November 1, 2011 Features

Cultural Competence: How Qualified Are You?

"How qualified do you believe you are to address cultural and linguistic influences on service delivery and outcomes?"

Most ASHA members—across practice setting and profession—believe themselves to be "moderately" or "very" qualified to provide culturally appropriate services, according to their responses to a number of surveys. Asked to rate themselves on a five-point scale, 73.5% of respondents on the 2011 health care survey of speech-language pathologists gave themselves a 3, 4, or 5, as did 73.5% of the audiologists and 71$ of the SLPs on the 2010 survey of school-based clinicians (ASHA, 2010a, 2010b, 2011).

Their answers attest that they are aware of and responsive to the influence of cultural and/or linguistic diversity in interactions with clients/patients, families, students, and colleagues.

And yet even those who are consciously aware of and practice cultural competence may unknowingly, unintentionally find themselves in situations that are not culturally sensitive. It's when we catch ourselves in these moments that a real breakthrough often takes place.

Here, three members share their "aha" moments—when a clinical or personal situation clarified the meaning of cultural competence and its application.

Karen Beverly-Ducker, MA, CCC-A, director of multicultural resources, can be reached at kbeverlyducker@asha.org.

 

Language Differences: More Than Expressive

by Irene Gilbert Torres

Cultural diversity is a defining feature of New York City. As a child in Brooklyn in the '50s, I was surrounded by a variety of immigrant groups. Each neighborhood—Irish, Jewish, Italian, Polish, Russian, Scandinavian, Greek, black—had its own flavor, feel, and ambience. People always knew where they were from; we were all Americans, but we were from somewhere else—no matter how many generations back that went.

Long before I became a speech-language pathologist I was aware of language differences. The different ways of speaking weren't wrong; that was just the way the Italian kids said something or the way the black kids said it or how the Jewish kids said it. We all understood one another and no one was criticized for ethnic speech. Even our teachers were from diverse backgrounds and spoke in many different ways.

Through the years I have considered myself to be relatively culturally competent. I have a culturally mixed family: My husband is a Cuban immigrant and I am a third-generation American of Irish descent. His parents spoke only Spanish and mine only English. I was educated in the City University of New York system and have always worked with groups different from my culture. I have served a totally Hispanic population, a totally Orthodox Jewish population, and for the last 20 years, a predominantly Afro-Caribbean population. The population of the school in which I work is about 98% African American/Caribbean; the rest are mostly Hispanic.

My education and experiences affect my awareness, attitude, knowledge, and skills. Language differences have always been salient to me and I try to be aware of what is culturally acceptable and what is an error. I take in-service courses on cultural sensitivity and keep up on research in the area of language diversity. I try to keep current with the information and to hone my skills in cultural competence.

I thought I was doing a good job with culturally competent service—until I met 4-year-old Kamari.

Kamari, from Jamaica, needed an evaluation. I am aware of Caribbean-based differences in language structure, such as no "s" to mark possessives ("That my mother hat"), use of the nominative third-person pronoun in all cases ("She take she dog for a walk," "She show she the hat"), no mandatory use of the verb "to be," and not marking the third-person present verb.

The children, although they use these forms, generally respond to Standard American English with little or no problem—or so I thought. I began Kamari's evaluation and he did not respond at all—not to the test questions, various inquiries about his age or name, or any of my attempts to interact with him verbally. He made intense eye contact but did not look at me quizzically or with confusion. It seemed that he had no idea what this "talking" thing was all about.

After several attempts to engage Kamari, I was beginning to become concerned about how I would score the test and write the report. He had played appropriately with toys in the waiting room and seemed to be alert and related, but he said nothing to me spontaneously or responsively.

As I was about to decide that Kamari was severely language-impaired, the intake coordinator knocked on my door to tell me that Kamari had been born and raised in Jamaica and had just arrived in the United States two weeks earlier. I was still perplexed by his total lack of response, and supposed out loud that if someone could speak to him using some Jamaican patois that perhaps he would respond.

At that point the graduate speech-pathology student who was working with me said that his family was Jamaican and that he could easily speak to the child using the dialect. Naïvely, I thought it would not make much difference. The student began to speak to Kamari using Jamaican patois. Kamari responded immediately and was extremely talkative. The student asked him the test questions (breaking protocol, of course) speaking patois or using Jamaican language structure. Kamari was able to respond to the test questions far above his age level when they were presented in that manner.

When we determined that Kamari did not have a language disorder and, in fact, was fairly advanced in his language skills, I asked the graduate student to ask Kamari why he hadn't responded to me. Kamari said that he couldn't understand me so why should he talk to me; apparently he did not want to make a mistake. He believed I wouldn't know what he was saying! I realized the error of assuming that the language differences were expressive only, and this episode made me more aware of the effect my speech might have on the children—a definite "aha" moment for me.

 

A Clash of Cultural Assumptions

by Barbara L. Rodríguez

Collaboration between families and professionals is one of the principal tenets of the Individuals with Disabilities Education Improvement Act of 2004 (IDEA). The implementation of this mandate is critically important to all families of children with disabilities. Early in my career as a speech-language pathologist, I learned an important lesson about building collaborative relationships with families to develop and set culturally relevant intervention goals.

Several years ago, I was the SLP serving high school students (ages 15–21 years) with moderate to severe developmental disabilities. The school's special education program adopted a community-based model of instruction to prepare students with disabilities to live, work, and play in integrated settings as adults, alongside their non-disabled peers. The multidisciplinary team, which included physical therapists, occupational therapists, classroom teachers, and other professionals, collaborated to improve students' daily living skills, personal and social skills, and occupational skills. Because community-based instruction is designed to increase independent living, intervention was delivered in meaningful and functional community settings and incorporated naturally occurring materials and situations to facilitate students' acquisition and generalization of life skills.

My "aha" moment in recognizing the significance of cultural competence occurred when the cultural assumptions held by the family of one of my students were in conflict with the program's philosophy and goals. My student, Anna (pseudonym), was in ninth grade. She was of Mexican-American origin, lived with her parents and siblings, and had significant cognitive disabilities. Her family's cultural assumptions were aligned with traditional Mexican culture and placed value on collectivism, interdependence, and familism (Triandis, 1995). Together, these values focus on whose goals and needs take precedence (an individual's or the group's), and the extent to which an individual is autonomous or embedded in and dependent upon his or her family.

In Anna's case, the powerful cultural discontinuity between her family's goals and expectations and those of school personnel was revealed at an individualized education program (IEP) planning meeting. During this meeting, members of the multidisciplinary team described Anna's strengths and weaknesses, and recommended corresponding intervention goals and objectives that were aligned with the program's overarching goal of independence. Anna's parents patiently listened to each recommendation, and although they were encouraged to ask questions, they did not. Near the meeting's conclusion, Anna's parents were asked to sign the IEP to acknowledge their agreement with the proposed educational plan. Anna's mother took the pen, looked to me and said, "Why would we want Anna to be independent? She will never live independently. We plan on caring for her as long as we are alive. Her family will always provide care for her needs."

"Aha!" Anna's family challenged some of the most deeply embedded values in American society—namely, independence and autonomy. My own assumption about independence as a goal had initially blinded me to the family's values of collectivism, interdependence, and familism in setting relevant intervention goals. Her IEP needed to be truly individualized by building upon her family's cultural beliefs and improving her life skills to enhance her participation within her individual environment.

Anna and her family taught me that to be an effective clinician, I must develop the ability to think, feel, and act in ways that acknowledge, respect, and build upon ethnic, sociocultural, and linguistic diversity (Lynch & Hanson, 2011). Although my "aha" moment occurred nearly 25 years ago, it serves as a reminder to me today that to be a clinically competent clinician I must also be aware, open, and flexible enough to assess anew the cultural values and experiences of each client and his or her family.

 

Is Race an Outdated Sociological Construct?

by Kay T. Payne

It hit me like a sucker-punch in the dark. Surely it was a misdiagnosis. How could I have elevated blood pressure and mounting cholesterol levels? The scene during my recent physical examination appeared surreal. I listened, barely discerning the words, as the physician explained that I must now forfeit snacks, ethnic food, and saturated fat, and engage in healthy eating and exercise.

Equally contributing to the shock was the realization that I had just been stereotyped! As an educated, middle-aged African American woman, I am well aware of health risks. My body mass index (BMI) is normal. Decades ago I gave up ethnic food for a heart-healthy diet. I attend yoga classes, exercise daily, and avoid risky behaviors. Although the laboratory results accurately indicated my physical condition, the physician's assumptions and recommendations were based on melanin and biostatistics.

This experience motivated me to ponder how many times I, as a clinician, had unwittingly subjected clients to similar stereotypical assumptions.

Eliminating cultural and racial disparities in health and health care is a major priority for the nation. Complex relationships among race, culture, socioeconomic status, and even literacy, language, and religion contribute to disparities. Over and beyond patient behaviors, health disparities also result from government policy and actions of insurance providers and health care professionals.

In my case, the assumption was that because of behaviors attributed to my racial designation, I bore sole responsibility for my condition. Yet as an African American, I am constantly reminded of my typical familial history of heart disease, hypertension, and diabetes, and I have chosen a healthy alternative. For me, lack of exercise and healthy diet were not the roots of the problems, and changing them was not the solution. In reality, the physician's delay or withholding of medical treatment could serve to put me further at risk.

Geneticists, bioethicists, and sociologists have recently suggested that the concept of race lacks scientific validity, and categories such as "black," "white," "Asian," and "Hispanic" are antiquated and irrelevant in modern genetically based medicine. Reporting in Nature Biotechnology, Johnathan Kahn (2011) states that constructions of race are not only scientifically flawed, but they also distort the understanding of ancestry in implications for health. Further, they can be socially dangerous by introducing new forms of discrimination and misallocation of resources to address health disparities.

Prevention and treatment of speech, language, and hearing disorders are incorporated in the objectives of Healthy People 2020; genomics and social determinants of health are among the new components. In clinical encounters we constantly make assumptions about a client's language in looking at targets of speech performance, and about the client's lifestyle in determining prognosis, selecting treatment, and evaluating progress.

For diagnosis we administer standardized tests that had few, if any, representatives of diverse populations in the norming sample. The vantage point of "personalized medicine" can be our guide to construction of new diagnostic instruments and procedures based on parameters other than race, such as familial predisposition, linguistic background, and environment.

In research, inclusion of diverse groups, if required, is often a petty annoyance. Institutional review boards (IRBs) do not set limits for inclusion nor do they require reflection on what is meant by the general ethnic/racial categories. For example, does "black/not Hispanic" include or exclude Haitians or African immigrants? Can "Hispanic" possibly capture the many subpopulations, national origins, and linguistic variations? Likewise, can research conducted on African Americans be widely generalized? Why not—research on Anglo-Americans has always been the standard. New horizons for research will distinguish race in regard to whether it is psychological, social, political, or biological.

Certainly race is not meaningful or legitimate when it subjects an individual to stereotyping. Yet inclusion is ineffective if it is so slight that its intended effects are cancelled out or if faulty assumptions are used in selection. However, visible manifestations of race are always important when they lead to equality, justice, and sensitivity.

As ASHA professionals, we know that self-awareness and cultural competence can further efforts toward eliminating health disparities related to speech, language, and hearing. As the discussion about the role of race in medicine progresses and expands, we too can follow the example of genetic medicine and question the applicability of the broad concept of race in our profession.

Irene Gilbert Torres, MS, CCC-SLP, has been a clinician in New York City for 38 years, mostly working with infants and preschoolers in Brooklyn's inner city. She concentrates on infant and preschool evaluations and graduate student supervision. Torres is a member of ASHA's Multicultural Issues Board and four ASHA special interest groups: Administration and Supervision, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations, School-Based Issues, and Global Issues in Communication Sciences and Related Disorders. Contact her at irenetorres@optonline.net.

Barbara L. Rodríguez, PhD, CCC-SLP, is associate professor of speech and hearing sciences at the University of New Mexico. Her research focuses on the environmental and cultural influences on bilingual children's language and literacy development. She is a member of Special Interest Group 14, Communication Disorders and Sciences in Culturally and Linguistically Diverse Populations. Contact her at brodrig@unm.edu.

Kay T. Payne, PhD, CCC-SLP, is a professor in the Department of Communication Sciences and Disorders at Howard University in Washington, D.C. She holds a master's degree in religious studies with a specialization in theological bioethics. Contact her at kpayne@howard.edu.

cite as: Torres, I. G. , Rodríguez, B. L.  & Payne, K. T. (2011, November 01). Cultural Competence: How Qualified Are You?. The ASHA Leader.

Cultural Competence and Oral Tradition

As work continues on the development of the formal tools to gather data on cultural competence, the technique of oral tradition offers valuable contributions to information collection efforts. Oral tradition, a practice common across cultures, refers to material and traditions transmitted through spoken words, usually from one generation to another. Information and messages are verbally transmitted in a number of forms such as folktales, sayings, ballads, or songs—usually in the absence of a writing system. ASHA has used the oral tradition in recording the cultural competence "aha" moments of several members, available at ASHA's multicultural webpage.

Cultural Competence and Ethics

The ASHA document Issues in Ethics Statement: Cultural Competence (ASHA, 2005) was developed to provide guidance to ASHA members and certificate-holders as they provide ethically appropriate services to all populations, while recognizing their own cultural/linguistic background or life experience and that of their client/patient/student.

The document includes several issues, such as:

  • Certain materials may be inappropriate and even offensive to some individuals.
  • Families may choose complementary and alternative medicine, traditional healing practices, and different communication styles, as opposed to mainstream diagnostic and therapeutic approaches. The clinician must have the cultural competence to accommodate these needs and choices, or at a minimum know when and where to seek assistance.
  • The clinician must be aware that "differences" do not imply "deficiencies."
  • When a clinician is not proficient in the language used by the client and family, a suitable interpreter should be used. The use of interpreters and others who are proficient in the language of the client and family does not negate the ultimate responsibility of the clinician in diagnosing and/or treating the client/patient.
  • A clinician must remember that bilingual skill (understanding and speaking the language) does not equate to bicultural skill (understanding and respecting the culture)—both are necessary for culturally competent service delivery.
  • Beliefs and values unique to the individual clinician-client encounter must be understood, protected, and respected. Care must be taken not to make assumptions about individuals based upon their particular culture, ethnicity, language, or life experiences that could lead to misdiagnosis or improper treatment of the client/patient.
  • Providers must enter into the relationship with awareness, knowledge, and skills about their own culture and cultural biases.
  • To address the unique, individual characteristics, and cultural background of clients and their families, providers should be prepared to be open and flexible in the selection, administration, and interpretation of diagnostic and/or treatment regimens.
  • When cultural or linguistic differences may negatively influence outcomes, referral to or collaboration with others with the needed knowledge, skills, and/or experience is indicated.


References

American Speech-Language-Hearing Association. (2005). Cultural Competence [Issues in Ethics]. Available at www.asha.org/policy/ET2005-00174/.

American Speech-Language-Hearing Association. (2010a). 2010 Schools survey summary report: Number and type of responses, Educational Audiologists [PDF]. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2010b). 2010 Schools survey summary report: Number and type of responses, SLPs [PDF]. Rockville, MD: Author.

American Speech-Language-Hearing Association. (2011). 2011 SLP health care survey summary report: Number and type of responses. Rockville, MD: Author. Available at http://www.asha.org/policy/ET2005-00174/.

Kahn, J. (2011). Mandating race: How the USPTO is forcing race into biotech patents. Nature Biotechnology, 29, 401–403.

Lynch, E. W., & Hanson, M. J. (2011). Development cross-cultural competence: A guide for working with children and their families (4th ed.). Baltimore, MD: Paul H. Brookes.

Triandis, H. (1995). Individualism and collectivism. San Francisco, CA: Westview.

U.S. Department of Education. (2007). 26th annual report to Congress on the implementation of the Individuals with Disabilities in Education Act 2004, Vol. 2. Washington, DC: Author.



  

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