The Impact of Cultural Diversity and Competence on Speech Therapy Treatment

Literature Review

“Multiculturalism is often used to refer to one or more particular minority, racial, and/or ethnic groups in the United States” (Stockman, Boult, & Robinson, 2004). Using the word ‘multicultural’ refers to the wide range of co-existing cultural groups within society. Due to the growth of diversity in society, multicultural instruction has been introduced into education. Multicultural instruction is important to have in the curriculum to meet the needs of growing cultural differences and to prepare the future professionals to succeed in this pluralistic society.

The presence of multiculturalism in society creates a montage of identities held by several different groups; these identities are influenced by values, as well as other cultural factors, related to the group’s culture (Fatima Oliveira, 2013). The culture that one prescribes to influences the way communication is interpreted. The reason communication can be interpreted differently among groups is due to the fact that meaning is filtered through an individual's values and identity. For this reason, it is mandatory in our society to be educated in cultural diversity and tailor communication to the audience.

“Cultural and linguistic competence is 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” (American Speech-Language-Hearing Association, 2017). Clinicians must understand that cultural differences do not characterize a disorder, and they must follow the Code of Ethics when delivering therapy treatment. Services should be respectful of individuals values, preferences, and language. Quality of service should not be based on ethnicity, age, socio- economic background, or any other factors.

For a healthcare provider to display cultural competence, basic values must be present: “Openness, awareness, desire, knowledge, sensitivity, and encounter” (Henderson, Horne, Hills, & Kendall, 2018, p. 590). Openness is characterized as the clinician not only having the desire to examine one’s own culture, but also look past their own culture and to acknowledge and digest other cultures. Clinician’s must also make themselves aware of the consequences that this world has created and the war fought between differing cultures, such as prejudice. The desire mentioned refers to clinical desire; the desire to learn about other cultures to further one’s clinical expertise in providing the best treatment for diverse populations. Cultural knowledge, the cornerstone of cultural competence, is a deep, intricate understanding of culture that can be gained from first-hand experience and through education, such as learning a foreign language. A clinician must show sensitivity and knowledge towards culturally delicate areas, which can include the area of healthcare. Lastly, the clinician must be immersed in an environment that allows the encounter of cultural diversity.

These six basic prerequisites for acquiring cultural competence are attainable as most clinicians today must have training in multicultural content as part of their American Speech-Language and Hearing Association (ASHA) certification requirements. ASHA accredited programs do not have a specific course about multicultural issues but instead infuse multicultural content within the existing curriculum. Stockman et. al., (2004) advocates for the use of integral infusion which requires multicultural issues to be embedded throughout the content of a given course and academic curriculum. Integral infusions objective is to blend existing knowledge with knowledge about the culture.

Cultural intelligence (CQ), one component of cultural competence, is defined as “a person’s capability to adapt effectively to new cultural contexts (Earley & Ang, 2003, p. 59)” (Griffer & Perlis, 2007). Cultural intelligence has four aspects for aspiring educators and clinicians. They include strategy, which is understanding one’s culturally diverse experience, knowledge, the act of learning the similarities, and differences of the parameters of cultural groups. The third aspect is motivation, which is a person’s interests in learning about different cultures and how to function in a culturally diverse setting. Lastly, behavior is the use of appropriate responses in various situations.

Aspiring educators and clinicians should see themselves as multiperspective, meaning to see one’s identity in many perspectives, such as age, race, gender, and socio-economic status. In doing this leads to cultural intelligence. (Griffer et. al., 2007). It is important for aspiring clinicians and educators to interact with individuals with different multiperspective identities from themselves, take courses with diverse faculty, complete clinical practicums and field placements with diverse individuals, and offer diverse persons to give guest lectures. When clinicians and educators immerse themselves in these multicultural environments, they grow their cultural intelligence, which carries over into their interaction with their students or clients.

The development of cultural competence is in part attributed to the immersion of the clinician into the workplace saturated with a culturally and linguistically diverse (CLD) population, but this is not the only factor that grows a clinician’s cultural competence. Howells, Barton, and Westerveld (2016) experimented the effects of not only experience with diverse populations in clinical placement, but also the effects of students’ backgrounds on cultural competence. The study consisted of 60 participants from two cohorts of students pursuing their master’s degree in speech-language pathology. The participants demographics varied in age, country of birth, and number of languages spoken. The use of surveys, written reflections, and focus groups measured the impact of the student’s background and clinical placement on student’s cultural awareness. Howells et. al., (2016) concluded that cultural competence increasingly developed in speech-language pathology students during the student clinical placement, and the background of the student even more so influenced the level of cultural competence. The interpretation for determining this influence was based on the measured qualitative information and compared to a previous study, Wells’ (2000) cultural development continuum. The qualitative information gathered regarding student’s desire to work with CLD populations and their confidence to work with CLD populations showed improvement as the students attended clinical placement, and the students from diverse backgrounds showed even greater improvement towards cultural competence after attending the clinical placement.

Due to populations becoming more diverse culturally and linguistically, the necessity for cultural competence grows (Matthews & Van Wyk, 2018). Facilities experience shortages of culturally competent healthcare workers, which leads to several consequences. Cultural incompetence leads to ethical dilemmas of the mistreatment of clients, such as giving preference to a particular individual based on their culture or showing intolerance towards a particular race. Miscommunications regarding health information also occur daily in healthcare settings, often due to a language barrier, when a lack of cultural competence is present and necessary measures are not taken on behalf of the client. Cultural incompetence can cause a barrier that impacts the client and family more than the effect of socio-economic or structural barriers (Matthews & Van Wyk, 2018).

Therapy ought to be delivered to CLD children in a culturally competent manner. Assessments should be non-biased such as dynamic assessments, portfolio assessments, narrative assessments, and structured observation. Assessments must be performed in each language the child speaks. Interventions also must be performed in the language the child speaks. If the clinician does not know the language, the clinician needs to use a bilingual support to assist in the manner.

The study consisted of nine speech language therapist (SLT) from Central Valley, California. There were no exclusionary criteria for race, ethnicity, or gender. SLT’s caseloads averaged 52 children with 25 being CLD. SLT’s participated in a recorded interview with the same set of core questions. The questions were transcribed and summarized using an open coding method. The codes were reviewed to notice commonalities across questions. The findings showed four themes including language being a barrier and a bridge, working with interpreters helped or hindered assessment and treatment of CLD children, having respect for cultural differences, and positive interactions with CLD family members (Maul, 2014). Through this study therapy techniques were developed to better assist SLT’s treatment of CLD children. Clinicians should be culturally sensitive by learning about cultural traditions of their students and understand cultural norms and how different cultures view importance of disorders in everyday life. An effective way to begin a rapport with CLD students and family members would be to learn some phrases of the languages the client speaks (Maul, 2014). The clinician must show cultural understanding to establish trust and open communication to successfully treat individuals from diverse backgrounds (Lemmon & Jackson-Bowen, 2013). Brunett and Shingles (2018) studied the effects of the cultural competence of healthcare professionals on the satisfaction of patients, and determined that patients tended to be more forthcoming and trusting of the professionals if they showed cultural competence. Patients who perceived their provider as being culturally competent also were more likely to follow the medical advice of the provider (Brunett & Shingles, 2018).

Purpose of the Study

The purpose of this study is to examine if cultural diversity has an impact on speech therapy treatment. This determination is important because speech-language pathologists have diverse caseloads and should be delivering treatment appropriately, which is explicitly stated in ASHA’s Code of Ethics. The study is to determine if additional cultural competence training is required to be taught to graduate students before becoming practicing clinicians.

Research Question

Does cultural diversity have an impact on speech therapy treatment?

Hypothesis

It is hypothesized that no changes will be present in the delivery of therapy due to the presence of cultural diversity. This belief is based on the grounds that the undergraduate and graduate curriculum of speech-language pathology students is embedded with cultural diversity. Additionally, according to ASHA’s Code of Ethics, every practicing speech-language pathologist must have cultural competence and the participating students have all attended schools accredited by ASHA.

Methods

Participants

Due to the study focusing on cultural competence and the diversity of future clients within the speech-language pathologist caseload, our participants will derive from two ethnicities. The ethnicities chosen to study are African American and Causcasian. There will be four different groups being studied; these groups include an African American clinician with a Caucasian client, an African American clinician with an African American client, a Caucasian clinician with an African American client, and lastly a Caucasian clinician with a Caucasian client. THIS WILL BE EXPANDED UPON ONCE PARTICIPANTS ARE OBTAINED (e.g. Each group will have _____ participant pairs selected from Valdosta State University Speech and Hearing Clinic). The inclusionary criteria are participants who attend Valdosta State University Speech and Hearing Clinic and are of the two ethnicities being used in the study. The exclusionary criteria are certified speech-language pathologist, any client not attending the Valdosta State Clinic, and other ethnicities besides African American and Caucasian. Gathering of participants will be completed by the professor from the Valdosta State Clinic.

Procedures

Our participants in the study carried out therapy typically, as if the participant was not participating in the study, and the session was recorded with a tape recorder. The recording is obtained one time for each participant. The recording was examined for a five minute period. The duration of the recording examined began 10 minutes into the session and stopped 15 minutes into the session. The first 10 minutes of the recording was eliminated from examination to allow for warm-ups to be completed and treatment to begin. If an interruption, such as a bathroom break, occurred during the five examined minutes of therapy, the time was paused prior to the interruption and continued once therapy continued to reach the five full minutes of therapy.

Measures

Three measures were obtained for each five minute recording of treatment. The first measure observed the talk time of the clinician, talk time of the client, and the length of silence. The number of total words (NTW) were calculated for both the clinician and the client. Lastly, the lexical diversity, number of different words (NDW), were measured for the clinician and the client to determine the complexity of speech. The independent variable for this study was the cultural diversity amongst the clinician and the client. The dependent variable was the manner that the therapy was carried out by the clinician.

Analysis

After reviewing the recorded therapy sessions, the data was analyzed using a calculation of the NTW and NDW. These data findings were compared to the norms of their peers. THIS WILL BE EXPANDED UPON (the norms of NTW and of NDW will be gathered by the professor overseeing the study). Finally, the results will be compared to the four different groups to show either an effect or no effect on therapy treatment.