Sowden, Ryann (2018) An investigation into the perceptions of “outsider” contributions to sustainable services for people with communication dis- abilities, in majority world countries. Doctoral thesis (PhD), Manchester Metropolitan University. Downloaded from: https://e-space.mmu.ac.uk/622346/ Usage rights: Creative Commons: Attribution-Noncommercial-No Deriva- tive Works 4.0 Please cite the published version https://e-space.mmu.ac.uk AN INVESTIGATION INTO THE PERCEPTIONS OF “OUTSIDER” CONTRIBUTIONS TO SUSTAINABLE SERVICES FOR PEOPLE WITH COMMUNICATION DISABILITIES, IN MAJORITY WORLD COUNTRIES. R SOWDEN PhD 2018 AN INVESTIGATION INTO THE PERCEPTIONS OF “OUTSIDER” CONTRIBUTIONS TO SUSTAINABLE SERVICES FOR PEOPLE WITH COMMUNICATION DISABILITIES, IN MAJORITY WORLD COUNTRIES. RYANN SOWDEN A thesis submitted in partial fulfilment of the requirements of the Manchester Metropolitan University for the degree of Doctor of Philosophy Department of Health Professions October 2018 !2 of !450 Abstract Background Services for people with communication disability (PWCD) are extremely limited in Majority World countries. Speech and language therapists (SLTs) provide many services for PWCD, but in Majority World countries the number of SLTs is small. Outsider (foreign) SLTs have been involved in providing services for PWCD in Majority World countries. Little is known about insiders’ (country nationals) and outsiders’ preferences for outsider-involvement; whether outsider involvement in the development of services follows a common trajectory; or what best practice for outsiders in developing sustainable services for PWCD in the Majority World should be. The aim of this study was to investigate the processes and perceptions of collaboration between insiders and outsiders, in developing services for PWCD in Majority World countries, with a particular emphasis on the contribution and roles of outsiders. Methods A two-phase, exploratory, mixed-method study used ethnographic and survey case study approaches. In phase one, interviews, document analysis, and participant observation were carried out in Uganda. Phase two formed a pilot study using a written survey with participants from five Majority World countries. Data were analysed using content analysis, Thematic Network Analysis and descriptive statistics. Results Ten thematic networks and three categories were generated from the two phases. Exploration of these resulted in 18 findings, which were integrated and synthesised to produce seven key statements. These key statements related to topics of power, roles, exchange, culture and development approaches. Discussion and Conclusions This study has added to the knowledge base by revealing insiders’ and outsiders’ perceptions of challenges of their power, roles and cultural appropriateness; their need for fair exchanges of contributions; and the need for plans, flexibility and overall commitment to ensuring sustainability. The key statements showed insider preferences for outsider contributions and !3 of !450 provide valuable guidance for outsider involvement at different stages of collaboration. !4 of !450 Contents Abstract 3 List of tables and figures 9 Acknowledgements 11 1 Introduction 12 1.1 Overview 12 1.2 Description of the study 12 1.2.1 Purpose of the research 13 1.2.2 A note on the terminology 14 1.2.3 Anticipated challenges in conducting the research 17 1.3 Aims and objectives 18 1.4 Thesis structure 19 1.5 Chapter summary 20 2 Background 21 2.1 Overview 22 2.2 Historical overview of colonisation 23 2.2.1 British colonialism 23 2.2.2 The end of the colonial era 24 2.2.3 Imperialism, neocolonialism and postcolonial theory 25 2.3 Development Theories 26 2.3.1 Modernisation Theory 26 2.3.2 Dependency Theory 29 2.3.3 World Systems Theory 32 2.3.4 Postdevelopment Theory 33 2.3.5 Implications of Development Theories for Health Services in Majority World 35 countries 2.4 Health and health services 38 2.4.1 Health service history in Majority World countries 39 2.4.2 Structure of health services in Majority World countries 42 2.4.3 Health system structure and development 43 2.5 Models of disability 46 2.5.1 Disability statistics 49 2.6 Communication disability and services for PWCD 50 2.6.1 History of services for PWCD 51 2.6.2 Communication disability service structure 52 2.6.3 Prevalence of communication disability 55 2.7 Outsider approaches to services for PWCD in the Majority World 59 2.8 Summary 67 !5 of !450 3 Methodology 69 3.1 Introduction 69 3.2 Philosophical approach 70 3.2.1 Epistemology 71 3.2.2 Theoretical perspective 72 3.2.3 Methodology 77 3.2.4 Methods 84 3.3 Ethical Considerations 86 3.4 Research quality 87 3.4.1 Enhancing research quality 88 3.5 Summary 94 4 Phase one: ethnographic case study - Uganda 95 4.1 Overview 95 4.2 Phase one country background 95 4.2.1 Country geography 95 4.2.2 A brief history of Uganda 95 4.2.3 People and population 96 4.2.4 Economy 96 4.2.5 Politics 97 4.2.6 Infrastructure 97 4.2.7 Education 98 4.2.8 Health 99 4.2.9 Disability 100 4.2.10 Communication disability in Uganda 100 4.2.11 Services for PWCD 101 4.3 Phase one objectives and methods 102 4.3.1 Method 1: Document analysis 103 4.3.2 Method 2: Interviews 107 4.3.3 Method 3: Participant observation 114 4.4 Results 120 4.4.1 Document analysis results 120 4.4.1.1 Category 1. Moving forward 121 4.4.1.2 Category 2. SLT roles 124 4.4.1.3 Category 3. Taking the lead 128 4.4.1.4 Summary 136 4.4.2 Insider interview results 138 4.4.2.1 Global theme 1. Mother - child relationship 139 4.4.2.2 Global theme 2. Shared values 145 !6 of !450 4.4.2.3 Global theme 3. Developing sustainable services 152 4.4.2.4 Summary 158 4.4.3 Outsider interview results 160 4.4.3.1 Global theme 1. Relationships 162 4.4.3.2 Global theme 2. Reconciling Ugandan independence and outsiders’ expertise 165 4.4.3.3 Global theme 3. Development approaches 169 4.4.3.4 Global theme 4. Embedding services in context 173 4.4.3.5 Summary 177 4.4.4 Participant observation results 179 4.4.4.1 Global theme 1. Togetherness 180 4.4.4.2 Global theme 2. Support 186 4.4.4.3 Summary 192 4.5 Discussion 192 4.5.1 The process and history of services for PWCD in Uganda 193 4.5.2 Insiders’ perception of outsiders’ contributions to services for PWCD 196 4.5.3 Outsiders’ perception of outsiders’ contributions to services for PWCD 200 4.5.4 Comparison of insiders’ and outsiders’ perceptions of outsider’ contributions to 202 services for PWCD 4.5.5 Insider and outsider collaboration 205 4.5.6 Limitations 207 4.6 Summary 209 5 Phase two: pilot study 210 5.1 Introduction 210 5.2 Research objective 210 5.3 Method 211 5.3.1 Country selection criteria 211 5.3.2 Survey instrument 217 5.3.3 Pilot survey 219 5.3.4 Participants 221 5.3.5 Data collection procedure 222 5.3.6 Data analysis 222 5.4 Results 223 5.4.1 Participant demographic data 223 5.4.2 Thematic Network 226 5.4.2.1 Global theme 1. Outsiders’ inherent status allows them to set terms of 227 collaboration 5.4.2.2 Summary 234 5.4.3 Outsider commonalities 235 5.4.4 Outsider roles 239 !7 of !450 5.4.5 Collaboration 241 5.4.6 Rationale for collaboration 247 5.4.7 Judgement on present outsider contributions and effectiveness 250 5.4.8 Ideal outsider qualities and contributions 257 5.4.9 Views on outsider perspectives 261 5.4.10 Insider/outsider equality 264 5.4.11 Summary 266 5.5 Discussion 266 5.5.1 Participant demographics 267 5.5.2 Insider perceptions of outsiders’ contributions to services for PWCD 268 5.5.3 Limitations 276 5.6 Summary 277 6 Discussion 278 6.1 Introduction 278 6.2 Findings from phase one and phase two 278 6.2.1 Power 280 6.2.2 Roles 284 6.2.3 Exchange 286 6.2.4 Culture 289 6.2.5 Development approaches 293 6.3 Development theories 295 6.3.1 Modernisation Theory 295 6.3.2 Dependency Theory 297 6.3.3 World Systems Theory 299 6.3.4 Postdevelopment Theory 300 6.3.5 A summary on development theories 302 6.3.6 Outsider context 302 6.4 Summary 303 7. Conclusion 304 7.1 Introduction 304 7.2 Summary of the study 304 7.3 Key statements resulting from the study 305 7.4 Implications for practice 306 7.5 Limitations 308 7.6 Areas for future research 313 7.7 Conclusion 315 References 317 Appendices 318 !8 of !450 List of tables and figures Tables Table 3.1 Research questions and data analysis used 79 Table 3.2 Research phases 84 Table 3.3 Philosophical approach 94 Table 4.1 Phase one research objectives and data collection 103 Table 4.2 Participant interview sample 108 Table 4.3 Participant observation 118 Table 4.4 Document analysis data 120 Table 4.5 Summary of document analysis codes, subcategories and categories 121 Table 4.6 Insider interview participants 138 Table 4.7 Summary of insider basic, organising and global themes 139 Table 4.8 Insider global theme 1. Mother-child relationship 140 Table 4.9 Insider global theme 2. Shared values 145 Table 4.10 Insider global theme 3. The Ugandan context 153 Table 4.11 Outsider interview participants 161 Table 4.12 Summary of outside of basic, organising and global themes 161 Table 4.13 Outsider global theme 1.