Culturally and Linguistically Appropriate Services in Rehabilitation

1. 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

2. 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

3. Cultural Health Comments The Japanese eat very little fatand suffer fewer heart attacks than Americans.The French eat a lot of fatand suffer fewer heart attacks than Americans.The Chinese drink very little red wineand suffer fewer heart attacks than Americans.The Italians drink a lot of red wineand suffer fewer heart attacks than Americans.

4. CONCLUSIONS: Eat and drink what you like. It’s speaking English that kills you.

5. 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?

6. Check Yourself – Okay or Not? 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?

7. Continuum of Cultural Competence adapted from Cross, Bazron, Dennis & Isaacs (1989) (Kohnert adaptation) Positive Negative Cultural Proficiency Cultural Competence Cultural Pre-Competence Cultural Blindness Cultural Incapacity Cultural Destructiveness (Minimal Level needed in healthcare)

8. Cultural Competence Achieving Cultural CompetenceAdministration on Aging, Dept of Health & Human Services “ 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) http://www.aoa.gov/prof/addiv/cultural/addiv_cult.asp

9. 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.

10. 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.

11. Check Others “Diversity” in perspective is dynamic – not inherent to an individual “Relational & Context-embedded” (Barrera & Corso, 2002) When you been ‘mainstream’? Diverse? ***Experience of Other*** Nett Cordero 2010

12. Cross Cultural Considerations To maximize patient care Nett Cordero 2010

13. Cross Cultural Considerations http://yalepress.yale.edu/yupbooks/salud/saludthreeballs.gif • 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

14. Perceived Causes of Clefting in Spanish-Speakers (Meyerson, 1990) • (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 • Higa de azabache o piedra roja • ‘Mal de Ojo’ (Castro, 1995; Diaz de Leon, 1996; Maestas & Erickson, 1992; Rodriguez & Olswang, 2003; Salas-Provance et al, 2002)

15. Perceived Causes of Disability & Folk Remedies • 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

16. Cultural Considerations: Role of community and extended family • Easier acceptance of the diagnosis: • Close-knit extended family support • Notion of ‘God’s Will’ – or disability as a ‘gift’ • Terms like ‘malito’, ‘enfermito’ • More difficulty accepting the diagnosis: • Belief that disability is a punishment for a past sin • 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)

17. Cultural Considerations: Role of community and extended family http://www.kirklees.gov.uk/community/health-care/childrenandfamilies/disabilityunit.shtml • 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)

18. Access to and Use of Medical Services • 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). • Role of community elders/leaders • Spiritual beliefs • Use of health services • Decreased utilization – even when available • Concerns regarding legal status, payments, etc.

19. Cultural Factors: Clinical Implications for Health Care • Consider carefully the response to folk beliefs, causes, and treatments discussed by family • Time schedule differences • Role of socialization • Professional as authority

20. Other Factors to Consider (Scheffner Hammer, et al, 2004) • 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

21. Double Check • 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 “top-down” communication • (Culhane-Pera et al, 2003) Nett Cordero 2010

22. Culturally Responsive Health Care • 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)

23. Culturally Responsive Health Care, continued….(Culhane-Pera et al, 2003) • 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?

24. Anchored Understanding Of Diversity 3rd Space Acknowledge the range & validity of diverse perspectives. Staying with the tension of differing perspectives. Respect Create opportunities for equalizing power across interactions. Establish interactions that allow equal voice for all perspectives. Reciprocity Collaboratively craft a response that integrates & provides access to the strength of diverse perspectives. Communicate the understanding that others’ perspectives have a positive intent. Responsiveness SKILLED DIALOGUE (Barrera & Corso, 2003) (slide design Kohnert, 2007)

25. Interpreters & Translators

26. Lost in Translation • Chevy Nova • Chevy ‘no va’ • Got Milk? • ¿Tiene Leche? • “Fly in leather” • ‘Volar en cuero’

27. Interpretation and Translation • Interpretation • Service provided by an interpreter that facilitates oral/manual communication between two languages • Simultaneous • Consecutive (Sequential) • Sight • Translation • Service provided by a translator that is similar to interpretation, but with written text.

28. Key Traits for Interpreters Working with Therapies • Neutral, Impartial • Not related to client • Not biased against the client • Ethnic, dialectal, racial issues exist within language groups • 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).

29. Therapist Role: Gathering Cultural Information • CultureGrams: • http://www.culturegrams.com • Endless number of local websites… • Cultural Informant (Mediator) • Other members of community • Designated professional

30. Therapist Role - Gathering Linguistic Information: Websites • Bilingual Mandarin-Chinese and English SLP Resources: • http://home.comcast.net/~bilingualslp/ • Spanish Pronunciation and Language: • http://www.uiowa.edu/~acadtech/phonetics/about.html • White Hmong Language and Culture: • http://www.tc.umn.edu/~kanx0004/ • Vietnamese Language and Culture: • http://vnspeechtherapy.com/vi/CVT/index.htm Nett Cordero 2010

31. Therapist Role - Gathering Linguistic Information: Books 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.

32. Translation of Test Instruments • 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. • What can be reported?

33. Interpreter Model - BID (Langdon and Cheng, 2002) and http://www.asha.org/about/leadership-projects/multicultural/interpret.htm • Briefing • Meeting with interpreter before session. Some areas that may be discussed include: • Goals of session • Interpretation style • Meeting vs. Evaluation • Review of terminology to be used • Test procedures • General or specific format of each test • Level of cuing appropriate • Repetition, rewording, gestural/eye gaze cues • reliability, validity

34. Interpreter Model - BID (Langdon and Cheng, 2002) and http://www.asha.org/about/leadership-projects/multicultural/interpret.htm • Briefing - continued • 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.

35. Interpreter Model - BID (Langdon and Cheng, 2002) and http://www.asha.org/about/leadership-projects/multicultural/interpret.htm • Interaction • Actual meeting or appointment with the interpreter and client. Steps to follow: • 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

36. Interpreter Model - BID (Langdon and Cheng, 2002) and http://www.asha.org/about/leadership-projects/multicultural/interpret.htm • 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

37. Interpreter Model - BID (Langdon and Cheng, 2002) and http://www.asha.org/about/leadership-projects/multicultural/interpret.htm • Debriefing • Meeting after the session to discuss the results • 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

38. Moochas Gracias