Among some Vietnamese Americans who come from the hills of Laos, sickness is believed to come from the gods. It is the Vietnamese priest who negotiates with the gods to restore health. Mr. A. T., diagnosed to be in the mild/moderate stage of dementia, was referred to the speech-language pathologist in a hospital for a bedside examination. The patient consistently refused to be tested and did not speak to the clinician. According to the family, Mr. A. T. was distrustful of Western hospitals and felt more comfortable when his community priest intervened on his behalf to his gods. A priest identified by the family was invited to accompany the SLP during testing. Mr. A. T. felt better when he saw his priest and participated fully in the assessment.
It is not unusual for an entire Hispanic family to be involved in health care decisions of an older family member. "Familismo" is the unifying cultural theme—that the needs of the family as a whole should be the priority. Mrs. A. S. has been diagnosed to have a right-hemisphere hemorrhagic stroke with accompanying disorders of left-side neglect and difficulties with abstract reasoning. Before scheduling outpatient treatment in the speech and hearing clinic, the SLP asks to meet with the family, which includes the patient's husband, father, mother, siblings, and children. Failing to recognize the hierarchical position of the eldest male in the family, the clinician addressed the patient's husband. He, in turn, deferred to his wife's father, who spoke on behalf of the family.
Situations like these are becoming more common in the health care arena. The results of the 2010 Census and population projections of the 2000 Census as reported in Healthy People 2010 (U. S. Department of Health and Human Services, 2000) indicate a significant increase in non-European populations in the United States during the next 40 years. By the middle of the 21st century, half (52.3%) of the U.S. population will be African, Hispanic, Asian, and Native American, making the terminology of majority and minority meaningless.
At the same time, the incidence for stroke and other chronic illnesses that affect language and cognition doubles every decade after age 55 (American Heart Association, 2007). Future projections show that the older adult cohort of African Americans (non-Hispanic), Asian American/Pacific Islanders, Hispanics (all ethnic groups), and American Indian/Alaskan Natives will grow in population at a rate more rapid than that of non-Hispanic whites over the next 40 years (see sidebar).
This growth in mature adult populations of people of color in the United States provides tremendous incentive for speech-language professionals to develop culturally sensitive policies and service delivery. It is widely recognized and reported that specific chronic and acute disorders, such as stroke, hypertension, and diabetes, affect several nonwhite populations at higher rates. It is also widely accepted that there have been and continue to be disparities in health care access and utilization that especially disadvantage people of color (Agency for Healthcare Research and Quality, 2004). Use of speech-language pathology services by adults who have traditionally been underrepresented on speech-language caseloads should be increased. Accomplishing this goal requires investigation and concerted planning by many stakeholders.
Each year, about 795,000 individuals experience a new (600,000) or recurrent (195,000) stroke (American Stroke Association, 2009). Specific ethnic groups historically have the highest prevalence of stroke risk factors and the highest incidence of strokes at earlier ages than any other ethnic groups in the country (Centers for Disease Control and Prevention, 2008).
African Americans and Hispanic Americans have been studied extensively for high blood pressure (HBP) and diabetes risk. Both groups are more likely than European Americans to suffer cerebrovascular accidents, or strokes, at an earlier age, and are less likely to recover fully from strokes (Payne & Stroman, 2004). There is also evidence of increased prevalence of stroke among Mexican Americans (168/10,000) compared with non-Hispanic whites (136/10,000). Furthermore, chronic diseases—such as hypertension and diabetes—that contribute to stroke are more prevalent in Hispanics, specifically, Mexican Americans and Puerto Ricans, than in non-Hispanic whites.
African Americans and Hispanics are not the only racial/ethnic groups at risk for stroke. In 2007, age-adjusted percentages of stroke among persons 18 years of age and over show that Asian American stroke prevalence is 2.6 per 100,000; non-Asian white prevalence is 2.2 per 100,000. Factors that contribute to elevated risk include infrequent medical visits due to the fear of deportation, language/cultural barriers, and lack of health insurance. Asian Americans are most at risk for heart disease, stroke, and diabetes (Hayes, Greenlund, Denny, Keenan, & Croft, 2005). In general, Asian Americans are less likely to have hypertension and other risk factors than non-Hispanic whites. Within this group, however, Native Hawaiian/Pacific Islanders are 30% more likely to be obese and to have high blood pressure, as compared to non-Hispanic white adults (American Heart Association, 2007); American Indian/Alaska Native adults are 60% more likely to have a stroke than their non-Hispanic white adult counterparts. American Indian/Alaska Native women have twice the rate of stroke than white women. American Indian/Alaska Native adults are more likely to be obese and have high blood pressure, compared to non-Hispanic white adults (American Heart Association, 2007).
Dementia affects all ethnic groups; however, stroke risk factors and prevalence determine the types of dementia diagnosed in persons of specific ethnic groups. High blood pressure, more common among African-Americans and a risk factor for stroke, can lead to a greater risk for developing Alzheimer's disease. African Americans may have a higher rate of vascular (stroke-related) dementia; the number of African Americans entering the age of Alzheimer risk (age 65 or older) is expected to more than double to 6.9 million by 2030 (Lloyd-Jones et al., 2010). Hispanics also have higher rates of vascular disease, and also may be at greater risk for developing Alzheimer's when compared to non-Hispanic whites. According to a growing body of evidence, risk factors for vascular disease—including diabetes, high blood pressure, and high cholesterol—also may be risk factors for Alzheimer's and stroke-related dementia (e.g., Tatemichi et al., 1992).
Implications for Service Utilization: Cultural Competence
Although the recent health care reform legislation is promising, it is too early to tell whether it will have a significant impact on the magnitude of health disparities among persons of color. Barriers to utilization of services, such as language differences, fear of deportation, distrust of the health care system, perceptions of inaccessibility, and unacceptability of rehabilitation services by nonwhite clients are factors that need to be systematically studied and addressed within speech-language pathology.
Fewer nonwhite persons use health services in general, and speech-language pathology services in particular, because of a combination of cultural, institutional, and policy barriers (Payne, 1997). Wallace and Freeman (1990), for example, found that African Americans under-utilize urban speech-language pathology clinics and frequently opt out of services before their completion, citing barriers to accessibility and cost. Related studies of health care utilization among non-white patients indicate that systematic barriers in the health care system have caused under-utilization of other health care services as well (U.S. National Institutes of Health, 2002).
These barriers persist, according to the 2007 National Report on Health Disparities. Utilization disparities related to race, ethnicity, and socioeconomic status still pervade the American health care system. Although varying in magnitude by condition and population, disparities are observed in almost all aspects of health care, including all dimensions of quality of health care and access to care, many clinical conditions and types of care, and within many subpopulations.
Despite the many challenges associated with accessibility and health disparities, SLPs' caseloads will increasingly reflect the changing demography of older Americans and will require clinicians to expand their knowledge and skills to deliver culturally competent services. Barriers that prevent the complete utilization of speech-language services by all persons will continue to affect functional recovery, quality of life, and the ability to re-integrate into home and work. To that end, emphasis on and training in cultural competence should be considered to be important clinical tools to encourage and maintain clients of color in clinical services (Harris, 1986).
Cultural and linguistic competence is service providers' systematic demonstration that cultural and ethnic differences are both valued and respected. Cultural competence is one the main ingredients in closing the disparities gap in health care by providing a way that patients and health practitioners can come together and talk about health concerns without cultural differences hindering the conversation, but rather enhancing it. In other words, health care services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse patients can help bring about positive health outcomes (U. S. Department of Health and Human Services, 2001, 2008).
For clinicians and other service providers wanting to provide this culturally competent care, some general guidance is offered:
Generate a Culturally Sensitive Case History
Generating a culturally sensitive case history takes into consideration the different definitions of who constitutes "family," including fictive kin (persons who are unrelated but who function as family), partners, and church members, as well as other areas of cultural divergence, such as religious customs, primary and secondary languages, preferred approaches to health and wellness, and personal/family perceptions of communicative disability (Payne, 1997).
Select the Most Culturally Competent Approaches to Assessment
Clinicians in a variety of settings use many recently revised language and cognitive assessment tools. Using these assessments, however, calls for cultural competence in the areas of humor, proverbs, and other figurative language evaluations. Qualls and Harris (2003) point out that age, working memory, and reading comprehension play a role in how African American research participants interpret figurative language. Clinicians should exercise care to modify or substitute existing figurative language stimuli with stimuli that are age-appropriate and culturally recognizable (Ulatowska et al., 2001). Modifications can be made to existing tests to increase their appropriateness for culturally diverse populations by developing local norms or norms for specific subgroups (e.g., ethnic adults). Clinicians also can substitute proverbs and idioms from the local communities instead of those used in standardized tests if they are not appropriate, and can use an interpreter for bilingual speakers when evaluating expressions that are specific to a particular language community. Several assessments for language and cognitive function also are available that are translated into other languages. These instruments may be used alone or in conjunction with English tests for a more comprehensive assessment. Finally, clinicians can make allowances in scoring for culturally and linguistically different responses that are close to target responses.
Develop and Maintain a Culturally Appropriate Environment for Intervention
In a culturally appropriate environment, every effort is made to minimize or remove the physical, cultural, language, and institutional barriers to intervention. Treatment for language disorders should be initiated with an understanding of the environmental and language context of the client and the client's family. Intervention programs for adults with language and cognitive disorders should include culturally relevant stimuli and experiences from the client's cultural community that help to tailor treatment to the language demands of the client's environment.
Provide Culturally Competent Family Counseling
Cultural variations affect how caregivers perceive the burdens of their caregiving and determination of which member of the family has the primary responsibility for a language and cognitively impaired family member (Payne, 2009). Family education and counseling programs can be made relevant by probing the family's need for education and support and by being respectful of culturally divergent views on disability and alternative solutions for health care (Stroman, 2000).
Several examples of culturally divergent views of disability must be considered when providing family counseling. For example, in many Japanese American families, hope must be preserved in any disability, no matter how serious the illness may be. Similarly, clinicians should be sensitive to the reluctance among some Chinese American families to acknowledge illness and serious conditions. Among some African American families, prayer and faith healing is the preferred method to deal with debilitating health conditions. Finally, for some American Indian families, the emphasis for restoring health is on the environment and the health and life of the person rather than treatment for an illness or a disease. The responsibility of being able to reasonably respond and treat this exponentially growing number of cases like these is not to be avoided, but welcomed through culturally competent practice.