Professional competence across professions and settings requires that audiologists and speech-language pathologists (SLPs) practice in a manner that considers the impact of cultural variables and language exposure and acquisition on their clients/patients. ASHA-certified practitioners have met rigorous academic and professional standards, including knowledge of cultural variables and how they may influence communication. See ASHA's Scopes of Practice in Audiology (ASHA, 2004b) and Speech Language Pathology (ASHA, 2007). Clinicians are responsible for providing competent services, including cultural responsiveness to clients during all clinical interaction. Responsiveness to the cultural and linguistic differences that affect identification, assessment, treatment, and management includes
- completing self-assessment to consider the influence of one's own biases and beliefs and the potential impact on service delivery;
- identifying and acknowledging limitations in education, training, and knowledge and seeking additional resources and education to develop cultural competence via continuing education, networking with community members, etc.;
- seeking funding for and engaging in ongoing professional development of cultural competence throughout one's career;
- demonstrating respect for an individual's race, ethnicity, gender, gender identity/gender expression, age, religion, nation origin, sexual orientation, and/or ability;
- integrating clients' traditions, customs, values, and beliefs in service delivery;
- identifying the impact of assimilation and acculturation on communication patterns during identification, assessment, treatment, and management of a communication disorder/difference;
- assessing/treating each client as an individual and responding to his/her unique needs, as opposed to anticipating cultural variables based on assumptions;
- identifying appropriate intervention and assessment strategies and materials that do not violate the client's unique values and/or create a chasm between the clinician and client and his/her community;
- using culturally appropriate communication with clients, caregivers, and family so that information presented during counseling is provided in a health literate format consistent with clients' cultural values;
- referring to/consulting with other service providers with appropriate cultural and linguistic proficiency, including using a cultural informant or broker;
- upholding ethical responsibilities during the provision of clinically appropriate services.
Clinicians also have a responsibility to advocate on behalf of consumers, families, and communities at risk for or with communication disorders and differences or swallowing and balance disorders. Advocacy specific to cultural competence includes
- collaborating with professionals across disciplines and with local and national organizations to gain knowledge of, develop, and disseminate educational, health, and medical information pertinent to particular communities;
- gaining knowledge and education of high risk factors (e.g., hypertension, heart disease, diabetes, fetal alcohol syndrome) in particular communities and the incidence and prevalence of these risk factors that can result in greater likelihood for communication/swallowing/balance disorders;
- providing education regarding prevention strategies for communication/swallowing/balance disorders in particular communities;
- providing appropriate and culturally relevant consumer information and marketing materials/tools for outreach, service provision, and education, with consideration of the health literacy, values, and preferences of communities taken into consideration;
- identifying and educating communities regarding the impact of state and federal legislation on service delivery.
Cultural and linguistic competence is as important to the successful provision of services as are scientific, technical, and clinical knowledge and skills. The ASHA Code of Ethics (ASHA, 2010) requires provision of competent services and the use of "every resource, including referral when appropriate, to ensure that high-quality service is provided." In addition, the code states that "individuals shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their level of education, training, and experience." These principles of ethics are not intended to serve as justification for the refusal of services or discrimination "in the delivery of professional services or the conduct of research and scholarly activities on the basis of race or ethnicity, gender, gender identity/gender expression, age, religion, national origin, sexual orientation, or disability."
Clinicians have an obligation to seek the information and expertise required to provide culturally competent services and are asked to carefully consider the basis for determining their need to refer and/or refuse services. See Issues in Ethics: Cultural and Linguistic Competence (ASHA Board of Ethics, 2013). ASHA's professional practices staff can provide assistance and resources in making this determination and in identifying resources to continually enhance cultural competence.
Developing cultural competence is an ongoing process, involving self-awareness and "cultural humility" and may require an attitude shift in which audiologists and SLPs recognize what they do not know about the relevant languages and cultures of the individuals, families, and communities they serve and seek to gain culture-specific knowledge and experience in these areas. Characteristics of the culturally competent clinician include the ability to
- simultaneously appreciate cultural patterns and individual variation,
- engage in cultural self-scrutiny to assess cultural biases and improve self-awareness,
- utilize evidence-based practice to include client characteristics, clinician expertise, and empirical evidence in clinical decisions,
- understand the communication contexts and needs of clients and their families by considering communication disorders within a social context.
In most instances, developing cultural competence begins with self-assessment, including a review of the clinician's personal history, values, beliefs, and biases; an assessment of how these factors might influence perceptions of communication abilities and patterns; and an understanding of how personal perceptions might influence interactions and service delivery to a variety of clients.
The continuum of cultural competence includes several stages.
Cultural Destructiveness—in which "attitudes, policies, and practices that are destructive to cultures and consequently to the individuals within the culture" (p. 29) are exhibited.
Cultural Incapacity—in which individuals and agencies do not seek to be "culturally destructive, but lack the capacity to help …"(p. 30).
Cultural Blindness—in which "the system and its agencies provide services with the expressed philosophy of being unbiased … and function with the belief that color or culture make no difference and that all people are the same" (p. 30).
Cultural Pre-Competence—in which there is awareness and an attempt to "improve some aspect of services to a specific population" (p. 31) and clinicians are aware of perceptions, values, and other elements of their own culture and of cultures different from their own.
Cultural Competency—a stage of "acceptance and respect for difference, continuing self-assessment regarding culture, careful attention to the dynamics of difference, continuous expansion of cultural knowledge and resources, and a variety of adaptations to service models" (p. 31). At this stage, clinicians are able to effectively use their cultural knowledge during interviewing, assessment, and treatment.
Cultural Proficiency—in which agencies hold "culture in high esteem … and seek to add to the knowledge base of culturally competent practice by conducting research, developing new therapeutic approaches based on culture, and publishing and disseminating the results of demonstration projects" (p.31). In this stage, clinicians champion cultural competence in practice by training others in cultural competence, recruiting personnel from diverse cultures, and conducting research that adds to the knowledge base.
(Cross, Bazron, Dennis, & Isaacs, 1989)
Self-assessment may reveal where a clinician is along the continuum of cultural competence. See ASHA's Cultural Competence Assessment tool. Specific steps in the development of cultural competence are identified based on a clinician's location along the cultural competence continuum, the essential characteristics of the culturally competent clinician, and a reflection on individual needs. Steps include
- learning about a client's/patient's culture(s), language, experience, history, alternative sources of care, and power differentials;
- developing a livable definition of what constitutes culture that allows for possible change, or redefinition, as clients and clinicians grow;
- demonstrating respect for the cultural background of clients by integrating the client's personal preferences and cultural practices into assessment and treatment, including recognizing the influence of culture on linguistic variations, which may result in variations in communication patterns due to the context, communication intent, and communication partner (Wyatt, 1995);
- recognizing that power in the clinical situation is reciprocal and that clients have the power or capacity to make choices and changes in their lives and to participate in service delivery as appropriate for their culture and personal preferences (Battle, 2000);
- identifying both explicit cultural variables discernible on the surface—such as external symbols, food, and language—and implicit variables, including religious practices and beliefs, spiritual beliefs, educational values, age and gender roles, child-rearing practices, and fears and perceptions;
- developing an ethnogenetic viewpoint that recognizes that groups, cultures, and the individuals within them are fluid and complex in their identities and relationships;
- moving away from ethnocentrism, the belief that one's way of life and view of the world are inherently superior to others' and more desirable (Leininger & McFarland, 2002);
- moving away from essentialism, which defines groups as "essentially" different, with characteristics "natural" to a group (Fuller, 2002, p. 199). Essentialism does not take into account variation within a culture and can lead health care professionals to stereotype their patients. As such, their clinical practice focuses on beliefs about groups instead of individuals.
While human nature is inherited, culture is learned; however, individuals within all cultures vary based on differences, preferences, values, and experiences. Hofstede (2011) identifies cultural dimensions that are globally applicable and are reflected in all aspects of life, including family life, child-rearing practices, education, employment, and health care practices. The broadest and most encompassing dimensions of cultural variability that have been identified are individualism-collectivism, power, distance, masculinity-femininity, uncertainty avoidance, long-term orientation, and indulgence vs. restraint. See cultural dimensions.
Cultural dimensions occur along a continuum, and an individual may demonstrate behavior that falls anywhere along the spectrum. Individual differences, circumstance, assimilation-the process of someone in a new environment totally embracing the host culture (Riquelme, 2013), and acculturation—the integration of the host culture with the native culture to varying degrees (Riquelme, 2013), may influence how cultural dimensions are manifested by each individual.
Implications of Cultural Dimensions
Cultural dimensions influence verbal and nonverbal behaviors in communicative interactions, affecting how individuals convey trust or distrust and what they interpret as friendly, unfriendly, interested, or bored behaviors. For example, friendliness is conveyed by polite listening in a high power distance culture, by formal and specific language in a strong uncertainty avoidance culture, by verbal disclosure of information in an individualistic culture, and by an assertive style of communication in a highly masculine culture. Failure to recognize these variations in interactions can result in crucial miscommunications.
The impact of cultural dimensions should be considered within the environment and within clinical interactions. An audiologist or SLP whose cultural beliefs are consistent with independence and active experimentation may face conflicts with families whose cultural beliefs support dependence and compliance if there is a lack of awareness of these cultural differences (Kalyanpur & Harry, 1999).
Professionals educated in U.S. schools typically value a low power distance and attempt to treat students, clients, and families as equals, encouraging them to participate in the development of therapeutic goals and objectives. Persons from high power distance cultures may question the competence of a professional who attempts to include them in the development of the interventions (Hwa-Froelich & Westby, 2003). Research suggests that, when patients view themselves as similar to their health care providers in terms of cultural and linguistic background, the health care provider-patient relationship is strengthened; patient-centered communication is one factor noted to affect perceived personal similarity (Street, O'Malley, Cooper, & Haidet 2008).
Cultural competence requires audiologists and SLPs to consider how values and norms are uniquely shaped. Even when individuals share similar cultural backgrounds, their values are shaped by their own experiences and interpretations of these experiences. Stereotyping uses preconceptions of a particular population and may result in inappropriate clinical judgments and decisions for a given client/patient and the client's family.
For example, cultural competence in dysphagia services includes the identification of the individual's personal food history and preferences. Stereotyping in dysphagia services could lead to recommendations based solely on the food preferences most often associated with the individual's cultural background.
Clinical competence requires clinicians to distinguish a communication difference from a communication disorder. A clinically competent clinician will gain sufficient knowledge of a client's/patient's cultural and linguistic background in order to avoid assuming that a communication pattern(s) constitutes a disorder when the pattern(s) may in fact be the result of cultural and linguistic variation.
When distinguishing between communication differences and communication disorders, audiologists and SLPs
- recognize that cultural dimensions and individual variation may influence eye-gaze behavior; facial expressions; body language; rules of social interaction; child-rearing practices; perceptions of mental health, health, illness, and disability; and patterns of superior and subordinate roles in relation to status by age, gender, and class;
- review cultural and linguistic variables and factors that may influence communication in order to determine if the communication patterns of an individual may be related to his/her cultural background;
- determine if the communication pattern is related to the individual's linguistic background (see bilingual service delivery);
- understand that differences may be related to limited exposure to and development of new cultural communication patterns;
- recognize that assimilation and level of acculturation may influence individual communication patterns and behaviors;
- identify a disorder as a breakdown in communication that is sufficient to negatively influence the effective use of symbols and message processing in the language used by the speaker;
- recognize that a regional, social, or cultural/ ethnic variation of a communication system is rule-based and should not be considered a disorder of speech or language.
Dynamic Assessment and Response to Intervention
Early intervening services are used to determine which children have intrinsic learning problems that cannot be explained on the basis of lack of experience with the tasks. Response to intervention and dynamic assessment are both early intervening approaches that can be used to decrease unnecessary referral to special education for struggling children who can benefit from modified instructional techniques. These approaches may be used to differentiate an underlying disability from differences, because they are highly focused on intended outcomes, individual needs, and data resulting from reliable screening measures (Hosp, n.d.).
Clinically competent service providers recognize and address the cultural and linguistic variables that affect service delivery while continuing to individualize assessment and treatment strategies. This individualization ensures that the audiologist or SLP does not overgeneralize regarding a person's cultural or linguistic background. When providing services, audiologists and SLPs consider
- if the environment set-up is inviting and accessible,
- the need to modify scheduling and appointment times due to cultural and individual values that may influence client/patient availability,
- the appropriateness and cultural sensitivity of materials utilized during assessment and intervention activities,
- family and client/patient perceptions of assessment, possible diagnosis, and intervention strategies.
The National Culturally and Linguistically Appropriate Services Standards in Health and Health Care (Office of Minority Health, U.S. Department of Health and Human Services, n.d.) provide a framework for all health care organizations to best serve the nation's increasingly diverse communities.
Clinical issues Portal pages include additional information regarding the impact of culture as it relates to specific clinical topics.
The Assessment Process
When conducting assessments, audiologists and SLPs consider the client's/patient's level of acculturation and assimilation within the mainstream culture. In addition, practitioners must determine how familiar and comfortable the individual is with social, interpersonal, academic, and testing practices, as familiarity with testing procedures may influence performance during the assessment process. An appropriate evaluation may have to be completed over multiple sessions if there is a need to assess a client/patient in more than one language, collaborate with an interpreter, utilize alternate assessment formats, and find and/or establish norms for a given client population.
Gathering a Case History
Case histories should include information about the individual's communication characteristics as they compare to others from the same community. Whenever possible, case histories should be collected using open-ended questions rather than asking respondents to select from options that may not be appropriate for them. Clinicians should refrain from creating assumptions about individuals or families based on general cultural, ethnic, or racial information and should use the case history process to gather specific knowledge of the views of clients and their families.
Ethnographic interviewing encourages the interviewee to provide information that they feel is relevant, rather than respond to clinician presented questions, and can provide insight into the client's and family's perceptions, views, desires, and expectations. Strategies for ethnographic interviewing include
- using open-ended questions rather than dichotomous questions that trigger a "yes" or "no" response,
- restating what the client says by repeating the client's exact words rather than paraphrasing or interpreting,
- summarizing the client's or parent's statements and providing the opportunity for correction in case of misinterpretation,
- avoiding multiple questions posed back-to-back and/or multipart questions,
- avoiding leading questions that tend to orient the person to a particular response.
- avoiding using "why" questions, because such questions tend to sound judgmental and may increase the client's defensiveness.
(Westby, Burda, & Mehta, 2003)
Under most conditions, the use of standardized tests alone does not reflect a comprehensive approach to determine whether an individual has a communication disorder. Test scores are invalid for a client who is not reflected in the normative group for the test's standardization sample, even if the test is administered as instructed. In these cases, the tests cannot be used to determine the presence or absence of a communication disorder. However, these tests can provide valuable descriptive information about a client's abilities and limitations in the language of the test (i.e., a test given in English will assess a child's ability in English).
No test can be completely culture-free. Most formal testing is unfamiliar to individuals who have not had exposure to the mainstream educational context and the culture of testing that includes both nonverbal and verbal components. Nonverbal aspects of the testing culture include
- perception of time;
- how one is expected to learn;
- how one is expected to respond in a testing context to the examiner, regardless of gender, culture, age, and/or socioeconomic background;
- attitudes toward display of abilities;
- attitudes towards guessing, using process of elimination, story telling, or conversing with an unfamiliar individual;
- test abstraction (e.g., naming protocols that require providing already shared information or situations in which the client is required to assume a "make believe" attitude in order to engage in an expected manner).
Verbal aspects of the testing culture include
- form of language,
- functions of language,
- content of language,
- organization of the language,
- pragmatic rules of social interaction.
Accommodations and Modifications
An accommodation of an assessment process, for the purpose of this page, refers to an adjustment or change to the environment or mode of client/patient response in order to facilitate access and interaction and to remove barriers to participation without changing what the test measures. A modification, for the purpose of this page, refers to a change in material, content, or acceptable response. Accommodations and modifications may be necessary to gain useful information about the client's abilities and limitations. However, some changes may invalidate the standardized score. Examples of accommodations and modifications include
- rewording and providing additional test instructions other than those allowed when presenting trial items,
- providing additional cues or repeating stimuli that may not be permitted on test or task items,
- allowing extra time for responses on timed subtests,
- skipping items that are inappropriate for the individual (e.g., items with which the client has had no experience),
- asking the individual for an explanation of correct or incorrect responses (when not standard procedure),
- using alternate scoring rubrics.
It is important to note that there can never be one-to-one translation for test items. Languages vary across a wide range, including order of acquisition of vocabulary, morphology, and syntactic structures. Well-developed standardized tests are difficult to find for individuals who use a language other than or in addition to spoken English. See bilingual service delivery.
It is the responsibility of the clinician to document all accommodations and modifications made during the assessment process in any and all reporting of the client/patient.
Some audiologists may rely on physiological measures in an attempt to circumvent the influence of language factors on assessment outcomes. However, all components of the audiologic evaluation, including speech audiometry testing, should be completed. It is important to note that
- speech recognition testing is intended to measure the threshold of intelligibility for speech and is not intended to measure vocabulary, familiarity, or intelligence;
- compromised performance on speech recognition testing may be due to a lack of familiarity with the test items and the test process;
- reducing the set size of the test so that it includes only those words with which the client is familiar may result in lower thresholds and overestimate a person's speech recognition skills;
- speech recognition tests are language specific. (It is not appropriate to simply translate, then use, a test that has been developed and normed in a specific language. Compromised performance may be due to language background rather than hearing and/or processing difficulties.)
Treatment should be initiated with an understanding of the environmental and language context of the client and the client's family, and every effort should be made to minimize or remove physical, cultural, linguistic, and institutional barriers to intervention. Culturally relevant stimuli and experiences are to be included in intervention programs as appropriate. During intervention, audiologists and SLPs consider the nature of family and caregiver involvement. Considerations that may influence client and family expectations of the clinician and therapeutic process include
- consistently deferring to the audiologist/SLP as the expert,
- cultural differences that influence the nature and level of client participation based on the client's perceptions of his/her role,
- therapy techniques that promote behavior patterns inconsistent with family values,
- how language and communication patterns are taught and influenced by the client/family culture and values.
Factors considered when selecting appropriate audiologic intervention include the impact of cultural influence on the
- acceptance of hearing loss as a disability,
- perceived value of medical intervention,
- cultural and social significance attached to hearing loss,
- role of gender as it relates to treatment options,
- language of treatment,
- listening environment or hearing health of the individual.
Culturally divergent views of disorder and disability are considered when providing counseling, because cultural variations affect patient and caregiver beliefs for the causes of a disorder as well as how the person with a disorder should be treated. Cultural views may also influence the goals of the patient as well as the caregiver's goals for the person with the disorder.
Each family unit has a system in which each member affects all other members (Bronfenbrenner, 1979). Relationships are built and maintained through communication and may be significantly impacted by a communication disorder. When counseling individuals and families it is important to recognize the unique relationships of a family system, including how a family member's disorder affects relationships among the members as well as the functioning of the family system.
Cultural dimensions that influence counseling include
- the effect of the disability on life participation in culturally relevant contexts,
- the need and/or acceptance of special treatment or education,
- acceptance of the use of technology for treatment,
- recognition that some practices may be judged to be harmful by the family and/or the mainstream,
- cultural values in conflict with mainstream values in terms of independence, individualism-collectivism, power-distance, uncertainty-avoidance, masculinity-femininity, hedonism, time orientation, indulgence, and restraint,
- the individual's and the family's views of the role each member plays or should play in the family.
Different cultures have remedies or practices that are not understood or embraced and that may be viewed as harmful by mainstream professionals. Professionals must discern whether cultural beliefs and practices are truly cultural variations or harmful to the client/patient. Culturally sensitive counseling can provide information as well as alternative and safe treatments (Westby, 2007).
In addition, religious or spiritual beliefs and practices may take precedence before educational or medical recommendations can be considered or accepted. If these beliefs or practices are misunderstood or unknown to professionals, they may interfere with or undermine educational and medical interventions (Fadiman, 1998).
Skilled dialogue is a specific technique that can be used to counsel and communicate with individuals. The three key qualities of the technique are
- respect and honoring of identity,
- reciprocity and honoring the voice of others, and
- responsiveness and honoring the connection between self and others.
(Barrera & Kramer, 2012).
A number of state and federal regulations have implications for the culturally competent provision of audiology and speech-language pathology services. Differences in state regulations are reflected in a number of requirements. See ASHA's state-by-state page.
Implications for practice relate, for example, to implementation of standardized procedures, access to and participation in services, language proficiency, mandated accommodations to facilitate participation by individuals with disabilities, access to federal funding, availability of interpreters, classroom inclusion, disproportionate representation by race and ethnicity of children with disabilities, reducing health care disparities, and privacy.
Individuals with Disabilities Education Act (IDEA)
2006 IDEA regulations made significant steps toward addressing problems with inappropriate identification and disproportionate representations by race and ethnicity of children with disabilities. A provision was added requiring states to review ethnicity data in addition to race data to determine the presence of disproportionality. Disproportionality refers to the overrepresentation or underrepresentation of a particular demographic group in special education program relative to the number in the overall student population (National Education Association, 2007). In the event that significant disproportionality is determined, not only will the state be required to review and revise policies, procedures, and practices, but the local education agency (LEA) will be required to reserve the maximum amount of funds under §613(f) of the statute to provide early intervening services to children in the LEA, "particularly, but not exclusively" to those in groups that were significantly over-identified. These regulations clearly define steps that states must take to address the problem of disproportionality in special education. See IDEA Part B Issue Brief: Culturally and Linguistically Diverse Students.
Health Insurance Portability and Accountability Act (HIPAA)
Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. This act gives the right to privacy to individuals from age 12 through 18. The provider must have a signed disclosure from the affected person before giving out any information on provided health care to anyone else, including the patient's parents. The administrative simplification provisions also address the security and privacy of health data. So that individuals can understand their rights, materials are to be provided in a manner that is culturally and linguistically accessible.
Family Educational Rights and Privacy Act (FERPA)
FERPA (20 U.S.C. § 1232g; 34 CFR Part 99) protects the privacy of student education records. The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. FERPA gives parents certain rights with respect to their children's education records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the high school level. So that individuals can understand their rights, materials are to be provided in a manner that is culturally and linguistically accessible. See FERPA regulations [PDF].
Title VI of the 1964 Civil Rights Act
Title VI of the 1964 Civil Rights Act prohibits discrimination in any federally funded program on the basis of race, color, or national origin. This includes any public or private facility, such as a hospital, clinic, nursing home, public school, university, or Head Start program that receives federal financial assistance, such as grants, training, use of equipment, and other assistance. According to the Office of Civil Rights, all providers who work for any agency funded by the U.S. Department of Health and Human Services (HHS) are required to provide language access services to patients who do not speak English.
Equal Educational Opportunities Act of 1974
The Equal Educational Opportunities Act of 1974 states "All children enrolled in public schools are entitled to equal educational opportunity without regard to race, color, sex, or national origin."
Executive Order 13166
Executive Order 13166 requires federal agencies to examine the services they provide, identify any need for services to those with limited English proficiency (LEP), and develop and implement a system to provide those services so LEP persons can have meaningful access to them. See guidance from HHS [PDF] applicable to health care providers who receive federal funds (e.g., via Medicare, Medicaid, State Children's Health Insurance Program).
Americans with Disabilities Act (ADA)
The ADA is intended to protect—and guarantee access to and participation in society for—persons with disabilities. The statute is specifically directed at employment, public accommodations, public services (i.e., services delivered by state and local governments), transportation, and telecommunication. To be protected by the ADA, one must have a disability, which is defined by the ADA as a physical or mental impairment that substantially limits one or more major life activities, have a history or record of such an impairment, or be perceived by others as having such an impairment.
Affordable Care Act
The Affordable Care Act addresses the expansion of health care coverage to populations that may not have been served in the past, explicitly linking health literacy to patient protection and then offering funds/grants for programs to increase cultural competence. The Patient Protection and ACA has specific language regarding patient-provider communication, including provisions to communicate health and health care information clearly, promote prevention, assure equity and cultural competence, and deliver high-quality care.