Cultural competency is much more than preparing translated word lists and testing materials for the audiology booth. It is ongoing, social, and multidimensional. And it requires open dialogue among professionals. To this end, the authors recently conducted a roundtable forum to identify challenges facing audiologists working with diverse children in northern New Jersey—and to find solutions.
The statistics point to the need for such discussion: The number of U.S. immigrants learning English as a second language has grown considerably in recent years. According to the U.S. census, the number of foreign-born residents is projected to rise from 31 million in 2000 to 48 million in 2025. The Hispanic population alone is projected to triple by mid-century.
For practitioners of audiology, a discipline with communication at its heart, the need to provide high-quality, culturally sensitive services and communicate with patients regardless of a language barrier is greater than ever before. With this goal in mind, 20 audiologists—two of them bilingual (Spanish/English)—working in hospitals, schools, and private practice participated in our project over four months. They identified the challenges they face in the assessment of bilingual children, and suggested possible solutions.
One major challenge cited by all respondents was language barriers in communicating with parents/guardians who accompany children to evaluations. Specific difficulties were identified in obtaining a detailed case history and in relaying recommendations for follow-up.
Bilingual children are not always accompanied by a bilingual parent/guardian. Nevertheless, it is imperative for the audiologist to obtain accurate detailed background information (birth history, complications, neonatal intensive care admissions, family history of hearing loss, developmental milestones, use of hearing aid, trauma, etc.).
All respondents indicated that incomplete background information could compromise clinical outcomes regardless of clinical protocol. It is equally important for parents to understand the test results, recommendations, and counseling provided by the audiologist.
Most respondents indicated they use ad hoc interpreters (family, staff members) and telephone "language lines" (commercial, over-the-phone interpreter services offering a variety of languages and dialects) as primary methods to overcome language barriers during history, intake, and recommendations. Two private-practice audiologists indicated they did not use or were not aware of the availability of language lines.
All respondents agreed that unremarkable histories and normal hearing test results were fairly easy to translate. Detailing risk factors for hearing loss and counseling on the identification of hearing loss (permanent or transient) are seen as challenges because many audiologists felt ad hoc translators did not always convey accurate information to parents. "I have no reassurance that the information was presented the way I intended to convey it," one respondent said.
Other challenges included:
- Lack of availability of testing materials—specifically word discrimination assessments, aided bilingual language outcomes tools, and auditory processing test materials—for bilingual children.
- Counseling regarding communication options for speech-language development in bilingual children with hearing loss.
Bilingual audiologists indicated they had no significant challenges with the actual assessment of bilingual pediatric patients. However, one indicated some difficulty understanding the various Spanish dialects (e.g., Cuban/Puerto Rican versus South American local dialects). The same bilingual audiologist also indicated difficulties with and lack of materials for explaining auditory neuropathy/dys-synchrony at a basic level in Spanish and other languages.
Breaking Through Barriers
Our discussions indicated many audiologists lack standardized interpretation options or protocols. Additionally, audiologists do not have access to all appropriate standardized speech audiometry testing materials to work with bilingual patients. Although language-specific tests have been developed, validity and lack of clinical research support remain salient concerns (Ramkissoon & Khan, 2003).
Audiologists face language challenges similar to those faced by other health professionals, including emergency medicine providers (Chan et al., 2010) and mental health care providers (Yeh, McCabe, Hough, Dupuis, & Hazen, 2003). In emergency medicine, the most common solution to communication barriers for emergency personnel is the use of ad hoc interpreters (Baker, Parker, Williams, Coates, & Pitkin, 1996) and language lines or telephone-based interpreter systems (Iezzoni, O'Day, Killeen, & Harker, 2004).
Many studies have indicated that ad hoc translators, although commonly used, are more likely than professional interpreters to commit errors that may have adverse clinical consequences. They are also unlikely to have training pertinent to medical/health sciences terminology and confidentiality issues. Language-line interpreter services appear to be a better choice when possible or feasible (Flores, 2005; Flores, Abreu, Schwartz, & Hill, 2000; Flores et al., 2003). Obviously, using an ad hoc interpreter is a better option than none when professional interpreters are not available.
There are no clear-cut solutions to the identified issues. However, many feasible and innovative suggestions were offered during our discussions.
- Translation tools and simple terminology. At a minimum, all staff should have ready access to translation tools [PDF] such as language cards or communication boards. Develop multilingual, closed-set history forms. Use straightforward visuals without anatomical terminology to explain results (e.g., a simple drawing or illustration of a middle-ear infection).
- Real-time translation applications. Research the development of computer software, smartphone, or Skype applications with real-time translations specifically designed for audiometric use. One respondent suggested that equipment manufacturers include a translation tool as part of the audiogram software used in PC-driven audiometers.
- Online resource development. Consider the development of a regional website managed by audiologists to address cultural diversity and language barriers at the local level. Such a website also may provide updated information about the demographics of local communities, pertinent cultural concerns, and case discussions. The website also can address the advancement of third-party reimbursement for interpreter services.
- Self-assessment. Many organizations—including ASHA and the National Center for Cultural Competence—have developed cultural competency self-assessment modules for clinicians. These self-assessments aim at identifying and developing cultural awareness, knowledge, and skill sets. Additionally, they provide opportunities for clinicians to self-assess their practice demographics and language needs.
- Expanded education and collaboration. Encourage local speech and hearing associations or audiology doctoral programs to offer introductory courses, such as "Spanish for the Audiologist." These courses may be offered in various languages and as part of continuing education credits. Develop relationships and partnerships with other health care disciplines (e.g., social work, psychology, nutrition, public health) and form collaborative, interdisciplinary efforts to address cultural diversity and language barriers.
- Local dialect. Bilingual audiologists may consider becoming familiar with the dialects and vocabulary of their practice's demographics, and compile a list of commonly used words that have different meanings based on dialect. For example, the Spanish word for "now/right now" is ahora/ahorita. In some Spanish dialects, ahorita implies "later," not necessarily "right now."
- Resources for parents. Bilingual audiologists also may compile a list of websites and resources in other languages to share with parents. For example, the Centers for Disease Control and Prevention (CDC) website includes a wealth of information on hearing loss in Spanish. Promote and advocate for standardized and recorded testing materials, including recorded picture identification boards, in various languages.
Health Care Literacy
Many patients, regardless of a language barrier, may have difficulty understanding basic health and medical information. However, health care literacy—"the degree to which individuals have the capacity to obtain, process, and understand any health information in order to make appropriate health decisions" (Nielsen-Bohlman, Panzer, & Kindig, 2010)—was not addressed during our discussions.
According to the Committee on Health Literacy of the Institute of Medicine, health literacy must be viewed in the context of language and culture. Use of simple illustrations (see Fig. 1 [PDF]) or terminology, rather than medical terms, is recommended when counseling parents and guardians (for example, use "ear doctor" instead of "ENT" or "otolaryngologist"). We can only speculate on the detrimental impact for children identified with permanent hearing loss when their parents do not understand the ramifications of the hearing loss, recommendations, or remediation options. Additionally, the diagnosis-to-remediation process often is complicated by extraneous steps from insurance carriers and the medical home, which can add to the confusion.
In our clinic, the AskMe3 format is used for handouts (both English and Spanish) to enhance communication and ensure parents and patients understand recommendations. This patient education program, from the National Patient Safety Foundation, is designed to promote communication between health care providers and patients. The program encourages patients to ask (and providers to answer) the following three questions:
- What is the main problem?
- What do I need to do?
- Why is it important for me to do this?
We are eager to explore and implement some of the solutions posed by our colleagues, particularly in establishing a local/regional website to address diverse patient populations in audiology practice. It is important for audiologists to recognize and address the unique cultures, languages, and health care literacy of our patients. We encourage clinicians to look at their practice demographics and determine their language and cultural needs, to identify challenges and explore low-tech or technology-driven solutions, to use simple visuals to delineate a process or recommendations to parents, and to ensure their recommendations are heard and interpreted with the intended context and meaning.