Explore Factors and Learn Strategies to
Provide Culturally and Linguistically
Appropriate Services in Rehabilitation
Kelly Nett Cordero, Ph.D., CCC-SLP
Karen P. Guerra, M.S., CCC-SLP
Thursday, October 9, 2014
Acknowledgements: Kathryn Kohnert, Ph.D., Marilyn Fairchild, M.A.,
Minnesota Speech-Language Hearing Association Multicultural Committee
Goals for Today

This presentation will provide an
overview of the factors for consideration
in the assessment and treatment of
culturally and linguistically diverse
patients/clients, including:
• cultural beliefs related to etiology of
disability
• cultural differences that impact clinical care
• linguistic differences which affect treatment
delivery
• use of interpreters
• designing an assessment session for a
patient/client from a different linguistic
background
Cultural Health Comments
The Japanese eat very little fat
and suffer fewer heart attacks than Americans.
The French eat a lot of fat
and suffer fewer heart attacks than Americans.
The Chinese drink very little red wine
and suffer fewer heart attacks than Americans.
The Italians drink a lot of red wine
and suffer fewer heart attacks than Americans.
CONCLUSIONS:
Eat and drink what you like.
It’s speaking English that kills you.
Today’s Agenda: Monitoring your
Cultural Responsiveness (Novations, 2008)
CHECK YOURSELF –
Perspectives, biases, assumptions,
judgments – Is there willingness to
leave comfort zone?
CHECK OTHERS –
Perspectives, thoughts, feelings,
expectations – Have you acknowledged
emotions? collected all opinions?
DOUBLE CHECK Are you supporting the missions, goals,
and values of your therapy practice? with
respect and appreciation?
Check Yourself
– Okay or Not?
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To shake hands with an individual of the other
gender?
To make direct eye contact during conversation?
To give a ‘thumb’s up’ or ‘A-okay’ sign?
Use a hand gesture to call someone over?
To ask a professional contact his/her age?
To ask a speaker to clarify information presented?
To not allow independence for daily activities that
could be completed the individual?
To not follow safety guidelines for feeding or other
daily activities?
Continuum of Cultural Competence adapted from
Cross, Bazron, Dennis & Isaacs (1989)
(Kohnert adaptation)
P
o
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t
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N
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g
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t
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Cultural Proficiency
Cultural Competence
Cultural Pre-Competence
Cultural Blindness
Cultural Incapacity
Cultural Destructiveness
(Minimal Level needed in healthcare)
Cultural Competence
“ A set of cultural behaviors and attitudes
integrated into the practice methods of a system,
agency, or its professionals, that enables them to
work effectively in cross cultural situations….
When professionals are culturally competent,
they establish positive helping relationships,
engage the client, and improve the quality of
services they provide. ” (p.9)
Achieving Cultural Competence
Administration on Aging, Dept of Health & Human Services
http://www.aoa.gov/prof/addiv/cultural/addiv_cult.asp
Cultural Competency:
Personal Reflection
American Speech-Language Hearing Association
(ASHA) tools:
American Speech-Language-Hearing Association. (2010). Cultural
Competence Checklist: Personal reflection. Available from
www.asha.org/uploadedFiles/practice/multicultural/personalreflections.pdf
___ I treat all of my clients with respect for their culture,
even though it may be different from my own.
___ I do not impose my beliefs and value systems onto my
clients, their family members or friends.
___ I accept my clients’ decisions as to the degree to which
they choose to acculturate into the dominant culture.
___ I recognize family members and other designees as
decision makers for services and support.
Cultural Competency: Service Delivery
American Speech-Language Hearing Association
(ASHA) tools:
American Speech-Language-Hearing Association. (2010). Cultural
Competence Checklist: Service delivery. Available from
www.asha.org/uploadedFiles/practice/multicultural/personalreflections.pdf
___ I consider the cultural/linguistic background of my
clients and their families when planning:
___ Appointments___ Community outings
___ Holiday celebrations___ Meals, snacks
___ I consider my clients’ beliefs in both traditional and
alternative medicines when prescribing a treatment
regiment.
___ I respect my clients’ decision to seek alternative
treatments from a holistic practitioner.
Check Others
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“Diversity” in perspective is dynamic
– not inherent to an individual
“Relational & Context-embedded”
(Barrera & Corso, 2002)
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When you been ‘mainstream’?
Diverse?
***Experience of Other***
Nett Cordero 2010
Cross Cultural
Considerations
To maximize patient care
Nett Cordero 2010
Cross Cultural Considerations
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Perceived etiology of disability
Role of the extended family and community
Access to and use of healthcare services
Other Cultural Factors
• Time Differences
• Role of Professional
• Role of Socialization
• Parenting/family values
http://yalepress.yale.edu/yupbooks/salud/saludthreeballs.gif
Perceived Causes of Clefting in
Spanish-Speakers (Meyerson, 1990)
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(Gorlin, 1983) asked mothers of children with clefts in
Mexico City about factors contributing to
formation of cleft
• 71% Paternal Alcoholism
• 63% Lunar eclipse during pregnancy
• 52% Punishment for sin
Use of metal keys/pins during
pregnancy and red pins/ribbons
in infancy
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• Higa de azabache o piedra roja
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‘Mal de Ojo’
(Castro, 1995; Diaz de Leon, 1996;
Maestas & Erickson, 1992;
Rodriguez & Olswang, 2003;
Salas-Provance et al, 2002)
Perceived Causes of Disability
& Folk Remedies
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Other perceived causes of
childhood illness/disability in
Mexican-Americans
• Susto (Fright)
• Mal aire (Bad Air)
• Imbalance of hot/cold
• God’s will, premonitions,
emotions
• Medical causes
Inverse relation between:
• acculturation & SES &
education
AND
• folk beliefs & remedies
(Diaz de Leon, 1996; Maestas &
Erickson, 1992; Rodriguez &
Olswang, 2003; Salas-Provance et
al, 2002)
Ear Candling
Cultural Considerations: Role of
community and extended family
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Easier acceptance of the diagnosis:
• Close-knit extended family support
• Notion of ‘God’s Will’ – or disability as a ‘gift’
• Terms like ‘malito’, ‘enfermito’
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More difficulty accepting the diagnosis:
• Belief that disability is a punishment for a
past sin
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Infanticide for cleft conditions reported as recently
as 20 years ago (Tarahumara Indians of the
Sierra Madre Mountains in Mexico)
• (Mull & Mull, 1987) in (Scheper-Hughes, 1990)
Cultural Considerations: Role of
community and extended family
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3rd graders in Yucatan, Mexico were more
accepting of a facial condition than one
involving a crutch, hand, or foot
In U.S., facial disorders were rated as less
acceptable than crutches, wheelchair, and
hand disabilities in a similar age
population
• (Sanchez & Harper, 1994)
http://www.kirklees.gov.uk/community/healthcare/childrenandfamilies/disabilityunit.shtml
Access to and Use of Medical Services
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Type of health services
• Western (biomedical)
• Non-western (folk)
• Folk medicine usage varies among Latino
groups and may often be blended with
western medicine (Meyerson, 1990).
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Role of community elders/leaders
Spiritual beliefs
Use of health services
• Decreased utilization – even when available
• Concerns regarding legal status, payments,
etc.
Cultural Factors:
Clinical Implications for Health Care
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Consider carefully the response to folk
beliefs, causes, and treatments
discussed by family
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Time schedule differences
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Role of socialization
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Professional as authority
Other Factors to Consider
(Scheffner Hammer, et al, 2004)
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Environmental Factors
• Immigration experience
• Level of Acculturation
• Educational level/experience
• Economic Resources
• Psychological Status
Family Structure
• Role of decision-making
• Expectations for marriage and
children
• Teaching vs. mothering
• Style of communicating with
children
Double Check
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Culturally Responsive attitudes:
• Openness, curiosity re: pt views, respect (even
if shown in different ways) increase likelihood
of success.
• Cultural humility increases likelihood of
success.
• Consider the power differential; avoid “topdown” communication
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(Culhane-Pera et al, 2003)
Nett Cordero 2010
Culturally Responsive Health Care
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Nonverbal communication
comprises up to 80% of a
message. (Carson, 1990)
Communication styles &
cultural responsiveness:
•
• Greetings
•
• Smiling and laughing
• Hand gestures
•
• Facial expressions
•
• Tone of Voice
•
• Touching
• Working with interpreters
Delivering bad news
Praising the beauty of a
child
Eye contact
Head Movements
Etc.
(Culhane-Pera, 2003)
Culturally Responsive Health Care,
continued
….(Culhane-Pera et al, 2003)
•
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What does the pt/fam think is wrong?
What does the pt/fam think caused the problem?
How has this affected the pt’s life?
What is the pt/fam afraid of?
What healing methods has the pt/fam tried?
What does pt/fam think will help?
Who usually makes decisions about the pt’s health
care?
• What concerns does pt/fam have about seeking help
from mainstream health care services?
• *What are pt/fam main expectations re: outcome of
this clinical encounter?
Anchored Understanding
Of Diversity
Acknowledge the range
& validity of diverse
perspectives.
Respect
Establish interactions that
allow equal voice for all
perspectives.
3rd Space
Staying with the tension
of differing perspectives.
Create opportunities
for equalizing power
across interactions.
Reciprocity
Communicate the
understanding that others’
perspectives have a positive
intent.
Responsiveness
Collaboratively craft
a response that integrates
& provides access to the
strength of diverse
perspectives.
SKILLED DIALOGUE
(Barrera & Corso, 2003)
(slide design Kohnert, 2007)
Interpreters &
Translators
Lost in Translation
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Chevy Nova
• Chevy ‘no va’
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Got Milk?
• ¿Tiene Leche?
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“Fly in leather”
• ‘Volar en cuero’
Interpretation and Translation
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Interpretation
• Service provided by an interpreter that
facilitates oral/manual communication
between two languages
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Simultaneous
Consecutive (Sequential)
Sight
Translation
• Service provided by a translator that is
similar to interpretation, but with written
text.
Key Traits for Interpreters
Working with Therapies
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Neutral, Impartial
• Not related to client
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Not biased against the client
• Ethnic, dialectal, racial issues exist within language
groups
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Professional, Trained
Able to maintain confidentiality, honest
Fluent in English and other language targeted
Available for follow-up appointments
Familiar with dialect and/or country of origin of
the client
* Successful interpretation involves the integration of two
verbal and non-verbal communication sets (Langdon,
2002).
Therapist Role: Gathering Cultural
Information
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CultureGrams:
• http://www.culturegrams.com
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Endless number of local websites…
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Cultural Informant (Mediator)
• Other members of community
• Designated professional
Therapist Role - Gathering
Linguistic Information: Websites
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Bilingual Mandarin-Chinese and English SLP
Resources:
• http://home.comcast.net/~bilingualslp/
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Spanish Pronunciation and Language:
• http://www.uiowa.edu/~acadtech/phonetics/a
bout.html
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White Hmong Language and Culture:
• http://www.tc.umn.edu/~kanx0004/
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Vietnamese Language and Culture:
• http://vnspeechtherapy.com/vi/CVT/index.htm
Nett Cordero 2010
Therapist Role - Gathering
Linguistic Information: Books
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Campbell, G. (1998). Concise Compendium of the
World’s Languages. New York: Routledge.
Goldstein, B. (2000). Cultural and Linguistic
Diversity Resource Guide for Speech-Language
Pathologists. San Diego: Singular.
Hua, Z. & Dodd, B. (Eds.) (2006). Phonological
Development and Disorders in Children: A
Multilingual Perspective. Clevedon, UK:
Multilingual Matters.
McLeod, S. (2007). International Guide to Speech
Acquisition. Clifton Park, NY: Thomson Delmar.
Translation of Test Instruments
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Translation of testing protocols must be
completed with caution!
• Difficulty of items may be altered by translation
• Differences in the hierarchy of skills difficulty
exist between languages
• Cultural differences may exist even if linguistic
adaptation is successful
• Use of normative information may not be
possible – unless the translated instrument is
standardized.
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What can be reported?
Interpreter Model - BID
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Briefing
• Meeting with interpreter before session.
Some areas that may be discussed include:
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Goals of session
Interpretation style
• Meeting vs. Evaluation
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Review of terminology to be used
Test procedures
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General or specific format of each test
Level of cuing appropriate
Repetition, rewording, gestural/eye gaze cues
reliability, validity
(Langdon and Cheng, 2002) and http://www.asha.org/about/leadershipprojects/multicultural/interpret.htm
Interpreter Model - BID
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Briefing - continued
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Establish rapport
Determine any signals that will be used between
therapist/interpreter to identify correct and
incorrect
Learn how to greet the family and say client’s
name in native language
Determine seating/working arrangements
You may choose to review the evaluation
materials with the interpreter for cultural/dialectal
appropriateness, but the final decision is yours.
(Langdon and Cheng, 2002) and http://www.asha.org/about/leadershipprojects/multicultural/interpret.htm
Interpreter Model - BID
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Interaction
• Actual meeting or appointment with the
interpreter and client. Steps to follow:
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Introduce yourself and the interpreter, in native
language of patient if possible
Explain the roles of each professional
Encourage interpreter to take notes and
interpret history forms if translation not
available
Use short sentences and avoid terminology and
idiomatic language that is not necessary
(Langdon and Cheng, 2002) and http://www.asha.org/about/leadershipprojects/multicultural/interpret.htm
Interpreter Model - BID
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Interaction - continued
• Leave enough pauses and have periodic checks
with interpreter on rate
• Look at the client when talking and if you speak
directly to them, ‘You’, not ‘she/he’
• Try not to alter meaning by making an explanation
too simple
• Be aware of gesture/nonverbal communication
that may be offensive to the family
• Provide native language written information for
literate families/patients
(Langdon and Cheng, 2002) and http://www.asha.org/about/leadershipprojects/multicultural/interpret.htm
Interpreter Model - BID
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Debriefing
• Meeting after the session to discuss the
results
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Get impressions on any of the child’s skills that
that can be judged by interpreter
Work on any scoring or interpretation that you
need native language assistance with
Discuss any follow-up appointments that are
needed and share contact information
(Langdon and Cheng, 2002) and http://www.asha.org/about/leadershipprojects/multicultural/interpret.htm
Moochas Gracias