Abstract/Summary

Introduction: In Saudi Arabia, despite the country’s relatively high expenditure on healthcare, where investment in health services by the Ministry of Health (MOH) has witnessed a rise from 6.49% of total government expenditure in 2010 to 7.27% in 2015 (Ministry of Health, 2015), access to speech and language therapy services is limited. Addressing the public’s inequitable access to resources is considered a major issue in Saudi Arabia’s healthcare system (Alkabba et al., 2012), where regular healthcare provisions, including speech and language therapy services, are not available to many of the country’s children living either in major cities or in rural or remote areas. One way to improve access for those who may otherwise be deprived of speech and language therapy assessment or treatment is through telepractice (TP). Studies investigating the use of TP services with children and adults who stutter have shown similar therapeutic outcomes when compared to traditional face-to face delivery (e.g. Carey et al., 2010; Lewis et al., 2008; O’Brian et al., 2014; Wilson et al., 2004); however, there is currently no evidence as to the viability of TP stuttering assessments for any age group (Lowe et al., 2013). The present research therefore investigates the validity and reliability of using a TP application to assess stuttering behaviour in school-age children. Methodology: Prior to commencing the main study, a questionnaire study was conducted to understand the assessment practices followed by speech language therapists (SLTs) in Saudi Arabia, particularly their assessment practices in the field of stuttering, so as to aid in the selection of the most relevant assessment activities related to stuttering in Saudi clinical settings. The Stuttering Severity Instrument (Fourth Edition) (SSI-IV) (Riley, 2009), Percentage of Syllables Stuttered (%SS), and the Severity Rating scale (SR) were chosen as assessment measures for the main study. Further, a study to investigate the reliability of the SSI-IV was conducted. The text of the SSI-IV examiner record form was translated into Arabic according to the Process of Translation and Adaptation of Instruments guidelines (WHO, 2015), and its relative and absolute reliability was investigated. The main study consisted of thirty children who stutter (CWS), aged between 6 and 15 and recruited from a speech therapy clinic in King Abdulaziz University Hospital in Riyadh. Children were divided into two testing conditions, either face-to-face-led or TP-led testing, and were administered the SSI-IV, %SS, and SR either face-to-face or via TP using two laptops with webcams, video conference software, and a broadband internet connection. Agreement and reliability of scoring in the two testing conditions were reported, in addition to questionnaires exploring children’s and their caregivers’ perceptions both before and immediately after the TP assessment being carried out. Results: Findings of the questionnaire study revealed that most respondents assess various dimensions of stuttering (covert and overt). With regard to the assessment of overt features of stuttering, most respondents reported the use of formal and quantifiable measures, such as the %SS and SSI. Respondents reported using a non-formal approach for the assessment of attitudes and quality of life through interviews. As for the reliability of the translated SSI-IV, high to very high relative intra- and inter-rater reliability was reported. Regarding absolute reliability, intra-rater reliability was more favourable when compared to inter-rater reliability. Finally, for the main study, 30 sessions were successfully carried out, with results revealing unsatisfactory levels of agreement when applying the Bland and Altman (1987) method. However, when discrepancies were found, it was comparable to those from traditional faceto- face studies. Generally, parents and children exhibited high levels of satisfaction and held a positive view regarding TP pre- and post-assessment. Discussion and Conclusion: Results of the questionnaire distributed to Saudi SLTs to explore their views regarding stuttering assessment highlight the need for SLTs to receive more training in the domain of stuttering in order to make them aware of up-to-date assessment tools and teach them to adapt well-established Western tools for the Arabic language or develop authentic assessment tools and scales for the target population. With regard to the SSI-IV reliability investigation, the results suggest that the Arabic version of the SSI-IV can reliably be used by SLTs for research and clinical purposes. However, the compromised absolute inter-rater reliability suggests that SSI-IV may not be appropriate for use when identifying minor changes in stuttering severity within an individual across time, when different SLTs measure the stuttering severity of the same client. The results of the main study suggest that conducting a stuttering assessment via TP for school-age CWS is feasible, reliable, and valid. Although the TP model posed some challenges for executing the assessment, mainly technological challenges, high levels of satisfaction were documented in the parents and children. The TP system and equipment chosen in this study has provided a basis for the delivery of TP stuttering assessment in a clinical setting, thus addressing the barriers to access that are present for school-age CWS in Saudi Arabia. These results are preliminary, but they can be seen as a building block for future research in TP assessment studies for CWS.