003).According to Kritz Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)paediatric health and developmental services in PHC can be found (Lequerica, 1997).According to Lequerica (1997)  Since the primary goal of research is to improve understanding of a phenomenon (Leedy & Ormrod, 2005), information produced by the current research study aims to identify certain problem areas.The research may also provide guidelines for identification and referral practices for ECI in the PHC context, which may be used to improve case finding in rural areas in South Africa.The information gathered through the research may also support the facilitation of a transdisciplinary team approach to service deliv ery in ECI in Ditsobotla sub-district, where effective collaboration between the PHC nurses, speech-language therapists, audiologists, and PHC programme managers may be established.

Aims and Objectives
The purpose of the study was to describe the characteristics of identification methods and referral practices for ECI currently followed by PHC personnel in the Ditsobotla sub-district.The following objectives were formulated:

□
To describe the features of the facilities in the PHC con text in order to determine the capacity for implementing an ECI programme for infants with risks for disabilities.

G
To describe the human resources available in order to determine the needs within the PHC context.

G
To describe the early identification methods and re sources currently used by the PHC personnel and man agers to detect health problems as well as developmen tal delay and disabilities in infants.
[] To describe the referral systems, between different organizational departments in one facility, and the net works between different institutions, which are currently being used by PHC personnel for ECI services.

G
To describe the PHC programme managers' views on how to implement an early identification and referral programme for infants with risks for disabilities and delays in an integrated PHC and ECI approach.

Research Design
A descriptive research study was conducted.A dominant-lessdominant research design was selected, which entailed the use of a quantitative approach, the dominant component, and a qualitative approach, the smaller or less-dominant component (Fouche & De Vos, 2005).The quantitative approach implied a formalized approach with explicit control during data-collection (Fouche & De Vos, 2005).A questionnaire and a rating scale were used as methods of data collection.The qualitative compo nent consisted of semi-structured interviews with programme managers to obtain an in-depth understanding of data already collected and that may have needed further clarification (Leedy & Ormrod, 2005).
To increase the reliability of the study, triangulation was used (De Vos, 2005).All participants gave voluntary informed consent to participate in the study.Information obtained from the participants was treated confidentially and reported anonymously.All efforts were made to conduct the research according to the ethical principles of no harm to participants, veracity, non-discrimination and sensi tivity to cultural and language differences between participants and the researcher.,

Participants
The two target populations were PHC personnel and PHC pro gramme managers who were employed by Ditsobotla sub-district, I which is part of the central district of North West Department of i Health.Both groups had to be proficient in English in or^er to participate in the study.Although Setswana is the most com monly used language in the sub-district, it was found that the participants were sufficiently proficient in English to understand and answer the interview questions.

Selection of participants
Stratified random sampling was used to select the participants in group 1, the PHC personnel (Strydom.& Venter, 2002).Stratifiy cations entailed that the specific population was divided in strata, which were homogeneous with regard to some characteristics (Strydom & Venter, 2002).The entire PHC personnel of Ditsobotla sub-district were divided into two strata according to the size of the PHC facilities: all the clinics operating for 8 hours and 10 hours per day were part of stratum 1, while all the PHC hospitals 50 DIE SUID-AFRIKAANSE TYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL, 56, 2009 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) and 24-hour clinics were part of stratum 2. The selection within the strata was random (Strydom & Venter, 2002) as the re searcher randomly selected the facilities to be included in each stratum.
In group 2 all the PHC programme managers of Ditsobotla sub district who complied with the selection criteria received informa tion brochures and were invited to participate.In this case the number of possible participants was limited.Non-random pur posive sampling was used since a group of participants to repre sent the population did not have to be identified (Leedy & Ormrod, 2005).

Description of participants
-Description of participants in Group 1: Approximately one third (20) of the PHC personnel in the entire sub-district were included in the study, with each stratum equally represented.The charac teristics of the participants in group 1 are summarised in Table 1.
According to Table 1 there were only a few differences between the participants of the two strata.The majority of the participants had nursing diplomas, all were working on a full-time basis, with an average of eight to 12 years working experience.The partici pants therefore had work experience which rendered them as informed research participants, although three participants had no formal training.

Description of participants in Group 2
The participants in Group 2 represented more than two thirds of the total of the PHC programme managers.A total of 12 PHC programme managers were working in Ditsobotla sub-district.All the programme managers were asked to participate, and a pilot study was conducted with one of the programme managers prior to the data collection.That left 11 PHC programme managers, eight of whom participated in the research.The other three po-

Material and Apparatus
The following material was exclusively developed for the data collection of the study: A summated rating scale for the description of the facilities (See Appendix A).
Summated rating scales are widely used for the description of environments where phenomena have to be evaluated on a con tinuum of, for example, excellent to inadequate (Leedy & Ormrod, 2005).The rating scale used was a means to analyse facilities and describe the available human resources.The rating scale provided not only the background to the study, but also relevant data which could point to strengths and weaknesses in the identi fication methods and referral systems of the PHC system in the Ditsobotla sub-district.The rating scale was also used to deter mine the capacity of the facilities to implement the different ECI functions.
The content of the rating scale included the following physical characteristics: water and electricity supply, the educational at mosphere of the waiting rooms, developmental screening materi als available, space for interviews and screening assessments, filing cabinets and filing system.tential participants were either on leave or were attending a THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL 56, 2009 51 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) The human resources and services to infants were also re corded for each study site.Face-to-face interviews to investigate the identification processes used by the participants in Group 1 A structured interview was used to collect data on the identifi cation processes, which included questions on the identification methods and the referral systems used by PHC personnel to iden tify and refer infants with developmental disorders or who are at risk for developmental delay.When the focus of a study is to in vestigate a process, in this case the identification process, struc tured interviews are especially suitable (Greeff, 2002).Although participants may not be as truthful in their responses as in the case of self-administered questionnaires, face-to-face interviews have the advantage of the highest response rate in survey re search (Leedy & Ormrod, 2005).
Face-to-face interviews with the participants in Group 2 on the implementation of an ECI programme with its emphasis on early identification A set of individual interviews with the participants in Group 2 was necessary in order to triangulate data, which brought differ ent views on the current identification methods, referral systems and teamwork to the fore and therefore led to more accurate descriptions of the same aspects.Furthermore the PHC pro gramme managers' opinion on the implementation of the differ ent ECI functions within the PHC package was obtained.The apparatus used during all the interviews was an Olym pus V N -240 P C digital voice recorder.The digital voice files were tran scribed and securely stored on a laptop computer.The first author was the only person to have access to the data.

Reliability and validity
With triangulation the reliability of the data was increased, as it was collected by means of different instruments and results could therefore be compared.Furthermore, two separate groups of participants were used to investigate the identification meth ods and referral systems, while the researcher's own field notes further supported the data obtained in the interviews.' A second reviewer was utilized to verify the interview recordings of both groups of participants.The reviewer listened to the re cordings while reading the transcriptions.Discrepancies between the text and voice recordings were discussed until agreement was found between the researcher and second reviewer.
Face validity of the instruments was ensured as the format of the measuring instruments corresponded with the objectives of the research.All questions of the interview schedules were rele vant and clearly formulated to ensure content validity.A senior speech-language therapist with working experience in primary health care reviewed the questionnaire and made suggestions to improve the relevancy of the questions.

Pilot studies o f the rating scale and interview schedules
Jeannie van der Linde, Alta Kritzinger, Aniel Redelinghuys Pilot studies were conducted to test the rating scale and the two interview schedules in order to increase the accuracy and reliability of the data.According to the selection criteria, two PHC nurses and one PHC programme manager were selected to be part of the pilot studies.The rating scale and interview schedules were adapted according to the results obtained in the pilot stud ies.

Procedures o f the main study
Based on the two strata, the different facilities to be included in the study were randomly selected from a total of 17 PHC sites in the sub-district.Ditsobotla sub-district, previously named Lichtenburg is part of the Greater Taung local municipality and forms the central district in the North West Province.The district is largely rural and has an unemployment rate of over 50%.The main in dustries are mining and quarrying, but agriculture is the focus (ESCOM, 2007).
During the first visit to a facility, permission was obtained to complete the rating scale.The researcher then filled in the rating scale without being intrusive.The completed rating scale was verified by one of the participants at each site so that a true re port of the facility was stored for data analysis.After explaining the reason for the visit, the facility manager introduced the re searcher to the potential participants in Group 1. Informed con sent was obtained from the participants in Group 1 and the struc tured interviews were conducted according to the interview schedules.The interviews were conducted at the participants' working facilities, in order to ensure that the participants did not have to travel and that they would be as comfortable as possible.
The interviews were conducted in a consultation room at the fa cilities Thereafter the researcher visited the participants of Group 2 at the district office of Ditsobotla sub-district.Informed consent was obtained and the semi-structured interviews were conducted in each participant's office.This made the participants feel comfort able and little hindrance was present due to the professional environment in which the interviews were conducted.

Data analysis \
The data of the structured interviews were analysed first, in order to determine which aspects needed further investigation and had to be included in the semi-structured interview schedule with participants of Group 2. The data obtained from the first interviews were analysed quantitatively according to the SAS system version 9.1 statistical computer software.As the analysis was done in Microsoft Excel, the data were stored electronically (Babbie, 2004).
Frequencies were calculated as data should be presented in a condensed form when the data consisted of a large number of observations (Steyn, Smit, Du Toit, & Strasheim, 1998).Basic and decide where further statistical analysis would be appropri ate.Fisher's exact test of independence was used for data with two attribute variables (Leedy & Ormrod, 2005).
The rating scales were analysed numerically, as the data collec tion method was quantitative.Procedures similar to those used to analyse the data from the structured interviews were therefore used for the analysis of the rating scale.
In qualitative research the data analysis and interpretation are closely connected (Leedy & Ormrod, 2005).This had to be taken into account when the results of the semi-structured interviews were analysed and interpreted.The researcher listened to the voice recordings and supplemented the transcriptions with field notes.Data were holistically read and re-read before the corpus was categorised according to themes.According to Leedy and Ormrod (2005) the researcher has to have a heightened and focused awareness of the data and subtle undercurrents during interviews have to be identified.Regularities were noted during the data analysis and categories of meaning emerged that could be presented as descriptive results.

RESULTS AND DISCUSSION
The results are presented and discussed in accordance with the objectives of the study.
The capacity of the facilities for implementing an early identifi cation programme for infants at risk of disabilities The basic features of the facility, the waiting rooms and consult ing rooms were evaluated according to the rating scale (See Ap pendix A) and described to determine the possibility of imple menting ECI functions in these facilities.Primary prevention ac tivities, such as talks to caregivers to promote normal communi cation and emergent literacy development, can possibly be imple mented in the waiting rooijns of the facilities, while identification and intervention of infants and young children, i.e. primary and secondary prevention, may be implemented in the consultation rooms.

j
The checklist results indicated that all PHC facilities which were investigated had electricity and water supply, although some water shortages and power breaks occur.All buildings were per manent structures and three clinics were recently renovated.The travelling distance from Lichtenburg, the town in the centre of the sub-district, is not more than 35 km.Most of the roads are not tarred and the public transport is by minibus taxis.The implica tion is that a speech-language therapist or an audiologist may be able to visit two clinics in close approximation on one day.
The results also indicated that not all facilities have the capac ity to implement ECI functions in waiting rooms and/or consulta tion rooms, but patient information was adequately protected by means of secured filing cabinets.Six of the ten clinics had limited seating space in the waiting rooms, which means that educa tional talks may not be possible.None of the waiting rooms had As only a few of the facilities have the capacity for all ECI func tions to be implemented, an incremental implementation of ECI services could be introduced.Speech-language therapists and audiologists therefore need to determine which levels of preven tion can be implemented at which facilities in the sub-district.It may be possible that one facility only has the capacity to support the implementation of the primary prevention level in ECI ser vices, while all three levels of prevention can be implemented at another facility.Since the waiting room capacity in the majority of the clinics was limited, it may imply that educational talks cannot be given and that only individual screening, assessment and in tervention can be offered at the clinic.Promotion of communica tion development and other information may be given to caregiv ers in the form of brochures in the local language.

The availability, needs and limitations of human resources with-in the PHC context
A shortage of PHC personnel will have an impact on the incre mental implementation of ECI functions.Since the PHC personnel may not be able to assist the speech-language therapist and audiologist in some of the ECI functions, the capacity and support of the human resources at the facilities need to be determined in order to establish which ECI functions can be effectively imple mented in the facilities.
According to the results there were community health nurses present at all the PHC facilities investigated, but not all were qualified at the time of the investigation.There were limited health care professionals such as doctors, speech-language therapists, audiologists and paediatricians working in the sub The referral systems used by PHC personnel to refer patients to speech-language therapists and audiologists.
According to Figure 1 the referral route is clear, but some diffi culties in making referrals are experienced.A total of 80% of the participants indicated that they experienced time delays when patients had been referred.A disturbing finding was that caregiv ers of infants and young children were asked to come back a number of times before the referral to the speech-language therapist was made.The distances between patients' homes and the hospitals need to be taken into consideration, as patients usually cannot afford to travel far on a regular basis.Due to the [Jh e PHC personnel receive little or no feedback from the speech-language therapists on their referrals The doctors visit clinics only a few times every week, which delays the referral process as the patient is referred to the doctor for an appointment The results from the current study indicated that few referrals were made to speech-language therapy and audiology services, which differs from developed contexts, such as the UK (Enderby & Petheram, 2000).In the UK many patients are referred to local speech-language therapy and audiology services, but the referral process also faces certain challenges.Factors influencing the referral process in the UK include limited knowledge of the risk factors for communication delay, long waiting periods for appoint ments, epidemiological and demographic factors, such as long travelling distances (Enderby & Petheram, 2000).The lack of human resources, financial constraints on families who need ECI I services and limited teamwork as reasons for poor referrals may be specific to rural communities in developing contexts.The sug gestions for improvement of the referral process clearly indicate that the participants were concerned about the difficulties and are positive about the implementation of an effective referral system: Against the background of difficulties to establish ECI services in South Africa, identified by Kritzinger (2000), it appears that iden tification and referral are but two aspects of many influencing ECI service delivery.Inadequate access to ECI facilities, the scarcity of facilities, limited knowledge about the benefits of ECI among caregivers and health care professionals, and limited, employ ment of early communication interventionists (Kritzinger, 2000) are other aspects which impact negatively on the professional obligation to expand ECI services in South Africa. 1 i In order to improve service delivery in rural areas and therefore make services more accessible to the communities, the findings indicated that the integration of ECI functions within the PHC package is feasible.The results of the study found an interest in ECI among primary health care personnel and managers and a positive attitude to improve services.A formal approach to imple mentation was suggested, and collaborative partnerships be tween management, PHC programme managers^and PHC person nel are feasible in the sub-district.The incremental rollout of ECI activities at PHC facilities may also improve teamwork, as col laboration is essential to improve the efficacy of early identifica tion and referrals.Since the introduction of ECI guidelines for speech-language therapists and audiologists in South Africa by Louw (1997), a theoretical framework for service delivery in the public sector has been described (Kritzinger & Louw, 2003).This framework pro vides a basis to assist in the planning of ECI implementation.Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.) inger andLouw (2003) ECI service delivery may be introduced to be consistent with the developmental stages of young children and the contexts where caregivers can be reached.Examples include services to the mother at antenatal clinics before the infant is born (providing preventative information on normal hearing and communication development); during the neonatal period in the postnatal ward (promoting mother-infant, attach ment and interaction, hearing screening and identifying risks for communication delay); during the postnatal period at immuniza tion clinics (follow-up hearing screening, identifying further risks and provide ECI, advocacy for education); and during the toddler years at day-care centres and nursery schools (providing ECI, training parents, facilitating a language and emergent literacyrich preschool curriculum to facilitate school readiness)(Kritzinger & Louw, 2003).With the exception of non-personal health services, integrating direct ECI services into seven of the different PHC programmes appears to be possible.The wide-ranging ECI functions such as promotion of normal development, prevention of feeding difficul ties, hearing loss and communication disorders, parent training, screening, early identification and providing assessment and intervention correspond with the different services provided within the variety of programmes in the PHC package.If certain ECI functions are shared among professionals in PHC, casefinding of infants at risk for communication delays or disorders may be improved and appropriate ECI services may be rendered to families at PHC facilities.Examples of successful integration of EARLY COMMUNICATION INTERVENTION FOLLOWED BY were based on evi-THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL 56, 2009 49 it ap pears that such a one-stop PHC service delivery model is pre ferred by families, and increases family participation.It is there fore important to investigate the feasibility of the integration of PHC and ECI programmes in a South African context where ECI services are lacking.
qualifications and work experience.A variety of programmes in the PHC package were represented by the managers, but those who managed the Maternal, child and women's health, Mental health and the HIV/AIDS programmes could not be included as participants as they were attending a course during the time allo cated for data collection.Table 2. Characteristics of the participants in group 2 (n=8) graphical presentations were used to better understand the data 52 DIE SUID-AFRIKAANSE TYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL, 56, 2009 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)THE IDENTIFICATION PROCESS IN EARLY COMMUNICATION INTERVENTION FOLLOWED BY PRIMARY HEALTH CARE PERSONNEL IN DITSOBOTLA SUB-DISTRICT posters or brochures on child development.Only five clinics had television monitors for educational videos.
district.Although an inadequate arrangement, an itinerant doctor visited nine different PHC clinics at least once a week.The tenth PHC facility is a hospital where a permanent doctor was em ployed at the time of data collection.The PHC personnel had limited knowledge regarding the avail ability of allied health care professionals at their facilities.The lack of knowledge of the different health care professionals work ing in the district may reflect an inadequate teamwork approach.Ineffective communication and collaboration between PHC nurses and other health care professionals, limited information regarding available services and no in-service training regarding the scope of practice of specialized services were further indica tors that an inadequate teamwork approach is present in Ditsobotla sub-district.It was estimated by the participants that, on average, approxi mately 165 infants were seen at the ten different PHC facilities on a daily basis.It is clear that the infant population of the sub district may be accessed through the PHC facilities.Limited hu man resources appear to be one of the reasons why screening for THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL 56, 2009 53 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)communication and hearing disorders was not carried out in Ditsobotla sub-district.The participants felt that it was the doc tors' responsibility to screen for hearing and communication dis orders in young children as they are trusted by caregivers.An interesting finding was that the participants felt that parents and family members share responsibility in identifying communication delays or disorders in the child's development.Human resources and an adequate team approach appear to be limited in Ditsobotla sub-district.By implementing ECI activi ties on a primary prevention level at all PHC facilities the following may be achieved: introduction of Speech-language therapy and Audiology, promotion of ECI services to both the PHC profession als and the caregivers and provision of information on early iden tification, stimulation of infants and young children and communi cation developmental milestones.The introduction of ECI to the PHC professionals and caregivers may provide the basis on which the incremental implementation of other ECI activities, such as developmental surveillance, can be achieved at PHC facilities that have the capacity to accommodate such ECI activities.ECI implementation may be established by coordinating the services with certain PHC programmes, i.e.Non-personal health services, Disease prevention and control, Maternal, child and women's health, HIV/AIDS, sexually transmitted infections and tuberculo sis, Mental health and substance abuse, and Health monitoring and evaluation.The early identification methods and resources currently used by the PHC personnel Posters on general health issues were numerous in the facili ties, but posters on infant and child development were absent.There is a great need to develop mass communication material in Setswana and English for ECI in this sub-district which has to be addressed by speech-language therapists and audiologists.The results clearly indicated that none of the facilities had checklists to use for developmental surveillance and therefore it appeared that PHC professionals were not conducting any formal develop mental screening of infants and young children.Appropriate checklists and case history forms for different South African con texts need to be developed so that children at risk of develop mental delays can be successfully detected and referred within the PHC facilities (Department of Health, 2000).The results indicated that PHC personnel use observation and that they talk to the child to determine if there is a problem in his/her communication development.Talking to the child to de termine the level of communication development is a positive initiative, but the participants indicated that they do not have a guideline to assist them in identifying atypical development.The informal method of talking to the child which is currently used in the sub-district does not appear to be valid and the PHC person nel are in need of locally developed, valid, reliable and easy to use identification methods.The participants clearly indicated a need for formalized and valid identification methods and inservice training on how to identify infants and young children with communication delay or hearing impairment.The participants viewed their identification method as largely ineffective and unre liable.Baby clinics, that form part of the Mother, Child and Women's Health Programme, were identified by the majority of the PHC personnel as the best PHC programme to implement the devel opmental surveillance of communication abilities in infants.

Figure 1 .
Figure 1.The referral process used by participants to refer patients for Speech-language therapy and Audiology services i referral system by implementing referral let ters where back-referral is mandatory Q)evising a simple and easy-to-use referral form on which pa tient information can be written with space provided for backreferral to the referring sister (in addition to the Road to Health Chart).[Employment of a full-time speech-language therapist in the sub-district Provide feedback to the sub-district on the referral process and schedule regular meetingsiwith provincial and national coordina tor in order to develop a new referral process THE IDENTIFICATION PROCESS IN EARLY COMMUNICATION [^Developing a team to address the needs of the infants and young children and their families in the community Information and training: Qmproving the awareness of the PHC personnel and training them in how to identify and refer infants and young children at risk for communication delay, instead of waiting for the doctor to make the referrals Qnform the public regarding the services and initiate work shops for parents and teachersThe suggestions for improvement are useful to establish ECI services in the sub-district.Practical aspects as well as manage rial and planning issues were included in the recommendations.It is clear that it was valuable to include the programme manag ers as participants in the research.The current teamwork approach and participant views on the implementation of an early identification and referral programme, and the integration of ECI and the PHC programmes through col laborative activities All the PHC personnel and PHC programme managers indicated that collaboration with other professionals would have a positive influence on case finding in ECI.The PHC personnel indicated that collaboration would positively influence the identification and referral of infants and young children at risk for communication delay, as infants and young children can be identified earlier and time-delays can be decreased in the referral process.The inclu sion of volunteers in collaboration with the PHC personnel in or der to improve identification of infants at risk of communication delays needs to be explored further as volunteers can make regu lar home visits in the community to support families with special needs.The majority of the PHC nurses indicated that teamwork should occur during early identification, referral and the early interven tion phases of ECI service delivery.Consequently it is essential to establish commitment, competencies and a supportive environ ment to ensure an effective collaborative teamwork model, so as to positively reinforce the implementation of ECI services in Ditsobotla sub-district.The PHC programme managers did not only provide relevant reasons for including the specific ECI function but also indicated the areas where collaboration should be implemented.The re sults indicated that the PHC programme managers have a clear understanding of ECI and of the importance of these services.Their knowledge of ECI may therefore positively influence the implementation of ECI functions by means of collaborative activi-THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL 56, 2009 55 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)ties in the district.Since they understand the importance of early identification and ECI, the PHC programme managers appeared to be motivated and ready to assist in the implementation of such activities.Consequently it is important to build on the partici pants' interest in ECI, which were stimulated by the current re search project.The programme managers discussed how and why the different ECI functions should be implemented in Ditsobotla sub-district: -To train mothers to stimulate their infants and children -The PHC programme managers indicated that this function will be beneficial to the infants as well as the mothers.To screen the communication and hearing abilities in young children -The majority of the PHC programme managers indicated that this function can be integrated in the programmes.The School Health programme was specified as a programme in which screening campaigns should be launched in order to identify young children in the following contexts: preschool playgroups, creches and in primary school.The Health promotion programme does not need to be included in the screening of infants and young children.This function needs to be implemented at facility level and the speech-language therapist should work in collabora tion with the facility managers.-To determine risks for communication delay in young children and to provide intervention -The PHC programme managers indicated that this is an important function to be integrated as communication delays or disorders in infants and young children can be prevented or decreased.The programmes should be in cluded in the implementation of ECI in the rural community as their resources are invaluable.Infants and young children in need of special services have to be referred as soon as possible.The Mother, Child and Women's and the School health programmes are implemented in contexts such as pre-schools where it is fea sible to monitor the communication development of infants and young children.-To advocate the education o f children -The PHC programme managers indicated that communities should be made aware of the importance of education.This ECI function may improve the future of many children.The School health programme needs to operate in collaboration with the schools in order to promote the importance of education.All programmes should be involved in promotional initiatives and the Departments of Health and Educa tion need to collaborate.-To facilitate the implementation o f a language and literacybased preschool curriculum to ensure school readiness -All the PHC programme managers supported the integration of this func tion into the PHC programmes.The Departments of Health and Education need to collaborate on school readiness.The educa tors should be trained to stimulate the communication develop ment of young children and facilitate the skills to be acquired at preschool level.Early learning centres and creches should be visited in collaboration with the School health programme.The training of the preschool personnel may also assist in identifying infants and young children at risk for communication delays.-To evaluate and monitor the collaborative activities -The PHC programme managers explained that it is very important to dem onstrate progress and to identify the problem areas which may exist.Statistics need to be monitored and the goals of the activi ties have to be kept in mind.The effectiveness of teamwork has to be evaluated and the PHC programme managers have to have regular meetings in order to monitor progress in a collaborative way.-Community awareness campaigns on ECI services and partici pation in health calendar day activities -The ECI programme should be integrated in the community by collaboration with the other PHC programme initiatives.The importance of community campaigns as a way to provide focused information and to intro duce new programmes to people was emphasized by the PHC programme managers.CONCLUSION AND IMPLICATIONS Since case finding and referrals are inadequate and ECI ser vices have not yet been established in Ditsobotla sub-district, certain limitations can be expected.The study found that the identification methods for infants at risk of communication delay or disorders are limited and unreliable, and that the referral sys tem appears to be ineffective in this impoverished rural district.
Kritzinger (2000) also described limited teamwork and limited 56 DIE SUID-AFRIKAANSE TYDSKRIF VIR KOMMUNIKASIE-AFWYKINGS, VOL, 56, 2009 Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012.)knowledge of ECI as problem areas in service delivery.The imple mentation of collaborative activities necessitates a commitment to integrated teamwork by all involved.The results of the current study showed a remarkable motivation by the participants for the implementation of ECI.Training of PHC personnel in ECI services and promotion of normal communication and literacy develop ment among young children form part of the different ECI primary prevention functions.These functions may be phased in at PHC facilities with sufficient capacity and human resources.Further more, training packages must be developed to address the infor mation needs experienced by PHC professionals, volunteers, parents and caregivers.The implementation of ECI functions within the PHC package may address some of the multiple problem areas in ECI service delivery in South Africa.The implementation of ECI services in rural areas in South Africa needs to be considered holistically, and the different programmes within the PHC package should be used as a means to reach the communities.

Figure 2 .
Figure 2. The incremental rollout of ECI functions within the PHC package THE SOUTH AFRICAN JOURNAL OF COMMUNICATION DISORDERS, VOL 56, 2009 57

Table 1 .
Characteristics of the participants in group 1 (n=20) course.The characteristics of the participants are summarised in

Table 2 .
According to Table 2 most of the programme managers had