Explore Factors and Learn Strategies to Provide Culturally and Linguistically Appropriate Services in Rehabilitation Kelly Nett Cordero, Ph.D., CCC-SLP

Explore Factors and Learn Strategies to Explore Factors and Learn Strategies to Provide Culturally and Linguistically Provide Culturally and Linguistically

Appropriate Services in Rehabilitation Appropriate Services in Rehabilitation

Kelly Nett Cordero, Ph.D., CCC-SLPKelly Nett Cordero, Ph.D., CCC-SLPKaren P. Guerra, M.S., CCC-SLPKaren 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 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 CommentsCultural Health Comments

The Japanese eat very little fatThe Japanese eat very little fatand suffer fewer heart attacks than Americans.and suffer fewer heart attacks than Americans.

The French eat a lot of fatThe French eat a lot of fatand suffer fewer heart attacks than Americans.and suffer fewer heart attacks than Americans.

The Chinese drink very little red wineThe Chinese drink very little red wineand suffer fewer heart attacks than Americans.and suffer fewer heart attacks than Americans.

The Italians drink a lot of red wineThe Italians drink a lot of red wineand suffer fewer heart attacks than Americansand suffer fewer heart attacks than Americans.

CONCLUSIONS:CONCLUSIONS:

Eat and drink what you like.Eat and drink what you like.

It’s speaking English that kills It’s speaking English that kills youyou.

Today’s Agenda: Monitoring your Today’s Agenda: Monitoring your Cultural Responsiveness Cultural Responsiveness (Novations, 2008)(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 Check Yourself – Okay or Not?– Okay or Not?

To shake hands with an individual of the other gender?To shake hands with an individual of the other gender? To make direct eye contact during conversation?To make direct eye contact during conversation? To give a ‘thumb’s up’ or ‘A-okay’ sign?To give a ‘thumb’s up’ or ‘A-okay’ sign? Use a hand gesture to call someone over?Use a hand gesture to call someone over? To ask a professional contact his/her age?To ask a professional contact his/her age? To ask a speaker to clarify information presented?To ask a speaker to clarify information presented? To not allow independence for daily activities that could To not allow independence for daily activities that could

be completed the individual?be completed the individual? To not follow safety guidelines for feeding or other daily To not follow safety guidelines for feeding or other daily

activitiesactivities??

Continuum of Cultural Competence Continuum of Cultural Competence adapted from Cross, Bazron, Dennis & adapted from Cross, Bazron, Dennis &

Isaacs (1989)Isaacs (1989)

Cultural ProficiencyCultural Proficiency

Cultural CompetenceCultural Competence

Cultural Pre-CompetenceCultural Pre-Competence

Cultural BlindnessCultural Blindness

Cultural IncapacityCultural Incapacity

Cultural DestructivenessCultural Destructiveness

(Minimal Level needed in healthcare)

Positive

Negative

(Kohnert adaptation)

Cultural CompetenceCultural Competence

“ “ A set of cultural behaviors and attitudes A set of cultural behaviors and attitudes integrated into the practice methods of a integrated into the practice methods of a system, agency, or its professionals, that system, agency, or its professionals, that enables them to work effectively in cross enables them to work effectively in cross cultural situations…. When professionals cultural situations…. When professionals are culturally competent, they establish are culturally competent, they establish positive helping relationships, engage the positive helping relationships, engage the client, and improve the quality of services client, and improve the quality of services they provide. ”they provide. ” (p.9)(p.9)

http://www.aoa.gov/prof/addiv/cultural/addiv_cult.asp

Achieving Cultural CompetenceAdministration on Aging, Dept of Health & Human Services

Cultural Competency: Cultural Competency: Personal ReflectionPersonal Reflection

American Speech-Language Hearing Association American Speech-Language Hearing Association (ASHA) tools:(ASHA) tools:

American Speech-Language-Hearing Association. (2010). American Speech-Language-Hearing Association. (2010). Cultural Cultural Competence Checklist: Personal reflectionCompetence Checklist: Personal reflection. Available from . 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 DeliveryCultural Competency: Service Delivery

American Speech-Language Hearing Association American Speech-Language Hearing Association (ASHA) tools:(ASHA) tools:

American Speech-Language-Hearing Association. (2010). American Speech-Language-Hearing Association. (2010). Cultural Competence Cultural Competence Checklist: Service deliveryChecklist: Service delivery. Available from . 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 OthersCheck Others

““Diversity” in perspective is dynamic Diversity” in perspective is dynamic – not inherent to an individual– not inherent to an individual

““Relational & Context-embedded” Relational & Context-embedded” (Barrera & Corso, 2002)(Barrera & Corso, 2002)

When you been ‘mainstream’? When you been ‘mainstream’? Diverse?Diverse?

***Experience of Other******Experience of Other***

Nett Cordero 2010Nett Cordero 2010

Cross Cultural Cross Cultural ConsiderationsConsiderations

To maximize patient careTo maximize patient care


Cross Cultural ConsiderationsCross Cultural Considerations

Perceived etiology of disabilityPerceived etiology of disability Role of the extended family and communityRole of the extended family and community Access to and use of healthcare servicesAccess to and use of healthcare services Other Cultural FactorsOther Cultural Factors

• Time DifferencesTime Differences• Role of ProfessionalRole of Professional• Role of SocializationRole of Socialization• Parenting/family valuesParenting/family values

http://yalepress.yale.edu/yupbooks/salud/saludthreeballs.gif

Perceived Causes of Clefting in Perceived Causes of Clefting in Spanish-Speakers (Meyerson, 1990)Spanish-Speakers (Meyerson, 1990)

(Gorlin, 1983) asked mothers of children with clefts in (Gorlin, 1983) asked mothers of children with clefts in Mexico City about factors contributing to Mexico City about factors contributing to

formation of cleftformation of cleft• 71% Paternal Alcoholism71% Paternal Alcoholism• 63% Lunar eclipse during pregnancy63% Lunar eclipse during pregnancy• 52% Punishment for sin52% Punishment for sin

Use of metal keys/pins during Use of metal keys/pins during pregnancy and red pins/ribbons pregnancy and red pins/ribbons in infancy in infancy

• Higa de azabache o piedra rojaHiga de azabache o piedra roja

‘‘Mal de Ojo’ Mal de Ojo’ (Castro, 1995; Diaz de Leon, 1996; (Castro, 1995; Diaz de Leon, 1996; Maestas & Erickson, 1992; Maestas & Erickson, 1992; Rodriguez & Olswang, 2003; Rodriguez & Olswang, 2003; Salas-Provance et al, 2002)Salas-Provance et al, 2002)

Perceived Causes of Disability Perceived Causes of Disability

& Folk Remedies& Folk Remedies Other perceived causes of Other perceived causes of

childhood illness/disability in childhood illness/disability in Mexican-AmericansMexican-Americans• SustoSusto (Fright) (Fright)• Mal aireMal aire (Bad Air) (Bad Air) • Imbalance of hot/coldImbalance of hot/cold• God’s will, premonitions, God’s will, premonitions,

emotionsemotions• Medical causes Medical causes

Inverse relation between:Inverse relation between:• acculturation & SES & acculturation & SES &

educationeducationANDAND• folk beliefs & remediesfolk beliefs & remedies(Diaz de Leon, 1996; Maestas & (Diaz de Leon, 1996; Maestas &

Erickson, 1992; Rodriguez & Erickson, 1992; Rodriguez & Olswang, 2003; Salas-Provance et Olswang, 2003; Salas-Provance et al, 2002)al, 2002)

Ear Candling

Cultural Considerations: Role of Cultural Considerations: Role of community and extended familycommunity and extended family

Easier acceptance of the diagnosis:Easier acceptance of the diagnosis:• Close-knit extended family supportClose-knit extended family support• Notion of ‘God’s Will’ – or disability as a ‘gift’Notion of ‘God’s Will’ – or disability as a ‘gift’• Terms like ‘malito’, ‘enfermito’Terms like ‘malito’, ‘enfermito’

More difficulty accepting the diagnosis:More difficulty accepting the diagnosis:• Belief that disability is a punishment for a Belief that disability is a punishment for a

past sin past sin Infanticide for cleft conditions reported as recently Infanticide for cleft conditions reported as recently

as 20 years ago (Tarahumara Indians of the Sierra as 20 years ago (Tarahumara Indians of the Sierra Madre Mountains in Mexico)Madre Mountains in Mexico)

• (Mull & Mull, 1987) in (Scheper-Hughes, 1990)(Mull & Mull, 1987) in (Scheper-Hughes, 1990)

Cultural Considerations: Role of Cultural Considerations: Role of community and extended familycommunity and extended family

33rdrd graders in Yucatan, Mexico were more graders in Yucatan, Mexico were more accepting of a facial condition than one accepting of a facial condition than one involving a crutch, hand, or foot involving a crutch, hand, or foot

In U.S., facial disorders were rated as less In U.S., facial disorders were rated as less acceptable than crutches, wheelchair, and acceptable than crutches, wheelchair, and hand disabilities in a similar age hand disabilities in a similar age populationpopulation• (Sanchez & Harper, 1994)(Sanchez & Harper, 1994)

http://www.kirklees.gov.uk/community/health-care/childrenandfamilies/disabilityunit.shtml

Access to and Use of Medical ServicesAccess to and Use of Medical Services

Type of health servicesType of health services• Western (biomedical)Western (biomedical)• Non-western (folk)Non-western (folk)• Folk medicine usage varies among Latino Folk medicine usage varies among Latino

groups and may often be blended with groups and may often be blended with western medicine western medicine (Meyerson, 1990).(Meyerson, 1990).

Role of community elders/leadersRole of community elders/leaders Spiritual beliefsSpiritual beliefs

Use of health servicesUse of health services• Decreased utilization – even when availableDecreased utilization – even when available• Concerns regarding legal status, payments, Concerns regarding legal status, payments,

etc.etc.

Cultural Factors: Cultural Factors: Clinical Implications for Health CareClinical Implications for Health Care

Consider carefully the response to folk Consider carefully the response to folk beliefs, causes, and treatments beliefs, causes, and treatments discussed by familydiscussed by family

Time schedule differencesTime schedule differences

Role of socializationRole of socialization

Professional as authorityProfessional as authority

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

Environmental FactorsEnvironmental Factors• Immigration experienceImmigration experience• Level of AcculturationLevel of Acculturation• Educational level/experienceEducational level/experience• Economic ResourcesEconomic Resources• Psychological StatusPsychological Status

Family StructureFamily Structure• Role of decision-makingRole of decision-making• Expectations for marriage and Expectations for marriage and

childrenchildren• Teaching vs. motheringTeaching vs. mothering• Style of communicating with Style of communicating with

childrenchildren

Double CheckDouble Check

Culturally Responsive attitudes:Culturally Responsive attitudes:• Openness, curiosity re: pt views, respect (even Openness, curiosity re: pt views, respect (even

if shown in different ways) increase likelihood if shown in different ways) increase likelihood of success.of success.

• Cultural humility increases likelihood of Cultural humility increases likelihood of success.success.

• Consider the power differential; avoid “top-Consider the power differential; avoid “top-down” communicationdown” communication

(Culhane-Pera et al, 2003)(Culhane-Pera et al, 2003)


Culturally Responsive Health Care Culturally Responsive Health Care

Nonverbal communication Nonverbal communication comprises up to 80% of a comprises up to 80% of a message. (Carson, 1990)message. (Carson, 1990)

Communication styles & Communication styles & cultural responsiveness:cultural responsiveness:• GreetingsGreetings• Smiling and laughingSmiling and laughing• Hand gesturesHand gestures• Facial expressionsFacial expressions• Tone of VoiceTone of Voice• TouchingTouching• Working with interpretersWorking with interpreters

• Delivering bad newsDelivering bad news• Praising the beauty of a Praising the beauty of a

childchild• Eye contactEye contact• Head MovementsHead Movements• Etc.Etc.

(Culhane-Pera, 2003)

Culturally Responsive Health Care, Culturally Responsive Health Care, continuedcontinued….(Culhane-Pera et al, 2003)….(Culhane-Pera et al, 2003)

• What does the pt/fam think is wrong?What does the pt/fam think is wrong?• What does the pt/fam think caused the problem?What does the pt/fam think caused the problem?• How has this affected the pt’s life?How has this affected the pt’s life?• What is the pt/fam afraid of?What is the pt/fam afraid of?• What healing methods has the pt/fam tried?What healing methods has the pt/fam tried?• What does pt/fam think will help?What does pt/fam think will help?• Who usually makes decisions about the pt’s health Who usually makes decisions about the pt’s health

care?care?• What concerns does pt/fam have about seeking help What concerns does pt/fam have about seeking help

from mainstream health care services?from mainstream health care services?• *What are pt/fam main expectations re: outcome of *What are pt/fam main expectations re: outcome of

this clinical encounter? this clinical encounter?

SKILLED DIALOGUE

3rd SpaceAnchored Understanding

Of Diversity

Acknowledge the range& validity of diverseperspectives.

Respect

Reciprocity

Responsiveness

Establish interactions thatallow equal voice for all perspectives.

Communicate the understanding that others’ perspectives have a positive intent.

Staying with the tensionof differing perspectives.

Create opportunitiesfor equalizing poweracross interactions.

Collaboratively crafta response that integrates & provides access to thestrength of diverse perspectives.

(Barrera & Corso, 2003) (slide design Kohnert, 2007)

Interpreters & Interpreters & TranslatorsTranslators

Lost in Translation

Chevy Nova• Chevy ‘no va’

Got Milk?• ¿Tiene Leche?

“Fly in leather”• ‘Volar en cuero’

Interpretation and TranslationInterpretation and Translation

InterpretationInterpretation• Service provided by an interpreter that Service provided by an interpreter that

facilitates oral/manual communication facilitates oral/manual communication between two languagesbetween two languages

SimultaneousSimultaneous Consecutive (Sequential)Consecutive (Sequential) SightSight

TranslationTranslation• Service provided by a translator that is Service provided by a translator that is

similar to interpretation, but with written similar to interpretation, but with written text.text.

Key Traits for Interpreters Key Traits for Interpreters Working with TherapiesWorking with Therapies

Neutral, ImpartialNeutral, Impartial• Not related to clientNot related to client

Not biased against the clientNot biased against the client• Ethnic, dialectal, racial issues exist within language groupsEthnic, dialectal, racial issues exist within language groups

Professional, TrainedProfessional, Trained Able to maintain confidentiality, honestAble to maintain confidentiality, honest Fluent in English and other language targetedFluent in English and other language targeted Available for follow-up appointmentsAvailable for follow-up appointments Familiar with dialect and/or country of origin of the Familiar with dialect and/or country of origin of the

clientclient* Successful interpretation involves the integration of two * Successful interpretation involves the integration of two

verbal and non-verbal communication sets (Langdon, verbal and non-verbal communication sets (Langdon, 2002).2002).

Therapist Role: Gathering Cultural Therapist Role: Gathering Cultural InformationInformation

CultureGrams:CultureGrams:• http://www.culturegrams.com http://www.culturegrams.com

Endless number of local websites…Endless number of local websites…

Cultural Informant (Mediator)Cultural Informant (Mediator)• Other members of communityOther members of community• Designated professionalDesignated professional

Therapist Role - Gathering Therapist Role - Gathering Linguistic Information: WebsitesLinguistic Information: Websites

Bilingual Mandarin-Chinese and English SLP Bilingual Mandarin-Chinese and English SLP Resources: Resources: • http://home.comcast.net/~bilingualslp/http://home.comcast.net/~bilingualslp/

Spanish Pronunciation and Language:Spanish Pronunciation and Language:• http://www.uiowa.edu/~acadtech/phonetics/http://www.uiowa.edu/~acadtech/phonetics/

about.htmlabout.html White Hmong Language and Culture:White Hmong Language and Culture:

• http://www.tc.umn.edu/~kanx0004/http://www.tc.umn.edu/~kanx0004/ Vietnamese Language and Culture:Vietnamese Language and Culture:

• http://vnspeechtherapy.com/vi/CVT/index.htmhttp://vnspeechtherapy.com/vi/CVT/index.htm


Therapist Role - Gathering Therapist Role - Gathering Linguistic Information: BooksLinguistic Information: Books

Campbell, G. (1998). Campbell, G. (1998). Concise Compendium of the Concise Compendium of the World’s LanguagesWorld’s Languages. New York: Routledge. . New York: Routledge.

Goldstein, B. (2000). Goldstein, B. (2000). Cultural and Linguistic Cultural and Linguistic Diversity Resource Guide for Speech-Language Diversity Resource Guide for Speech-Language Pathologists. Pathologists. San Diego: Singular.San Diego: Singular.

Hua, Z. & Dodd, B. (Eds.) (2006). Hua, Z. & Dodd, B. (Eds.) (2006). Phonological Phonological Development and Disorders in Children: A Development and Disorders in Children: A Multilingual Perspective.Multilingual Perspective. Clevedon, UK: Clevedon, UK: Multilingual Matters.Multilingual Matters.

McLeod, S. (2007). McLeod, S. (2007). International Guide to Speech International Guide to Speech Acquisition.Acquisition. Clifton Park, NY: Thomson Delmar. Clifton Park, NY: Thomson Delmar.

Translation of Test Instruments Translation of Test Instruments Translation of testing protocols must be Translation of testing protocols must be

completed with caution!completed with caution!• Difficulty of items may be altered by translationDifficulty of items may be altered by translation• Differences in the hierarchy of skills difficulty Differences in the hierarchy of skills difficulty

exist between languagesexist between languages• Cultural differences may exist even if linguistic Cultural differences may exist even if linguistic

adaptation is successfuladaptation is successful• Use of normative information may not be Use of normative information may not be

possible – unless the translated instrument is possible – unless the translated instrument is standardized.standardized.

What can be reported?What can be reported?

Interpreter Model - Interpreter Model - BBIDID BriefingBriefing

• Meeting with interpreter before session. Meeting with interpreter before session. Some areas that may be discussed include:Some areas that may be discussed include:

Goals of sessionGoals of session Interpretation styleInterpretation style

• Meeting vs. EvaluationMeeting vs. Evaluation Review of terminology to be usedReview of terminology to be used Test proceduresTest procedures

• General or specific format of each test General or specific format of each test • Level of cuing appropriateLevel of cuing appropriate• Repetition, rewording, gestural/eye gaze cuesRepetition, rewording, gestural/eye gaze cues• reliability, validityreliability, validity

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

Interpreter Model - Interpreter Model - BBIDID BriefingBriefing - continued - continued

Establish rapport Establish rapport Determine any signals that will be used between Determine any signals that will be used between

therapist/interpreter to identify correct and therapist/interpreter to identify correct and incorrect incorrect

Learn how to greet the family and say client’s Learn how to greet the family and say client’s name in native languagename in native language

Determine seating/working arrangementsDetermine seating/working arrangements You may choose to review the evaluation You may choose to review the evaluation

materials with the interpreter for cultural/dialectal materials with the interpreter for cultural/dialectal appropriateness, but the final decision is yours.appropriateness, but the final decision is yours.


Interpreter Model - BInterpreter Model - BIIDD InteractionInteraction

• Actual meeting or appointment with the Actual meeting or appointment with the interpreter and client. Steps to follow:interpreter and client. Steps to follow:

Introduce yourself and the interpreter, in native Introduce yourself and the interpreter, in native language of patient if possiblelanguage of patient if possible

Explain the roles of each professionalExplain the roles of each professional Encourage interpreter to take notes and Encourage interpreter to take notes and

interpret history forms if translation not interpret history forms if translation not availableavailable

Use short sentences and avoid terminology and Use short sentences and avoid terminology and idiomatic language that is not necessaryidiomatic language that is not necessary


Interpreter Model - BInterpreter Model - BIIDD Interaction - continuedInteraction - continued

• Leave enough pauses and have periodic checks Leave enough pauses and have periodic checks with interpreter on ratewith interpreter on rate

• Look at the client when talking and if you speak Look at the client when talking and if you speak directly to them, ‘You’, not ‘she/he’directly to them, ‘You’, not ‘she/he’

• Try not to alter meaning by making an explanation Try not to alter meaning by making an explanation too simpletoo simple

• Be aware of gesture/nonverbal communication that Be aware of gesture/nonverbal communication that may be offensive to the familymay be offensive to the family

• Provide native language written information for Provide native language written information for literate families/patientsliterate families/patients


Interpreter Model - BIInterpreter Model - BIDD

DebriefingDebriefing• Meeting after the session to discuss the Meeting after the session to discuss the

resultsresults Get impressions on any of the child’s skills that Get impressions on any of the child’s skills that

that can be judged by interpreterthat can be judged by interpreter Work on any scoring or interpretation that you Work on any scoring or interpretation that you

need native language assistance withneed native language assistance with Discuss any follow-up appointments that are Discuss any follow-up appointments that are

needed and share contact informationneeded and share contact information


Moochas GraciasMoochas Gracias

Documents

Explore Factors and Learn Strategies to Provide Culturally and Linguistically Appropriate Services in Rehabilitation Kelly Nett Cordero, Ph.D., CCC-SLP