Cultural Competence in Professional Service Delivery

Introduction

In the 21st century, speech-language pathologists (SLPs) and audiologists in the United States are serving an increasingly culturally and linguistically diverse (CLD) population. The World Health Organization (WHO) has recognized in its International Classification of Functioning, Disability and Health (ICF; WHO, 2001) that the ability of individuals with impairments in body structure and function to participate in life activities is influenced by environmental factors that include aspects of culture, language, race, and ethnicity. Professionals need to understand and appreciate the influence of these factors if they are to provide appropriate evidence-based assessments and interventions—and this requires that professionals become culturally competent. ASHA has been proactive in developing policy documents for serving diverse populations, such as Knowledge and Skills Needed by Speech-Language Pathologists and Audiologists to Provide Culturally and Linguistically Appropriate Services (ASHA, 2004) and Cultural Competence, an Issues in Ethics statement (ASHA, 2005). Increasing research on multilingual language learning, educational and health disparities in diverse populations, and cultural influences on learning and health care beliefs has necessitated an updated approach to provision of services that is responsive to cultural and linguistic diversity. This document describes the changing demographic trends, cultural competence and cultural dimensions, and influences of culture on communication development and disabilities.

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Definition of the Topic

SLPs and audiologists assess individuals to determine the presence of a hearing, speech, language, or swallowing disorder, and provide treatment services to individuals with these disorders. The key to assessment and treatment services is to consider the individual. Individuals served come from diverse cultural and linguistic communities. Culture refers to the integrated pattern of learned behavior, including thoughts, communications, knowledge, beliefs, and values of a group, that is passed from one generation to the next (Salzmann, 2007). Cultural variables can include age, ability, race, ethnicity, experience, gender, gender identity, sexual orientation, linguistic background, national origin, religion, and socioeconomic status. These differences in culture and language play an integral part in the provision of services. It is the ethical duty of all SLPs and audiologists to provide services with careful and respectful consideration and incorporation of the cultural and linguistic variables that have an impact on service delivery and efficacy. To achieve high-quality service delivery for all individuals, SLPs and audiologists must be culturally competent. In addition, as members, they have a responsibility to work toward achieving cultural competency (ASHA, 2004) by engaging in ongoing learning throughout their careers. There are several key points that must be considered in any discussion of culture. The first is that everyone has a culture. This is not a term reserved for individuals from specific racial/ethnic groups. Every individual has a unique set of values, beliefs, and perspectives that have been shaped by life experiences and by interactions with people. The second key point is that culture is as dynamic as people are. Cultural norms are not stagnant, but instead change over time. For example, in the United States, it was once the norm to institutionalize individuals who were disabled. With changes in the perception of disabilities, this is no longer common practice. Not only has the perception of individuals with disabilities changed, but the value that Americans place on equal rights for everyone has changed over time. The dynamic nature of people will also influence an individual's level of assimilation and acculturation. Acculturation, or the process by which one group assimilates or adopts the cultural values and behaviors of another group, must be considered during clinical interactions. That is, individuals should not be stereotyped or categorized based on characteristics of a specific ethnic group. Although an individual may look and act like others from a specific group; he or she may have adopted some values and behaviors of other groups that have influenced his or her level of assimilation and acculturation. This leads to the third important consideration, the idea of implicit versus explicit behaviors. Battle (2002) described explicit cultural variables as those discernible on the surface, such as clothing, external symbols, food, and language. Implicit variables, on the other hand, are internal; they include “age and gender roles within families, child-rearing practices, religious and spiritual beliefs, educational values, fears and attitudes” (Battle, 2002, p. 5). All of these important factors are outlined to emphasize that culture is not just a set of categories, but is a dynamic element inherent in everyone.

The reasons for advocating for SLPs and audiologists to be culturally competent parallel those identified by the National Center for Cultural Competence (Goode & Dunne, 2003):

• to respond to current projected demographic changes in the United States

• to eliminate long-standing disparities in the health status of people of diverse racial, ethnic, and cultural backgrounds

• to improve the quality of services and health outcomes

• to meet legislative, regulatory, and accreditation mandates

• to gain a competitive edge in the marketplace

• to decrease the likelihood of liability/malpractice claims.

Cultural competence has been described as a continuum of attitudes and behaviors relative to cultural and linguistic differences. It is a developmental process that evolves over an extended period of time. Cross, Bazron, Dennis, and Isaacs (1989) developed a model of cultural competence that describes six stages along the continuum: cultural destructiveness, cultural incapacity, cultural blindness, cultural pre-competence, cultural competency, and cultural proficiency. Individuals and organizations are at various levels of awareness, knowledge, and skills along the cultural competence continuum. The journey to becoming culturally proficient involves movement along this continuum, which requires ongoing self-assessment and continuous expansion of cultural knowledge refined through cross-cultural encounters. The pre-competence level is equivalent to an awareness stage in which clinicians are aware of perceptions, values, and other elements of their own cultures and those of cultures different from their own. Self-awareness is the starting point of the journey toward cultural proficiency. Assessing one's own cultural influences as well as learning about other cultures is key to enhancing cross-cultural communication. The competence level is equivalent to an application level, in which clinicians effectively use their cultural knowledge during interviewing, assessment, and treatment. The proficiency level is equivalent to an advocacy stage, in which clinicians champion culturally competent practice by training others in cultural competence, recruiting personnel from diverse cultures, and conducting research that adds to the knowledge base of communication disorders and differences in diverse populations. It is imperative that ASHA members continually and critically assess their own levels of competence and strive to attain cultural proficiency through continuing education.

This lifelong and critical self-assessment, admission of limits, and acquisition of knowledge have been referred to as “cultural humility” (Tervalon & Murray-Garcia, 1998). Cultural humility requires an attitudinal shift in which SLPs or audiologists acknowledge what they do not know and seek to gain knowledge of and experience with the relevant languages and cultures of the individuals they serve. Additionally, it is imperative that SLPs and audiologists recognize the cultural and linguistic variables that affect service delivery while continuing to individualize assessment and treatment strategies. This individualization ensures that the SLP or audiologist does not overgeneralize regarding a person's culture or language differences. Some individuals choose to maintain their native culture and language, while others choose to assimilate to the mainstream culture (Cheng, 1996; Davis-McFarland, 2008; Kayser, 1996). This acculturation process will be different for every person and may change depending on surrounding people, setting (e.g., work, home, church), and other variables. An individual's level of acculturation may have a significant impact on the identification, assessment, treatment, and management of communication disorders and differences.

Cultural competence requires values, attributes, knowledge, and a skill set to work effectively cross-culturally (National Center for Cultural Competence, 2004). A number of organizations have adopted and implemented the foundations of cultural competence. The Office of Minority Health has expanded the concept of cultural competence to include access to interpreter services in health care settings, consideration of individual health and illness experiences, and the rights to respectful and nondiscriminatory care. They have also developed 14 comprehensive standards on culturally and linguistically appropriate services (CLAS) in health care (U.S. Department of Health and Human Services, 2001). The American Academy of Pediatrics (2004) uses the term culturally effective care to incorporate the outcomes of the physician–patient or physician–family interaction. A culturally competent system of care acknowledges and incorporates, at all levels, the importance of culture, the assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, the expansion of cultural knowledge, and the adaptation of services to meet culturally unique needs. All of these recent steps toward providing culturally competent care stem from the seminal work conducted by Cross, Bazron, Dennis, and Isaacs (1989), who proposed that elements essential to improving an organization's cultural competence included valuing diversity, conducting self-assessments, being aware of the dynamics of cultural interactions, integrating cultural knowledge within organizational systems, and adapting to the communities it serves.

The compelling need for cultural competence emerges from current and projected growth in the cultural and linguistic diversity of the U.S. population and the increased demand for accountability. In 2010, the U.S. Census Bureau reported that, of the 308.7 million people residing in the United States, an estimated 111.9 million (36%) identified themselves as members of a racial or ethnic group other than “non-Hispanic, White” (Humes, Jones, & Ramirez, 2011). The 2009 American Community Survey reported that 38.5 million, or 12.5% of the total population at that time, foreign-born residents live in the United States (Grieco & Trevelyan, 2010). Data from the 2007 American Community Survey indicated that 20% of people aged 5 and older (55.4 million of the population at that time) reported speaking a language other than English at home (Shin & Kominski, 2010). School caseloads reflect the growing diversity among students. The U.S. Department of Education (ED) reported that, for the 2008–2009 academic year, an estimated 5,346,673 English language learners (ELLs; also referred to as limited English proficient in federal legislation) were enrolled in public schools, representing nearly 11% of the total enrollment in pre-K through grade 12 (U.S. Department of Education, 2011). The Data Accountability Center, set up by the Department of Education, reported that in 2007, of the 6,007,832 students ages 6 through 21 served under the Individuals with Disabilities Education Improvement Act of 2004 (IDEA 2004), approximately 19% had a speech or language impairment and 1.2% had a hearing impairment. Statistics indicated that, of the students receiving services for a speech/language impairment, 15.21% were Black (not Hispanic), 19.44% were Hispanic, 3.2% were Asian/Pacific Islander, and 1.3% were American Indian/Alaska Natives (U.S. ED, 2007). The same source reported that students with a primary disability defined as having a hearing impairment who received special education services included 16.02% Black (not Hispanic), 24.17% Hispanic, 5.32% Asian/Pacific Islander, and 1.2% American Indian/Alaska Natives.

Demographers predict significant growth in non-white and Hispanic populations over the next 25 years (U.S. Census Bureau, 2008). The changing U.S. demographics validate the likelihood that current and future speech and hearing professionals will have a more diverse client population. Given this outlook, it is clear that improving cultural competence will require a career-long commitment to education on this topic.

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Health Care Disparities

To enhance the quantity and quality of service to all individuals, SLPs and audiologists must be cognizant of current health care disparities. A report by a committee of the Institute of Medicine in 2002 reviewed over 100 studies that assessed the quality of health care and described disparities among various racial and ethnic groups. A review of the literature found that variability by race existed for those receiving medical procedures, even with analogous factors such as income, insurance, age, and severity levels. The review also reported that individuals from specific racial and ethnic groups were less likely to be given routine medical procedures and overall were provided lower quality of health services. The report prompted the Institute of Medicine committee to recommend that awareness of this issue must significantly increase in order to address it. The committee also called for use of evidence-based practice (EBP) to guide service delivery and make it more equitable for all individuals, increased recruitment of health care providers from historically underrepresented racial/ethnic groups who might be more likely to provide services in communities of targeted racial/ethnic groups and medically underserved communities, and increased use of interpreters to provide improved quality of care for individuals whose native language is not English. Recently, the Institute of Medicine has expanded this scope and prioritized addressing the issue of health care disparities in various racial/ethnic groups; individuals from low socioeconomic status; and the lesbian, gay, bisexual, transgendered population (Institute of Medicine, 2010).

In 2010, the Joint Commission on Accreditation of Healthcare Organizations developed a new set of standards for patient-centered communication that are supported in the publication Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care: A Roadmap for Hospitals (The Joint Commission, 2010). The Joint Commission has stated that these are “important components of safe, quality care” (p. 4). The new standards, effective January 1, 2011, are accompanied by guidelines on how to comply with the mandates. The Roadmap for Hospitals offers guidance on establishing qualifications for language interpreters; identifying the patient's oral and written communication needs; providing language interpreting and translation services; respecting cultural, spiritual, and religious beliefs as they relate to health care needs; and accommodating the needs of patients with disabilities. These types of policy changes have the potential to lessen existing health care disparities and significantly affect the way SLPs and audiologists provide services.

Best EBPs will provide the foundation for meeting the needs of persons with speech, language, hearing, balance, and swallowing impairments. Appropriate clinical application of research data on the implementation of EBP procedures requires that professionals use such findings in combination with culturally sensitive approaches. This strategy ultimately yields the most effective assessment and intervention services to meet the needs of all individuals. The integration of EBP with cultural competence enables professionals to address the components of the WHO's ICF, thereby decreasing the negative impact of environmental factors that lead to poor performance and promoting environmental factors that enhance an individual's ability to participate as part of a family and a community.

Health care disparities for racial and ethnic populations result in delayed identification of and intervention for communication disorders. This is a critical issue for populations that have a higher incidence of speech, language, and hearing disorders. Native American and Alaskan Native infants, for example, have higher rates of otitis media and associated outpatient and hospitalization visits than do children in the general U.S. population (Curns et al., 2002). Alaskan Eskimo, African American, and Hispanic children have disproportionately higher rates of prematurity and meningitis. African American children also have higher rates of cytomegalovirus and lead poisoning (Scott, 2002; Van Naarden & Decoufle, 1999).

According to the 2007–2008 Gallaudet Research Institute's national demographic survey of deaf and hard of hearing youth, half (50.7% of the 36,710) were from historically underrepresented racial or ethnic minority groups.

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Legal and Regulatory Issues

SLPs and audiologists must be knowledgeable of federal and state laws that have an impact on service delivery. Title VI of the 1964 Civil Rights Act prohibits discrimination in any federally funded program on the basis of race, color, or national origin. This includes any public or private facility such as a hospital, clinic, nursing home, public school, university, or Head Start program that receives federal financial assistance such as grants, training, use of equipment, and other assistance. In 2000, Executive Order 13166, “Improving Access to Services for Individuals with Limited English Proficiency,” was issued requiring all federal agencies to establish a plan to ensure that federally funded programs and activities are equally accessible by limited English proficient individuals and to ensure meaningful access to their programs and activities.

The U.S. educational system also has taken specific measures to ensure equal access to services. The Equal Educational Opportunities Act of 1974 ensures the rights of all students, regardless of race, color, or national origin, to educational services, including a provision that requires school districts to take appropriate action to overcome language barriers that impede equal participation in educational programs. IDEA 2004, Part B, supports nondiscriminatory service delivery by establishing the following:

• Assessment and other evaluation materials should not be racially or culturally discriminatory.

• Assessment and other evaluation materials are to be provided in the child's native language or other mode of communication and in the form most likely to yield accurate information on what the child knows and can do academically, developmentally, and functionally, unless it is clearly not feasible to do so.

• A child must not be determined to be a child with a disability if the determinant factor is lack of appropriate instruction in reading or math, or limited English proficiency.

• When an individualized education program (IEP) is developed for a child with limited English proficiency, the language needs of the child as they relate to the IEP must be considered.

Additionally, the 2006 IDEA regulations made significant steps toward addressing problems with inappropriate identification and disproportionate representation by race and ethnicity of children with disabilities. A provision was added requiring states to review ethnicity data in addition to race data to determine the presence of disproportionality (§300.646). Disproportionality refers to the overrepresentation or underrepresentation of a particular demographic group in special education programs relative to the number in the overall student population (National Association for Bilingual Education, 2002). In the event that significant disproportionality is determined, not only will the state be required to review and revise policies, procedures, and practices, but also the local education agency (LEA) will be required to reserve the maximum amount of funds under §613(f) of the statute to provide early intervening services to children in the LEA, “particularly, but not exclusively” to those in groups that were significantly overidentified. These regulations clearly define steps that states must take to address the problem of disproportionality in special education.

Another important law is the No Child Left Behind (NCLB) Act of 2001. Title III of NCLB was established to ensure that ELL students (referred to as limited English proficient in NCLB legislation) attain English language proficiency, attain high levels of academic achievement in English, and meet the same state academic content and academic achievement standards that all children are expected to meet. Under NCLB, schools must show adequate yearly progress (AYP) in ensuring that all students achieve academic proficiency in order to close the achievement gap. In October 2008, the Department of Education released final interpretations of Title III that clarified that no ELL student, even those recently arrived or those with disabilities, is exempt from annual English language proficiency assessments. The only exemption is for an ELL student who has attended school in the United States for less than 12 months; in this case, he or she may be exempt from one administration of a state's content assessment in reading/language arts. Although no other exemptions are allowed, the final regulations noted that, for those ELL students with a disability, the school must provide appropriate accommodations.

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Culture and Communication

Communication is embedded in culture; therefore, communication by a group cannot be understood without a thorough understanding of the cultural factors that affect this communication. These factors are linked to the historical, geographic, social, and political history that unites the group and provides its commonality (Battle, 2002). The process of becoming culturally competent is complex and dynamic. It involves the exploration of the unique and complex dimensions that each individual brings to the clinical interaction. Understanding sociocultural factors is essential. Communication is more than just the words we speak or the manual codes we use; it also encompasses the less recognized aspects of culture that are evident in our communication. These include eye behavior; facial expressions; body language; rules of social interaction; child-rearing practices; perceptions of mental health, health, illness, and disability; and patterns of superior and subordinate roles in relation to status by age, gender, and class. Sociocultural factors significantly influence communicative interactions (Curenton, & Justice, 2004; Inglebret, Jones, & Pavel, 2008). SLPs and audiologists must consider the impact of this knowledge on service delivery.

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Cultural Dimensions

Cultures vary along a number of dimensions. Several taxonomies have been proposed to explain the variations that exist in cultural values, beliefs, and behaviors dating back to research conducted by Hall in the 1970s and confirmed by more recent research from Hofstede and Hofstede in 2005. The dimensions identified are globally applicable and are reflected in all aspects of life including family life, child-rearing practices, education, employment, and health care practices. The broadest and most encompassing dimensions of cultural variability that have been identified are individualism–collectivism, power distance, masculinity–femininity, uncertainty avoidance, and long-term orientation (see the Appendix for additional information).

The individualism–collectivism dimension focuses on the value of individual rights and achievements. A culture with a high individualism rating elevates the individual as opposed to the group; in contrast, a culture with a high collectivist rating values the group over the individual. This dimension has a significant impact on the way children behave because the basic elements of human culture are first learned in the family setting. The individualism–collectivism dimension also influences the way cultures view disability. A survey of Australian health care workers showed different reactions to becoming disabled among various immigrant communities (Hofstede & Hofstede, 2005). In the individualist communities (Anglo and German in this case), persons with disabilities tended to remain optimistic and cheerful, resenting dependency and being helped, and planning for a future life that was as normal as possible. Families treated the children with disabilities as much as possible like other children. In the collectivist communities (Greek, Chinese, Indian, Arab), the experience was more an expression of grief, shame, and pessimism. The disability was seen as a shame on the family and a stigma on its members and, consequently, the child would more often be kept out of sight.

The individualism–collectivism dimension is isomorphic with a dimension influencing communication style (Gundykunst & Ting-Toomey, 1988; Ting-Toomey, 1997). Individualist cultures tend to use a low-context communication style and collectivist cultures tend to use a high-context communication style. A high-context communication style or message tends to be “vague, indirect, and implicit, whereas … a low-context (communication style) tends to be direct and explicit” (Samovar, Porter, & McDaniel, 2010, p. 217). Unawareness of these cultural differences may lead to miscommunication and mistrust. Although no culture exists exclusively at either end of the low–high context continuum, the culture of the United States is placed toward the lower end, slightly above the German, Scandinavian, and Swiss cultures. Most Asian and Native American cultures fall toward the high-context end of the continuum; African American and Mexican American cultures would lean more toward the high-context end. The level of context influences all other aspects of communication. The U.S. educational system is essentially a low-context, individualist culture. Students must be able to produce extended texts that will be comprehensible to an unknown audience without support from others; many recent immigrants are from collectivist, high-context cultures.

Hofstede and Hofstede (2005) identified another set of cultural dimensions from a study of a multinational corporation (IBM) in 53 countries (Hofstede, 1980). The power distance dimension refers to how a society views the equality or lack thereof among its members. For example, in a high power distance society, children are expected to be obedient toward their parents. Independent behavior on the part of a child is not encouraged. Respect for parents and other elders is seen as a basic virtue. Young children are looked after and are not expected to experiment for themselves. In a low power distance society, children are more or less treated as equals. The goal of child socialization is to encourage children to take control of their own affairs as soon as they can. Active experimentation is encouraged. The masculinity and femininity dimension demonstrates the extent to which a society adheres to a male dominated model. A society is called masculine when emotional gender rules are distinct: men are expected to be assertive, tough, and focused on material success, whereas women are expected to be modest, tender, and concerned with the quality of life. A society is called feminine when emotional gender roles overlap: both men and women are expected to be modest, tender, and concerned with the quality of life. In feminine cultures, people, quality of life, nurturance, and equal sex roles prevail. In masculine cultures, students try to make themselves visible in class and compete openly with each other; it is important to be the best in the class. In feminine cultures assertive behavior and attempts at excelling are frowned upon; excellence is not something one displays.

The uncertainty avoidance dimension encompasses the degree to which a culture tolerates ambiguity or lack of specificity. Cultures high in uncertainty avoidance have a greater need for rules and predictability. Students in high-uncertainty cultures favor structured learning situations with precise objectives, detailed assignments, and strict timetables. Teachers are expected to be the experts. In contrast, individuals in low-uncertainty avoidance cultures are more tolerant of opinions different from what is expected. These students prefer open-ended learning situations with vague objectives, broad assignments, and no timetables. They accept a teacher who says “I don't know” and when parents are called in, they are expected to be active participants in their child's learning process.

The long- versus short-term orientation refers to whether a society exhibits a pragmatic future-oriented perspective or a conventional historic point of view. A long-term orientation fosters virtues oriented toward future rewards, in particular, perseverance and thrift. A short-term orientation fosters virtues related to the past and present—in particular, respect for tradition, preservation of “face,” and fulfilling social obligations (Hofstede & Hofstede, 2005).

The U.S. educational system leans toward an individualistic, low power distance, low uncertainty avoidance, masculine orientation, and long-term orientation. An SLP or audiologist whose cultural beliefs are consistent with independence and active experimentation may face conflicts with families whose cultural beliefs support dependence and compliance if there is a lack of awareness of these cultural differences (Kalyanpur & Harry, 1999). Professionals educated in U.S. schools with the aforementioned orientation typically value a low power distance, and attempt to treat students, clients, and families as equals, encouraging them to participate in the development of therapeutic goals and objectives. Persons from high power distance cultures may question the competence of a professional who attempts to include them in the development of the interventions (Hwa-Froelich & Westby, 2003). Kalyanpur and Harry (1999) reported that children with disabilities from culturally diverse backgrounds were typically referred to special education programs by mainstream staff who viewed special services as a right of children living in a literate, highly technological society that values independent functioning. Many of these children, however, came from nonliterate, nontechnological backgrounds where the children were socialized to be dependent on their families and communities for all of their needs. Thus, children were displaced, were denied services, or received services that were not valued or wanted by the family because of these misunderstandings and lack of cultural knowledge.

These cultural dimensions influence verbal and nonverbal behaviors in communicative interactions (Pedersen & Ivey, 1993), affecting how individuals convey trust or distrust and what they interpret as friendly, unfriendly, interested, or bored behaviors. For example, friendliness is conveyed by polite listening in a high power distance culture, by formal and specific language in a strong uncertainty avoidance culture, by verbal disclosure of information in an individualistic culture, and by loud talk in a highly masculine culture. Failure to recognize these variations in interactions can result in crucial miscommunications.

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Research Findings on Culture and Communication

The values reflected by these cultural dimensions guide the child-rearing practices of societies. Child-rearing practices influence how children learn language, what they learn, and when they learn it (Crago, 1992; Hwa-Froelich & Vigil, 2004; Rogoff, 2003; Schieffelin & Ochs, 1986; Shatz, 1991). Knowledge of the nature of cultural variations can give SLPs and audiologists insight into the behaviors and traits clients and families value, thereby facilitating cross-cultural interaction and minimizing opportunities for miscommunication and misunderstanding.

Child-rearing styles in individualist cultures value and support autonomy, emotional independence, and individual initiative. Collectivist child-rearing styles value system supports, group identity, emotional dependence, and group solidarity. Parents using an individualistic parenting style tend to follow a child's lead, whereas parents using a collectivist style stress directing a child's attention to teach the correct way to do something. When caregivers follow a child's lead, they label what a child is attending to and hence emphasize noun learning (Fernald & Morikawa, 1993); in contrast, caregivers using a collectivist style tend to direct and manipulate the child's activities, and hence use more verbs than nouns (Choi & Gopnik, 1995; Vigil & Westby, 2004). For clinical purposes this is important when assessing a child and determining the goals for language intervention, especially with ELLs or multilingual children.

The power distance dimension also influences the nature of parent–child interactions (Johnston & Wong, 2002). Johnston and Wong noted this in a study that contrasted the child-rearing beliefs and verbal interaction practices of Chinese and Western mothers of preschoolers. Their survey results showed that parent–child interaction patterns reflect cultural belief systems. The Chinese mothers were much less likely to report that they often prompt their young child for personal narratives, talk with the child about unshared events of the day, or allow the child to converse with adults who are not family members. Such activities would potentially treat the child as an equal conversational partner and hence reflect an expectation for independence and early verbal competence. This type of verbal interaction would contrast with traditional Chinese parents' value of social interdependence (Johnston & Wong, 2002).

A study comparing Mexican-American and Anglo-American mothers' beliefs and values about child rearing, education, and language impairment (Rodriguez & Olswang, 2003) also revealed the influences of the individualist/collectivist and power distance dimensions. In this study, Mexican-American mothers placed a higher value on conformity, whereas the Anglo-American mothers placed a higher value on self-direction. Reflecting a belief in a power distance between teachers and parents, Mexican-American mothers believed that the school had the main responsibility for educating children and parents should not question the teacher's educational methods.

Conflict can occur between the cultural values of the family and those of the educational system (Hwa-Froelich & Westby, 2003; Kalyanpur & Harry, 1999; Lamorey, 2002). The goal of special education is to increase children's abilities to function as independently as possible by acknowledging individual differences and promoting individual strengths. This philosophy may clash with the cultural values and beliefs of the families enrolled in special education programs. For example, in a study conducted by Hwa-Froelich and Westby (2003), it was reported that Head Start programs tend to use developmentally based practices with individualized child-directed activities. However, Southeast Asian parents' goals for their children who attended a Head Start program were not oriented toward developing independence and self-esteem. A primary goal for the parents was that their children develop obedience and respect. As children developed more independent behaviors in preschool, parents reported greater difficulties in disciplining them. Furthermore, like the Mexican-American mothers in the Rodriguez and Olswang (2003) study, the Vietnamese parents expected teachers to be authorities and to have the right and authority to make decisions regarding children's formal education (Hwa-Froelich & Westby, 2003).

Bagli (2002) reminds us that conflicts between the cultural values of the family and those of the SLP or audiologist are also present in the Deaf community. The Deaf community is a microcosm of the larger hearing community in which it resides, representing different cultures, ages, and genders. Culture may affect the way a family accepts a diagnosis, copes with the emotional impact of having a deaf child, interacts with the professional, implements treatment, allows clinicians to participate with the family in early intervention, and tolerates what may be perceived as intrusion from the clinician.

Huer and Saenz (2003) described the effect of culture on the knowledge and perceptions of health care and speech-language pathology services. Immigrant populations may have limited access to speech and language services in their native countries prior to immigration. Specific communities may also have their own traditional ways of caring for individuals with disabilities (Bebout & Arthur, 1992; Erickson, Devlieger, & Sung, 1999; Maestas & Erickson, 1992; Rodriguez & Olswang, 2003; Salas-Provance, Erickson, & Reed, 2002). When families hold such beliefs, they may be unlikely to seek or access educational, medical or other health care services provided in the United States.

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Summary

The abundance of diversity initiatives by institutions, organizations, and governmental agencies signals an increasing awareness of our current reality and highlights the importance of becoming culturally competent. Empathetic listening is a valuable attribute of the professional that facilitates communicative interaction, but continued development of cultural competence will foster an effective cross-cultural exchange. In the policy document Knowledge and Skills Needed by Speech-Language Pathologists and Audiologists to Provide Culturally and Linguistically Appropriate Services (ASHA, 2004), ASHA specifies the knowledge and skills needed by SLPs and audiologists if they are to be culturally competent. For SLPs and audiologists to provide appropriate services, they must be able to communicate effectively with the persons they serve. The adverse effects of cross-cultural miscommunication and cultural differences are well documented in the literature. Unexplored or misunderstood sociocultural differences between patients and physicians can lead to patient dissatisfaction, poor adherence to treatment, and poor health outcomes (Weissman et al., 2005). If SLPs and audiologists are to minimize miscommunication, they must gather information about other cultures. This can be done by (a) learning through books, the arts, and technology; (b) talking and working with individuals who can act as cultural guides and mediators; (c) participating in the daily life of another culture; and (d) learning the language of another culture (Lynch & Hanson, 2004). Having knowledge about cultural variations in values, beliefs, and child rearing practices can also promote better cross-cultural communication. While the ultimate goal is to increase one's cultural competence and achieve cultural proficiency, it should be recognized that this is a career-long journey that requires continuous education and self-evaluation.

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Research Directions

The continued transformation of U.S. demographics stresses the need to develop sound evidence-based practices in the field of speech-language pathology and audiology that address service delivery to diverse populations. While research has progressed in the past 10 years, there is a great need for continued investigation in this area. Future research should focus on topics such as efficacious assessment and treatment strategies as well as the effectiveness of culturally competent care in the field of speech-language pathology and audiology. There also continues to be a need for the collection of normative data of speech and language development in culturally and linguistically diverse populations. Research must rapidly expand in this area to find evidence that supports best practice that is culturally and linguistically appropriate.

Appendix A — Cultural Dimensions

Table 1.