Cultural Competence in Health Care

The rapidly altering United States demographics have dramatically affected health care service provision. According to the U.S. 2000 Census, approximately 18% of the population over age 5 speaks a language other than English in the home. This number is projected to increase.

Consequently, speech-language pathologists and audiologists working in the health care setting must be prepared to provide services that are respectful of and responsive to cultural and linguistic needs of a diverse patient population.

For instance, health care disparities in racial and ethnic minorities in the United States can no longer be discounted or ignored. The Institute of Medicine (IOM) Report, Unequal Treatment, summarized a growing body of literature documenting racial or ethnic differences in health care outcomes for many different diagnoses including coronary artery disease, diabetes, cancer, and HIV. Health care providers have to overcome cultural and communication barriers that may negatively influence appropriate diagnosis and treatment, provide culturally competent health care, and create health care systems that provide equitable access to all clients/patients.

Expanding Government Resources

CLAS Standards

What is culture? According to the U.S. Department of Health and Human Services' Office of Minority Health (OMH) Culturally and Linguistically Appropriate Services (CLAS) standards, culture is defined as "the thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious or social groups." The OMH established a set of 14 national CLAS standards in health care that constitute mandates, guidelines, and recommendations intended to inform, guide, and facilitate required and recommended practices related to culturally and linguistically appropriate services.

The standards are divided into three sections-Culturally Competent Care, Language Access Services, and Organizational Supports for Cultural Competence. These standards define how health care information is received, how rights and protections are exercised, what is considered to be a health problem, how symptoms and concerns about the problem are expressed, who should provide treatment for the problem, and what type of treatment should be delivered.

Executive Order 13166

President Clinton's signing of Executive Order 13166 in August 2000 was a landmark event in attempting to "improve access to federally conducted and federally assisted programs and activities for persons, who, as a result of national origin, are limited in their English proficiency (LEP)." This order reminded agencies of Title VI of the Civil Rights Act of 1964, which guarantees that "no person in the United States shall, on the ground of race, color or national origin, be excluded from participation in, be denied benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance."

Expanding ASHA Resources

It is incumbent upon ASHA members, as lifelong learners, to become culturally competent-that is, to develop their skills when working with all clients/patients regardless of cultural and linguistic (CL) background.

An important example of an ASHA resource available to members is the document, "Knowledge and Skills Required by a Speech-Language Pathologist or Audiologist to Provide Culturally Competent Services." This document was developed by the Multicultural Issues Board and reminds us that every client, just as every clinician, has a culture. The development of competence begins with each of us, as individuals, and it proceeds along a continuum. Progress results from valuing differences, self-assessment, building cultural knowledge, and adapting practice to reflect the patient's CL background. An understanding of our own culture and values is essential in order to fully understand how those values may affect our interactions with clients and how we deliver services.

Generalizations of cultural characteristics, behaviors, and values may be accurate, however, only to a certain extent. They will never be wholly true of an individual. Within any culture, there is always a broad range of behaviors. Clinicians must be aware of patient-related factors that affect behavior. These factors include age, socioeconomic status, educational level, patterns of acculturation and assimilation, and the client's knowledge of health systems, conditions, and treatments.

Our goal should be to tailor our verbal and nonverbal interactions to the individual patient and family. This goal can be achieved only by being sensitive to the client's cultural and linguistic context. The clinician's desire to help and educate culturally and linguistically diverse clients with warmth and openness is not enough to ensure that they understand or accept our recommendations. The practice of speech-language pathology and audiology must include educating and counseling individuals and families regarding acceptance of, adaptation to, and decision making about assessment and treatment recommendations pertaining to communication, swallowing, or other upper aerodigestive concerns (see SLP Scope of Practice, 2001, and Audiology Scope of Practice, 2004).

Counseling, Assessment and Management of Individuals with Neurogenic Communication Disorders

Given the cultural and clinical heterogeneity of the United States, a one-size-fits-all approach is not effective. CL variables significantly influence clinical interactions, in turn affecting understanding and acceptance of treatment approaches and therapeutic outcomes.

Working with patients and families requires creating an environment of trust and mutual respect. Therefore, acquiring knowledge about non-verbal aspects of communication is essential and includes learning about parameters specific to individual cultures. For example, consider the personal distance one should sit or stand from somebody or the significance of body motions and gestures.

Gaining knowledge of salient cultural features also includes learning about social organization and communication styles. Does the culture have an individual or collectivist orientation? Is the focus on the nuclear or extended family? Is the communication style implicit or explicit?

Such information will assist the clinician in determining specific, culturally sensitive ways to conduct counseling sessions, cultural encounters in which the client and family are directly engaged and where the communication is aligned with the values and beliefs of the individuals without evidence of stereotyping. At times, the use of a trained professional interpreter, or cultural guide, will be necessary. The interpreter should be very familiar with the purposes and objectives of the session and the need for confidentiality and know the importance of a nonjudgmental attitude regarding the information exchange. Data gathering must include getting the insider's rather than the outsider's view. The use of ethnographic interview techniques is most effective in this process (see "Asking the Right Questions in the Right Ways" in The ASHA Leader Online, April 29, 2003). Ethnographic interviewing coupled with attentive listening will allow the clinician to discover values, skills, and knowledge embedded within the individual and the family.

Identifying cultural and linguistic variables, obtaining more information about them, and addressing them in assessment and management practices can enhance clinical service delivery. Some key CL variables are described below.

Time & Space Issues

Concepts of time and space vary across cultures. Concepts of space govern judgments of acceptable distance and/or forms of touch between communication partners.

Concepts of clock-time versus event-time orientation influence clients' timely arrival for scheduled appointments, their comfort with pre-specified duration of sessions, and their expectation to be accommodated if they miss or cancel a session. A clock-time orientation refers to an individual's strict adherence to time as the key factor deciding the starting and end point of an interaction. Persons from a cultural group with an event-time orientation tend to be more process-oriented so that the natural conclusion to a process drives the starting and end points of an interaction, rather than how long the process takes.

Extended Family Participation

The involvement of multiple family members in caregiving is almost always socially and emotionally beneficial for the client. However, family members may be advised if frequent family visits contribute to client fatigue during treatment or cause overstimulation. Fatigue and overstimulation are common in clients who have recently had a stroke or traumatic brain injury. When multiple family members are involved, it can be difficult to determine who is the "responsible party." That individual needs to be clearly identified and approached for making decisions regarding the client. This is because rules for disclosure of information to extended family members vary and can be seen as a breach of confidentiality, depending on the client's cultural background and the clinical diagnosis.

Verbal & Emotional Expression

Culture influences communication in complex ways. For example, it may not always be acceptable to address elders by their first name. Similarly, verbal assent may not imply agreement with clinician recommendations but simply discomfort with expressing disagreement. Often, clients/caregivers are conscious about their non-mainstream opinions and reluctant to state them. Cultures also vary in the value placed on expressing emotions. Consequently, some caregivers may appear unusually stoic because they may not openly express emotions to a clinician they do not know very well. Similarly, if a client is upset, it may not be typical for that person to reveal feelings or state displeasure.

Hierarchy of Perceived Status

In some Asian and Latino cultures, health care professionals are regarded more positively and are more highly respected than other professionals. This may result in clients' attaching great importance to a clinician's opinions, reactions, and behavior. This reverence may result in clients being less forthcoming if they disagree with a clinician. Other clients may consider the physician's role to be superior because clients are unfamiliar with the role of the SLP or audiologist.

Alternate Healing Systems

Cultures differ considerably in their views about health and illness, and may have strong beliefs in alternate healing systems such as acupuncture among Chinese-Americans, Ayurvedic medicine among Asian-Indians, and religious/spiritual ceremonies among Hmong and Native American individuals. These systems are not always evidence-based but are frequently critical for clients' satisfaction. Some third-party payers are responding to this; the Arizona VA partly reimburses Navajo veterans receiving treatment from medicine men.

Specific disorders/conditions and the health care system

Clients and caregivers from different cultures often do not fully understand Medicare or Individualized Education Plan (IEP) regulations, covered services, and financial obligations for services not covered by health plans. Clients with disabilities who have not always lived in the United States may be unaware of their rights under the Americans with Disabilities Act (ADA). For example, an Asian-Indian parent was pleasantly surprised to learn that she could recommend goals for inclusion on her child's IEP. Similarly, an Armenian-American woman was confused about a change in her husband's status from Medicare Part A to Part B coverage. Her husband had recently had a massive stroke and she could not understand why the amount of therapy services was being reduced when her husband had barely begun recovering. We should not assume clients' prior knowledge of clinical diagnoses/terms, concepts unique to rehabilitation, or of reimbursement for services.

Language Barriers for SLPs

Resources are available to members with a diverse clientele. Try these:

• Use ASHA brochures and information packets that are available in other languages. For example, the brochure "How Does Your Child Hear and Talk?" exists in Spanish and Chinese.
• Create a binder or cue cards with simple greetings and positive reinforcement phrases in commonly spoken languages treated at your facility (Hello, Yes/No, Stop, You look great!, Are you all right?, What would you like?, etc.)
• Create a simple 8.5" x 11" laminated communication board with large, clear pictures of things such as water, food, toilet seat, wheelchair, person sleeping, person in pain. This will enable individuals with language barriers, severe aphasia, or tracheotomy tubes to communicate basic needs.
• Develop a directory of interpreters with their contact information, as well as a list of bi/multilingual facility staff that may be able to assist with translation needs.

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Andrea Moxley, is ASHA's project manager in the Office of Multicultural Affairs. Contact her at amoxley@asha.org.
Nidhi Mahendra, is a certified SLP and a postdoctoral fellow in the department of speech and hearing sciences at the University of Arizona. Contact her at nidhi@email.arizona.edu.
Carmen Vega-Barachowitz, a native of Puerto Rico, is director of the speech-language pathology department at Massachusetts General Hospital in Boston. Contact her at cvegabarachowitz@partners.org.

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Definitions

• Culture: The thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.
• Cultural and linguistic competence: A set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations.
• Culturally and linguistically appropriate services: Health care services that are respectful of and responsive to cultural and linguistic needs.
• Interpreter: A person specially trained to translate oral or signed communications from one language to another.
• Translator: A person specially trained to translate written text from one language to another.
• (From National Standards for Culturally and Linguistically Appropriate Services in Health Care. (2001). Washington D.C.: U.S. Department of Health and Human Services, OPHS Office of Minority Health.)

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Strategies for Enhancing Cultural Sensitivity

General Strategies

Professionals can enhance their cultural sensitivity by:

• Becoming aware of differences in cultural attitudes toward health, disability, and illness. These differences affect attitudes toward augmentative and alternative communication devices, surgery, aggressive medication, feeding and tracheotomy tube placement, etc.
• Asking explicit questions and identifying clients' views about their problem, its cause, its appropriate treatment, and their expectations from the treatment process
• Establishing a collaborative relationship with clients' families
• Respecting a family's autonomy in decision-making
• Validating the client's or family's opinions as legitimate views of a situation-this helps to create an atmosphere of trust and mutual respect.

Specific Strategies

• Conduct in-service training using case study approaches to highlight the influence of CL variables on a particular client's functioning. In-service topics should routinely emphasize inter-cultural sensitivity and should be targeted not only to certified nursing assistants but also to other clinical and administrative staff.
• Become aware and make colleagues aware of resources and experts available through ASHA and state associations. ASHA has a registry of speakers and consultants on multicultural issues. Similarly, the California Speech-Language-Hearing Association has an online resource center that provides names and locations of bilingual SLPs.

References and Resources

American Speech-Language-Hearing Association. (2001). Scope of practice in speech-language pathology. Rockville, MD: Author.

Battle, D. E. (2002). Communication disorders in multicultural populations (3rd ed.). Woburn, MA: Butterworth-Heinemann.

California Speech-Language-Hearing Association. Online Resource Center. www.csha.org/resource.htm.

Chen, G. M., & Starosta, W. J. (1998). Foundations of intercultural communication. Boston: Allyn & Bacon.

Helman, C. G. (2000). Culture, health, and illness (4th ed.). Woburn, MA: Butterworth Heinemann.

Kleinman, A. (1988). The illness narratives. New York: Basic Books.

Smedley, B., Stith, A., & Nelson A. (2002). Unequal treatment: Confronting racial and ethnic disparities in health care. Report produced for the Institute of Medicine. Washington, DC: National Academy of Sciences.

U.S. Census Bureau. (2000). Language use, English ability and linguistic isolation for the population 5 years and over by state: 2000. www.census.gov/population/cen2000/phc-t20/tab01.pdf.