Cultural Competency in Auditory Rehabilitation

1. Cultural Competency in Auditory Rehabilitation Presented by Ronald Jones, Ph.D., CCC-A and Scott Bally, Ph.D., CCC-SLP Norfolk State University Gallaudet University Norfolk, VA Washington, D.C rjones@nsu.eduscott.bally@gallaudet.edu Recognizing that differences make a difference National Early Hearing Detection And Intervention (EDHI) Conference February 2-3, 2006 Renaissance Washington D.C. Hotel Washington, D.C.

2. Faculty Disclosure InformationIn the past 12 months, we have not had a significant financial interest or other relationship with the manufacturer(s) of the product(s) or provider(s) of the service(s) that will be discussed in our presentation.This presentation will (not) include discussion of pharmaceuticals or devices that have not been approved by the FDA, nor any unapproved or “off-label” uses of pharmaceuticals or devices.

3. Introduction This presentation will: • Provide basic information on the changing demographics of U.S. populations and the health disparities befalling some of those populations, to include hearing impairment; • List strategies to help practitioners identify specific cultural factors that tend to interfere with the delivery of competent auditory rehabilitation services, and • Offer recommendations on proven methods for working successfully with hearing impaired individuals whose social, educational, economic, or cultural backgrounds are vastly different from those of the practitioner.

4. U.S. Demographics - 2002 Total U.S. Population = 280 million people Ethnic/Racial Groups: (2002) • Euro-Americans 198 million (71.1%) • Hispanic-Americans 34 million (12.5%) • African-Americans 34 million (12.4%) • Asian-Americans 11 million ( 4.0%) • Native-Americans 2 million ( .7%)

5. Projected U.S. Population increases (%) by year 2010 & 2050: 2010 2050 • Asian Americans: 5% 9% • Hispanic Americans: 15% 24% • African Americans: 12% 13% • Euro Americans: 67% 53% • Native Americans: .8% .8%

6. Location/Population of Euro-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. Bowen California Geographical SurveyCalifornia State University, Northridge http://130.166.124.2/USpage1.html

7. Location/Population of African-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. Bowen California Geographical SurveyCalifornia State University, Northridge http://130.166.124.2/USpage1.html

8. Location/Population of Hispanic-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. Bowen California Geographical SurveyCalifornia State University, Northridge http://130.166.124.2/USpage1.html

9. Location/Population of Native-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. Bowen California Geographical SurveyCalifornia State University, Northridge http://130.166.124.2/USpage1.html

10. Location/Population of Asian-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. Bowen California Geographical SurveyCalifornia State University, Northridge http://130.166.124.2/USpage1.html

11. Demographic Changes in the U.S. • By 2050, it is estimated that racial/ethnic “minorities” will make up approximately 50 percent of the U.S. population. • This growth will necessitate that changes be made in the way we see and do things, particularly with respect to the delivery of human resource services.

12. Examples of health disparities between white population and ethnic minority populations in the U.S. • Minority populations suffer higher rates of morbidity and mortality. • Infant mortality rates are 2 1/2 times higher for African Americans and 1 1/2 times higher for American Indians/Alaska Natives. • African American men under 65 suffer from prostate cancer at nearly twice that of white Americans. • Asian Americans and Pacific Islanders have the highest rates of tuberculosis. • Hispanic Americans have two to three times the rate of stomach cancer. • American Indians/Alaska Natives suffer from diabetes at nearly three times the average rate, while African Americans suffer 70 percent higher rates than white Americans. • More than 75 percent of AIDS cases among women and children occur among racial/ethnic minorities, primarily African American and Hispanic American. • Although Asians and Pacific Islanders (A/PIs) tend to be one of the healthiest populations in the United States, different groups within this population vary widely on health indicators. For example, women of Vietnamese origin have cervical cancer rates nearly five times that of white women. • The infant mortality rate of American Indians and Alaska Natives is almost double that of whites, and the infant death rate among African Americans is more than twice as high as that of whites. • Hispanics living in the United States are almost twice as likely to die from diabetes, and they have higher rates of high blood pressure and obesity. Health Resources and Services AdministrationU.S. Department of Health and Human Services

13. Cultural and linguistic barriers that racial/ethnic minorities encounter when seeking health care: • Lack of communication and comfort can occur between patient and provider when cultural differences in perceptions of illness, disease, and medical roles are not recognized and addressed, thereby adversely affecting health outcomes. • Providers do not have adequate knowledge about research findings which indicate that many disease conditions disproportionately impact minorities. • Lack of health insurance, • Immigration status, • Poverty, • Discrimination, • Lack of access to high quality educational opportunities, • Unavailability of transportation and childcare, and • Inconvenient and insufficient hours of operation at health facilities. Health Resources and Services AdministrationU.S. Department of Health and Human Services

14. Minority health focuses on: • Addressing the multiple complex issues related to eliminating health disparities for racial/ethnic minorities. • Facilitating an understanding of the benefits of culturally competent health care, thereby reducing the potential for misdiagnosis of clients and inappropriate treatment. • Promoting an understanding of racial and ethnic differences in response to drugs. • Stimulating the development of strategies to overcome racial biases in the delivery of health care. • Fostering the integration of culturally-related health factors into the design of intervention programs. • Supporting the adoption of policies and research initiatives that enhance health outcomes for underserved minority populations and • Directly address the design and delivery of health care systems that respond to the specific needs of racial/ethnic minorities. Health Resources and Services AdministrationU.S. Department of Health and Human Services

15. Hearing loss and its rehabilitation

16. Incidence per 10,000 of Congenital Defects/Diseases

17. Prevalence of Hearing Impairment in the U.S. by Age Group and Race Source: Data from the National Center for Health Statistics. (1994). National Health Interview Survey. Series 10, No. 188, Table 2. Hyattsville, MD: National Center for Health Statistics.

18. Statistics • According to the Gallaudet Research Institute, 45.2 percent of the children in the United States who are deaf or hard-of-hearing are racial/ethnic minorities. Of this total: • 17 percent are African American, 20.4% are Hispanic, 4.2% are Asian American/Pacific Islander, 0.8% are American Indian/Alaskan Native, and 3.1% cite other or multiethnic background (Holden-Pitt & Diaz, 1998). • The clients audiologists serve mirror the demographic changes in the U.S. population. Gallaudet Research Institute Holden-Pitt & Diaz, 1998

19. Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree of hearing loss Age at onset Fortunately, the quasi-prescriptive approaches used by audiologists are fairly amenable at addressing differences between mild, moderate, severe and profound hearing losses Personality Socio- economics Culture

20. Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree of hearing loss Age at onset Personality Different diagnostic and therapeutic approaches Are available to accommodate the behavior and linguistic needs of clients. Socio- economics Culture

21. Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree of hearing loss Age at onset Individual and/or group therapy approaches Used to accommodate the personality (i.e., (introvert, extrovert) characteristics of clients that tend to impact on the delivery and reception of therapeutic approaches. Personality Socio- economics Culture

22. Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree of hearing loss Age at onset Factors into the availability of services and client’s capacity to purchase high end products Personality Socio- economics Culture

23. Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree of hearing loss Where differences in the values, attitudes, beliefs, behaviors, etc. of certain ethnic minority groups can affect the interaction between them and practitioners. Age at onset Personality Socio- economics Culture

24. Culture Defined: “A shared system of values, attitudes, beliefs, and learned behaviors, which are shaped by such factors as geographic or social proximity, common education, age, gender, and sexual preference.“ Low, S.M. (1984). The cultural basis of health, illness and disease. Soc Work Health Care; 9:13-23.

25. “Cultural Jeopardy” How to play: A definition will be presented and you must determine the appropriate word from the list.

26. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture The ability to be open to learning about and accepting of different cultural groups. Cultural Sensitivity 1

27. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture A belief that racial differences produce an inherent superiority of a particular race. Racism 2

28. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture A generalization of characteristics that is applied to all members of a cultural group. Stereotype 3

29. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture A subconscious belief in negative stereotypes about one’s group that results in an attempt to fulfill those stereotypes and a projection of those stereotypes onto other members of that group. Internalized oppression 4

30. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture A belief in the inherent superiority of one pattern of loving over all and thereby the right to dominance. Heterosexism 5

31. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture To make a difference in treatment on a basis other than individual character. Discrimination 6

32. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture The recognition and acknowledgement that society is pluralistic. In addition to the dominant cultural, there exists many other cultures based around ethnicity, sexual orientation, geography, religion, gender, and class. Multiculturalism 7

33. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture An attitude, opinion, or feeling formed without adequate prior knowledge, thought, or reason. Prejudice 8

34. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture The belief in the inherent superiority of one sex (gender) over the other and thereby the right to dominance. Sexism 9

35. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture A body of learned beliefs, traditions, principles, and guides for behavior that are shared among members of a particular group. Culture 10

36. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture To judge other cultures by the standards of one’s own, and beyond that, to see one’s own standards as the true universal and the other culture in a negative way. Ethnocentrism 11

37. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture As a biological concept, it defines groups of people based on a set of genetically transmitted characteristics. race 12

38. Prejudice Ethnocentrism Stereotype Sexism Multiculturalism Cultural Sensitivity Ethnicity Racism Race Internalized Oppression Discrimination Heterosexism Culture Sharing a strong sense of identity with a particular religious, racial, or national group. Ethnicity 13

39. Cultural Competence Defined 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. "Competence" implies having the capacity to function effectively as an individual and an organization within the context of the cultural beliefs, behaviors, and needs presented by consumers and their communities. Office of Minority Health (OMH) , 2001

40. How can cultural competence be achieved in aural rehabilitation? Begin with the routine aural rehabilitation process, but infuse cultural perspectives into both diagnostic and therapeutic aspects, particularly in the following areas:

41. Aural Rehabilitation Plan with infusion of major cultural considerations Psychosocial Adjustment Hearing Aids Regular Follow-up Evaluations and Services Information and Affective Counseling Client Evaluation Assistive Devices Communication Training Nancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, 1998 p.271 (with permission)

42. Aural Rehabilitation Plan with infusion of marginal cultural considerations Marginal Cultural Considerations Psychosocial Adjustment Hearing Aids Regular Follow-up Evaluations and Services Information and Affective Counseling Client Evaluation Assistive Devices Communication Training Marginal Cultural Considerations Nancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, 1998 p.271 (with permission)

43. Aural rehabilitation plan with infusion of cultural considerations during client evaluation Psychosocial Adjustment Hearing Aids Regular Follow-up Evaluations and Services Information and Affective Counseling Client Evaluation Assistive Devices Communication Training Nancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, 1998 p.271 (with permission)

44. Patient Evaluation • Questions asked during the preliminary diagnostic processes should be relevant and to the point. • Double-barreled or judgmental questions should be avoided. • Build upon positive statements, think from a constructive point of view • Use words that come naturally to you, but are meaningful to the client. • Avoid questions requiring merely “yes” or “no” responses

45. Aural Rehabilitation Plan with insertion of cultural considerations for information and affective counseling Psychosocial Adjustment Hearing Aids Regular Follow-up Evaluations and Services Information and Affective Counseling Client Evaluation Assistive Devices Communication Training Nancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, 1998 p.271 (with permission)

46. Informational and Affective Counseling • Use educational and informational approaches that will capture the client’s attention and interest. • Informational booklets, pamphlets, etc. provided to clients should be relevant and representative of the racial, ethnic or minority groups being served. • Avoid stereotyping (e.g., appearance, behaviors, etc.) and misapplication of personal information garnered during case history. • Take a proactive, problem solving approach

47. Aural Rehabilitation Plan with insertion of cultural considerations for personal adjustment counseling Psychosocial Adjustment Hearing Aids Regular Follow-up Evaluations and Services Information and Affective Counseling Client Evaluation Assistive Devices Communication Training Nancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, 1998 p.271 (with permission)

48. Psychosocial Adjustment • Use cultural referents to establish therapeutic goals and objectives • Explore client’s prior experiences with hearing healthcare services • Explore client’s support system (i.e., family, community, social services agencies, ) to determine their adequacy • Refer client’s whose needs exceed your capacity to assist or to rehabilitate.

49. Aural rehabilitation plan with insertion of cultural considerations in communication training Psychosocial Adjustment Hearing Aids Regular Follow-up Evaluations and Services Information and Affective Counseling Client Evaluation Assistive Devices Communication Training Nancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, 1998 p.271 (with permission)

50. Communication Training • For auditory training, incorporate culturally relevant materials into Communication training activities (i.e., culturally popular music, speeches, etc.) • For linguistically diverse clients, consult with interpreters regarding methods and materials that are more relevant to client’s interests or needs. • Determine the cultural relevance and appropriateness of speech-reading training, before initiating such training.