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Our work experiences in Soweto and KwaZulu-Natal highlighted the effect of multilingualism on audiological practice. We trained as audiologists in apartheid South Africa during the 1980s when institutions followed the U.S. or British model of education and faculty were primarily White and spoke English or Afrikaans. Our training did not address issues of multiculturalism or multilingualism, and the importance of this omission was immediately evident when we accepted our first jobs at Baragwanath Hospital in 1989. Situated in Soweto, this hospital served mainly Black Africans and reflected the inequitable distribution of speech-language pathology and audiology services.
The current client-practitioner profile reveals that 80% of the population and less than 1% of qualified speech-language pathology and audiology professionals are indigenous, Black African first-language speakers. More importantly, South Africa has 11 official languages and the typical client we encountered knew at least three languages. In fact, most clients were circumstantial multilinguals with linguistically diverse backgrounds. Thus, our traditional training and audiological practice was not always effective, or valid.
The first resource available to us was interpreters. Although those individuals had assisted with delivering audiology services for many years, they were not formally trained or certified. Their greatest contribution was facilitating the clinical interaction, as the audiologists were all English speakers. Interpreters effectively conditioned young children in play audiometry but the audiologist worked alone with adults, using basic knowledge of the client’s language.
In aural rehabilitation sessions, interpreters were the primary communicators with clients, essentially translating the clinician’s English into the client’s language. Although the use of interpreters seems ideal, interpreter bias often led to the omission, rephrasing, or paraphrasing of information. Thus, audiologists were often uncertain about intervention accuracy. Unfortunately, using interpreters undermined the development of trust in the clinical relationship, as clients often seemed more comfortable with the interpreter because of their shared linguistic and cultural background. Current training in South Africa encourages audiologists to know at least one African language. For example, students at the University of Durban-Westville (UDW) are required to take a class in Zulu, the regional majority African language.
Another resource available at Baragwanath Hospital was rudimentary word lists for speech audiometry. Previous audiologists and interpreters compiled these lists in Zulu, Xhosa, and Sotho. Being trained in the use of English tests only, these language-specific word lists were very useful because our multilingual clients had difficulty with the traditional tests. Limited knowledge of English and unfamiliarity with the test items compromised their performance. English-speaking audiologists with very basic knowledge of the client’s language used these word lists via monitored live voice testing to evaluate SRT and suprathreshold word recognition ability.
Subjectively, these lists appeared to have greater validity than the English tests; however, no formal research information was available about their development, validity, or reliability. In addition, the lists did not meet the U.S. criteria for the development of speech audiometric materials. For example, an important limitation of the Zulu SRT word lists is that they are monosyllabic test items, whereas research shows that speech threshold is optimally evaluated with bisyllabic items. The paucity of research on African languages makes audiologists in South Africa dependent on English-based principles to guide their selection of test materials.
Communication Choices
Multilingualism and cultural background complicate the selection of a communication method. To facilitate an informed choice, however, all communication options are presented through a skilled interpreter (informally trained) in an intensive family counseling session. In South Africa, options include the aural-oral (AO) or bilingual-bicultural (BLBC) communication approaches, with total communication (TC) being phased out. Hearing loss is typically identified at a late age, after the child has already been exposed to one or more Black African languages.
A family opting for the AO approach makes the final decision on a first language, but they are guided by the dictates of the school system. The English medium of instruction has been adopted in most schools, even those described as historically black institutions.
For a family choosing the BLBC philosophy, options include sign language (similar to American Sign Language), English, and one other African language. However, there is seldom a choice of languages due to restrictions of the school system. All schools for the deaf in KwaZulu-Natal have adopted the BLBC philosophy where the second language adopted after sign language is English. Family objections necessitate relocation or foregoing formal education because only a small number of schools cater to the needs of children who are deaf. For children who are hard of hearing, mainstream schools offer services only at the elementary school level.
Amplification options include hearing aids and are discussed parallel to communication choices. Cochlear implants are not the norm in South Africa, due to high cost and lack of implant centers in KwaZulu-Natal. Bilingual interpreters are used extensively during the hearing aid evaluation to facilitate realistic expectations.
In aural rehabilitation sessions, bilingual or manual interpreters facilitate meeting goals appropriate to the communication choice. Early intervention (EI) using either parent guidance and/or family-centered intervention is often offered to families that choose either the AO or BLBC philosophy. When the child enters school at age 3, the focus shifts from EI to direct intervention by a school-based clinician. At UDW, students are trained to provide services within an ecological (naturalistic) philosophy viewing the child as a whole, including family, environment, and linguistic background.
—Ishara Ramkissoon and Farhana Khan
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