"Thinking out of the box" is a familiar concept to the speech-language pathologist providing dysphagia services. The clinician choosing to specialize in the assessment, treatment, and management of swallowing and swallowing disorders, for example, must look at the anatomy and physiology previously learned in the context of speech production, and gear that knowledge to another function: deglutition. This is not unlike infusing knowledge of multicultural factors into current dysphagia practice.
The notion of cultural competence as a best practice is not just "something nice to do." Current population demographics in the United States are changing, and in many cities traditional racial/ethnic minorities are now a majority. In the context of cultural competence, however, we need to look outside certain traditions, and expand our definition and notion of culture. This means thinking of diversity as more than ethnically based diets and speaking another language. Both of these are valid and indispensable in providing culturally relevant services, but fall short at meeting the complete goal of providing the best services possible.
It is up to us to define culture more broadly, and ensure that our services are culturally relevant and appropriate. In today's dysphagia practice, we need to expand our definition of culture to include not only patients who are ethnically diverse, but those who may belong to a different religious group, follow a different lifestyle, shop at a different supermarket chain, or even eat different foods. All of these factors may influence the patient's views of disability, of Western medical treatment, the roles of family members and of clinicians, the different gender roles, and the ways in which we show respect.
The reality is this: What is the point of conducting an evaluation and making specific recommendations for postures, exercises, or diet modifications, if we cannot ensure that the patient/caregiver will follow up? We need to look at all the data factors involved, and not just use the latest clinical and technologically advanced protocols. It is of utmost importance to relate to the patient and develop a mutually respectful relationship in order to maximize our diagnostic and treatment outcomes. We need to examine our own views and understand that every patient possesses individual differences and belief systems. This may involve looking beyond our standardized assessments and treatment protocols to find other ways to achieve common goals. Although no single clinician can be expected to have complete knowledge of all the different cultures in his or her geographic area, each should be able to access information needed to provide culturally competent services.
In order to further our understanding of a particular culture, Wallace (1998; see references online) provides a framework that includes learning about the patient's culture and beliefs. Wallace also suggests that we must consider how cultures may vary with their views of generational status, concepts of time, views of wellness and disability, participation in alternative medicine, and views of Western medical treatment.
Specific to dysphagia, we must also address the individual's learning style and daily routine. The clinician must understand that sometimes it will be important to make treatment recommendations directly to the patient and, at other times, it is essential to include extended family. The clinician must have knowledge of a variety of epidemiological factors for specific groups and be familiar with ethnographic interviewing techniques. It is also essential to understand that certain racial and ethnic groups may have an increased prevalence of high-risk diseases that may result in neurological impairment.
Moreover, our role as SLPs needs to be understood from the perspective of the patient. As health care providers, we are viewed differently by different cultural groups: We may be the main authority, or we may simply be viewed as advisors. In addition to food preferences, social organization, and spiritual orientation, we must also address health practices. This not only includes the individual's view of our role, as mentioned above, but also beliefs regarding overall health, as well as access to health care. Not all persons have access to a well-trained SLP who specializes in dysphagia. For example, some cultural groups are known to use Emergency Department services as their primary source of health care; others view well-being from a more holistic/homeopathic perspective. Not everyone will accept a recommendation for tube feedings, so the clinician may need to look at other alternatives.
In addition, sensitivity to patients' knowledge of medical terminology is of utmost importance. Not everyone understands terms such as NPO, aspiration, or the concept of "no liquids by mouth." Differences in this arena may not only be related to language barriers, but to age, educational status, employment, and other factors. Differences in learning styles should also be acknowledged; some people learn best in the context of demonstration, whereas others prefer written recommendations.
Although we may not be able to match each client/patient with a provider from his/her own culture, as professionals, we can develop the appropriate skills to deliver culturally competent services to all patients with swallowing disorders. It is no longer a "nice thing to do"-it is now a clear requirement if we are to achieve positive, appropriate assessment/treatment outcomes in our multicultural society.