Cultural Competency in Auditory Rehabilitation Recognizing that differences make a difference...

Cultural Competency in Auditory Rehabilitation

Recognizing that differences make a difference

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 [email protected] [email protected]

National Early Hearing Detection And Intervention (EDHI) Conference

February 2-3, 2006Renaissance Washington D.C. Hotel

Washington, D.C.

Faculty Disclosure Information In 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.

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.

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%)

U.S. Demographics - 2002 Total U.S. Population = 280 million people

2010 2050 Asian Americans: 5% 9% Hispanic Americans: 15% 24% African Americans: 12% 13% Euro Americans: 67% 53% Native Americans: .8% .8%

Projected U.S. Population increases (%) by year 2010 & 2050:

DIGITAL ATLAS OF THE UNITED STATES Dr. William A. Bowen California Geographical SurveyCalifornia State University, Northridgehttp://130.166.124.2/USpage1.html

Location/Population of Euro-Americans

Location/Population of African-Americans


Location/Population of Hispanic-Americans


Location/Population of Native-Americans


Location/Population of Asian-Americans


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.

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 Administration

U.S. Department of Health and Human Services

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.



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.



Hearing loss and its rehabilitation

Incidence per 10,000 of Congenital Defects/Diseases

30

12 11

6 52 1

0

10

20

30

40

Age (yrs.) African American (%)

Euro-American (%)

3-17 1.2 1.9

18-44 2.1 4.9

45-64 7.2 13.4

65 and older 18.7 30.1

Total (ave.) 7.3 12.5

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.

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

Factors that might affect therapeutic outcomes in audiology/aural rehab:

Culture

Fortunately, the quasi-prescriptive approaches used by audiologists are fairly amenable ataddressing differences between mild, moderate, severe and profound hearing losses

Degree of hearing loss

Age at onset

Personality

Socio-economics


Culture

Different diagnostic and therapeutic approaches Are available to accommodate the behavior andlinguistic needs of clients.


Age at onset

Personality

Socio-economics


Culture

Individual and/or group therapy approachesUsed to accommodate the personality (i.e.,(introvert, extrovert) characteristicsof clients that tend to impact on the delivery and reception of therapeutic approaches.


Age at onset

Personality

Socio-economics


Culture

Factors into the availability of services andclient’s capacity to purchase high end products


Age at onset

Personality

Socio-economics


Culture

Where differences in the values, attitudes, beliefs,behaviors, etc. of certain ethnic minority groupscan affect the interaction between them andpractitioners.


Age at onset

Personality

Socio-economics

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 HealthCare; 9:13-23.

““Cultural Jeopardy”Cultural Jeopardy”

A definition will be presented and you must determine the appropriate word

from the list.

How to play:How to play:

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.


1

A belief that racial differences produce an inherent superiority of a

particular race.

Racism

2

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

A generalization of characteristics that is

applied to all members of a cultural group.

Stereotype

3

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


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

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

A belief in the inherent superiority of one

pattern of loving over all and thereby the right to

dominance.

Heterosexism

5

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

To make a difference in treatment on a basis other than

individual character.

Discrimination

6

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


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.

Multiculturalism7

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

An attitude, opinion, or feeling formed without

adequate prior knowledge, thought, or

reason.

Prejudice

8

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

The belief in the inherent superiority of one sex (gender) over the other and thereby

the right to dominance.

Sexism

9

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


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

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


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

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

As a biological concept, it defines groups of people

based on a set of genetically transmitted characteristics.

race

12

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

Sharing a strong sense of identity with a particular religious,

racial, or national group.

Ethnicity

13

Prejudice

Ethnocentrism

Stereotype

Sexism

Multiculturalism


Ethnicity

Racism

Race


Discrimination

Heterosexism

Culture

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

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:

Aural Rehabilitation Plan with infusion of major cultural considerations

Nancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, 1998 p.271 (with permission)

ClientEvaluation

Information and AffectiveCounseling

CommunicationTraining

Assistive Devices

Hearing Aids

Psychosocial Adjustment

Regular Follow-up

Evaluationsand Services

Aural Rehabilitation Plan with infusion of marginal cultural considerations

ClientEvaluation



Assistive Devices

Hearing Aids


Regular Follow-up


MarginalCultural Considerations

MarginalCultural Considerations


Aural rehabilitation plan with infusion of cultural considerations during client evaluation

ClientEvaluation



Assistive Devices

Hearing Aids


Regular Follow-up



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

Aural Rehabilitation Plan with insertion of cultural considerations for information and affective counseling

ClientEvaluation



Assistive Devices

Hearing Aids


Regular Follow-up



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

Aural Rehabilitation Plan with insertion of cultural considerations for personal adjustment counseling

ClientEvaluation



Assistive Devices

Hearing Aids


Regular Follow-up




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.

Aural rehabilitation plan with insertion of cultural considerations in communication training

ClientEvaluation



Assistive Devices

Hearing Aids


Regular Follow-up



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.

Assessing your cultural awareness

Stage Development of Cultural Awareness

Stage 1: Unawareness of cultural/social issues

Description: Person does not entertain any cultural/social difference hypotheses

Consequence: Person does not understand the significance of an individual’s cultural/social background. Tends to be naïve with respect to cultural/social difference issues.

Stage 3: Consideration of cultural/social differences

Description: A person becomes hyper-vigilant in identifying cultural/social factors and is at times confused in determining the cultural/social significance of a person’s actions.

Consequences: The consideration of cultural/social influences is initially perceived as a distraction, something which Negatively impacts on social effectiveness (education, business, health, etc.) Later. Values relating to differences are recognized and begin to be considered.

Stage 2: Heightened awareness of culture and social differences

Description: A person is suddenly aware that cultural factors are important in fully understanding another person.

Consequences: Initially feels unprepared to relate to culturally/socially different person. Frequently applies one’s own perception of the person’s background usually based on stereotypes, and therefore fails to understand the significance of cultural/social influences for developing behaviors.

Stage 4: Cultural/social sensitivity

Description: A person entertains cultural/social difference hypotheses and carefully tests these hypotheses from multiple sources before accepting cultural/social explanations.

Consequences: Increased likelihood of accurately understanding the role of culture, etc. in a person’s social functioning.

Assessing your cultural values

Determining your own cultural values: The following lists of statements represent two divergent cultural perspectives. Place an (X) at a location between each pair of statements to indicate the strength of your conviction for the statement of your choosing.

Mastery over naturePersonal control

DoingTime dominatesHuman equality

Individualism/privacyYouth

Self sufficiencyCompetition

Future orientationInformalityDirectness

Practicality/efficiencyMaterialism

Harmony with natureFateBeingPersonal needs dominateHierarchy/rank/statusGroupEldersBirthright/inheritanceCooperationPast or present orientationFormalityIndirectnessIdealismSpiritualism

Statement |___|___|___|___|___|___|___|___|Statement

VeryStrong

VeryStrong

Adapted from Schilling & Brannon, 1986

Explanation: The statements to the left side of the page are representative of Anglo-Saxon, European–American cultures. The statements to the right side of the page are representative of Ethnic minority sub-cultures.









Euro-American

Ethnic minority American

Cultural Pattern #1 – Alignment with Euro-centric American cultural values









VeryStrong

VeryStrong


X X X X XX X XX X X X XX

Cultural pattern #2 – Alignment with Ethnocentric American cultural values









VeryStrong

VeryStrong











VeryStrong

VeryStrong



Cultural pattern #3 – Non-Alignment, culturally neutral; in state of cultural transition between Euro-centric and Ethno-centric values

Cultural pattern #4 – Culturally non-aligned, maybe uncertain about cultural dimensions, or unfamiliar with concepts associated with cultural identity, or the significance of these culturally-based statements









VeryStrong

VeryStrong


X X X X X

X X X X X X X X X

An Aural Rehabilitation Model

Bally’s Aural Rehabilitation Model

Bally (1999) introduced a model that illustrates how the diagnostic and rehabilitative aspects of audiologic management can be merged. The model shows the multiple components and various levels (tiers) of interactions involved in contemporary audiometric and aural rehabilitative processes.

Bally’s Aural Rehabilitation Model (cont’d)

With only minor modifications, Bally’s model is an excellent vehicle for demonstrating how cultural competence can be infused into the aural rehabilitation process. The following schematics illustrate the models components and interactions:

Personal FactorsC

onte

xtu

al S

yste

ms

Macro-Systems

Time

Psychological Factors

Meso-Systems

Micro-Systems

Biolo

gica

l

Cogni

tive

Affecti

ve

Behav

ioral

Spirit

ual

Asses

smen

ts

Rehab

ilitat

ion

Accom

mod

ation

Bally’s Aural Rehabilitation Model

Personal Factors

Biolo

gica

l

Spirit

ual

Bally’s Personal Factors

In this model, Biological refers to the function or in this case a malfunction of the auditory system

Spiritual refers to the inextricable desire of many humans to entreat a “higher power’s” help in their time of need.

Cogni

tive

Affecti

ve

Behav

ioral


Bally’s Psychological Factors

Cognitive refers to the thought processes and level of understanding a person has regarding their hearing loss.

Behavioral refers to the actions a person takes regarding managementof their hearing problems

Affective refers to the emotional reactions a person experiences from being hearing impaired

Personal Factors

Psychological Systems

Micro-Systems

Biolo

gica

l

Cogni

tive

Affecti

ve

Behav

ioral

Spirit

ual


Factors Connected

When personal and psychological factors are inter-connected, they comprise Bally’s concept of the Micro-systems. These are those basic factors the client brings to the diagnostic and rehabilitation processes.

Conceptually, all of these factors develop over a period of time

Time

Micro-System Identifiers focus on Assessment)

Point where: Preliminary diagnostic processes (i.e.,

case history, medical exam, etc.) are initiated at this level.

Hearing loss is identified and discussed with client

Hearing “handicap” and hearing aid candidacy is determined.

Hearing rehabilitation plan is introduced.

Scott Bally (1999)

Micro-Systems (cont’d)Hearing handicap inventories and scales

are used specifically to identify: Personal or individual resilience factor\

s Client’s concerns regarding their loss

of hearing Immediate effects of hearing loss on

interpersonal communication Other interpersonal effects (i.e., worry,

fear, loss of self esteem, etc.).

Scott Bally (1999)

Personal Factors

Biolo

gica

lCog

nitiv

eAffe

ctive

Behav

ioral

Spirit

ual



Meso-Systems

Micro-Systems

Biolo

gica

l

Cogni

tive

Affecti

ve

Behav

ioral

Spirit

ual

Asses

smen

ts

Rehab

ilitat

ion

Con

text

ual

Sys

tem

s*

The Meso-Systems (A focus on Rehabilitation)

*Contextual systems refer to how the personal and psychological factors interact at various levelsin the model.

Time

Meso-System Identifiers:

Those factors that account for rehabilitation outcomes:

Accessibility to hearing healthcare services and practitioners in the client’s community

Availability to family support and other support groups

Availability to educational support services for hearing impaired children, and parent groups

Scott Bally (1999)

Personal Factors

Biolo

gica

lCog

nitiv

eAffe

ctive

Behav

ioral

Spirit

ual


Macro-Systems

Time


Meso-Systems

Micro-Systems

Biolo

gica

lCog

nitiv

eAffe

ctive

Behav

ioral

Spirit

ual

Asses

smen

ts

Rehab

ilitat

ion

Accom

mod

ation

Con

text

ual

Sys

tem

s

The Macro-Systems(A focus on Adaptations)

Macro-System Identifiers

National-based systems that influence aural rehabilitation services:

Science/Technology advances Social security Medicare/Medicaid Welfare (welfare reform) Federal laws (i.e., ADA, IDEA, etc.)

Scott Bally (1999).

Macro-System Identifiers: Science/TechnologyThe major influences on economics, social accessibility, quality of life issuesSocial securityMedicare/MedicaidWelfare (welfare reform) Federal laws (i.e., ADA)

Meso-System Identifiers:Availability of services and practitioners in the communityFamily support and support groupsEducational support for hearing impaired childrenParent support groups for hearing impaired children

Micro-System Identifiers:Starting point for rehabilitation processesHearing disability is identified using conventional aassessment techniques and devices (i.e., pure tone, SRT, SD, etc.)Hearing aid evaluations are conductedSpeech reading assessments are conductedHearing handicap inventories and scales help identify:Personal or individual resilience factorsConcerns regarding loss of hearing Effects on interpersonal communicationOther interpersonal effects (i.e., self esteem, etc.)

Cognition Spiritual Behaviors

Biological

Psychological Factors Personal Factors

Micro-Systems

Meso-Systems

Macro-Systems

Affective

Bally’s Model

Another look at Bally, with cultural perspectives identified.

Cognition

Spiritual

Affective Behaviors

Biological

Cultural Factors

Micro-Systems

Meso-Systems

Macro-Systems

Modified Aural Rehabilitation Model with Cultural Factors

Jones, 2001

A Minority Perspective

In 1987, Jones and Richardson-Jones found a disturbing pattern of hearing healthcare issues following a series of health-care screenings conducted in a number of communities across the city of Richmond VA. The majority of African-American senior citizens, who had failed the hearing screening tests, expressed serious concerns about their hearing losses.

A Minority Perspective (cont’d)

Some of their concerns were consistent with those of non-minorities residents. However, most were not.

Common concerns of minority and non- minority elders found with hearing loss:

The nature and extent of the hearing loss.

What caused the hearing loss? Will it get worse? What can be done to correct it? What will it cost?

Jones and Richardson-Jones (1987)

The Minority Perspective (cont’d)

Although the African-American seniors in the Richmond study had comparable concerns with those of their non-minority counterparts, there were several notable differences between the two groups. The African-American seniors differed with regards to:

•the level of their general knowledge and understanding about the ear and hearing processes (cognitive);


• their reaction as to what they would do or could do about the hearing loss (behavior), and

• how they felt about having to contend with a hearing loss and its associated problems (affective).


•Although the types of hearing losses identified (e.g., sensorineural, conductive, mixed) were comparable between minorities and non-minorities, there as a notable delay in minorities seeking assistance, thereby exacerbating the hearing condition (biological)

Summary of differences between non-minority and minority senior citizensNon-Minorities: Likely to have had prior positive

experience(s) with hearing aids or assistive devices

Have other family members or friends who have worn hearing aids

Expect to be able to experiment with hearing aid prior to purchasing

Have access to more information about hearing aids and other devices

Have positive expectations about the outcome of hearing aid use and aural rehabilitation

Minorities: Little to no experience with

hearing aids, etc. Not likely to know anyone

who has worn a hearing aid Has no expectation of being

able to try hearing aids before purchasing

Does not have access to additional information about hearing aids, etc.

Has less than positive expectations about the outcome of hearing aid use and aural rehabilitation

Jones and Richardson-Jones, (1987)

Regarding the Micro-Systems, “ Minorities” tend to have:

• Misconceptions of the role of some health care providers (e.g., “What does an audiologist do?”• Less experience with testing procedures and rehabilitation

Biolog

ical

Spiri

tual

Behav

ioral

Cognit

ive

Emot

iona

l

Micro-Systems

Jones & Richardson-Jones, 1989

Regarding the Micro-Systems, “ Minorities” tend to have: (cont’d)

• More peripheral health and/or social problems associated with socio-economic issues (e.g., limited financial resources).

Regarding the Meso-Systems, “Minorities” tend to have:

• Little to no social connection to healthcare from which to garner personal support and “free” information• Less knowledge and experience with amplification devices

•

•.

Biolog

ical

Spiri

tual

Behav

ioral

Cognit

ive

Affecti

ve

Meso-Systems

Jones & Richardson-Jones 1989

Regarding the Meso-Systems, “Minorities” tend to have: (cont’d)

•Few if any family or friends who have worn hearing aids, consequently no direct support is available from someone familiar with problems associated with hearing loss


Regarding the Macro-Systems, “ Minorities” tend to have:

• Limited access to privately managed healthcare providers; relying instead on social service agencies and clinics for healthcare • More negative experiences with healthcare delivery which predisposes one to have negative expectations of outcome

•

Biolog

ical

Spiri

tual

Behav

ioral

Cognit

ive

Affecti

ve

Macro-Systems

•

Jones & Richardson-Jones, 1989


Regarding the Macro-Systems, “ Minorities” tend to have: (cont’d)

•More negative attitudes in general toward government sponsored programs like Medicare and Medicaid


A Demonstration

Biolog

ical

Spiri

tual

Cognit

ive

Behav

ioral

Affecti

ve

An effective rehabilitation model

Hearing impairment is discovered

Client’sResponse

Person overwhelmed by emotional factors:Uncertainty, fear, frustration, irritation, etc.; Begins responding to life issues.

Response

May start praying

Response

Begins thinking about what to do about hearing problem(s). Checks resources.

Response

Takes action! Goes to see the doctor

Response

Follows doctor’s recommendations tosee an audiologist.

Response

Follows audiologist’s recommendations totry a hearing aid and aural rehabilitation

Response

Fears, concerns, worries, etc. are reducedbecause of effective management of hearingloss.

Response

Maintains rehabilitation program

Response

Stays abreast of latest advances in technology and rehabilitation approaches.

Response

Fears, concerns, worries, etc. are reduced even further because of ongoing effective management of hearing loss.

Response

If hearing loss worsens, has medical resources for assistance.

Response

Another model in action

Biolog

ical

Spiri

tual

Cognit

ive

Behav

ioral

Affecti

ve

Hearing loss is identified

Client’sResponse

Response

Person overwhelmed by emotional factors:uncertainty, fear, frustration, irritation, etc.; begins Responding to life issues

Client Prays

Response

Continues to worry about problem

Response

Prays some more!

Response

Response

Person fails to take more direct action

May not have all the information neededto appreciate the significance of theproblem

Response

Doesn’t take necessary steps to get information or appropriate help.

Response

Delays or postpones action until circumstances (e.g., economic, social, etc.)change.

Response

Maintains high spirituality basethroughout process

Never takes effective action, and lives with the condition.

Hearing status continuesto change

Still worrying about it.

Response

Unsubstantial knowledge and misinformation about hearing loss continues.


The results of the Richmond Study (Jones and Richardson-Jones, 1989) suggested that African-American seniors, and possibly other minority groups, who are in similar socio-economic circumstances, should be approached in a manner that is different from that of more mainstreamed non-minority populations.

Cultural Awareness: Selected Strategies

An audiological practice should begin to incorporate culturally relevant protocols from the moment the client makes his/her initial contact with the clinic or center:

Greetings should be culturally relevant using proper titles, nicknames only if desired, and culturally appropriate body gestures.

Case history should be sensitive to cultural nuances (i.e., privacy issues, stigmatas, taboos, etc.) and release forms should be translated if possible or explained in the native language using an interpreter.

Test instructions should be translated and printed on cards for either the clinician or client or to read. These cards could be useful not just in the clinic but also during hearing screening at fairs and industrial sites. Instructions could be taped and played back.

Test Procedures - the test procedures should be thoroughly explained- in either spoken or written form- in the client’s native language. This will help to allay fears and offset concerns related for example to potential pain and equipment used.

Preliminary assessment (i.e. otoscopy, earphone placement, hearing aid fitting, etc.) should begin with an understanding on the part of the clinician that touching the face or the head, removing a veil or headpiece may be offensive in some cultures. Always ask first.

Socio-cultural differences have a potential of creating cross-cultural conflicts:

As a result there may be…. mild discomfort between parties (i.e. clinician and

client), which can lead to non-cooperation with clinical

protocols, and distrust of recommendations, and general disintegration of therapeutic relationship.

Conflicts may stem from a misinterpretation of… Clinician’s role in relationship Offense at the authority exuded by clinician Communication styles and approaches Intent of physical contact Gender and sexuality issues Other factors

Strategies

1) Rather than attempting to learn an encyclopedia of culture-specific issues, a more practical approach is to explore the various types of problems that are likely to occur in cross-cultural Clinical/therapeutic encounters and to learn to identify and deal with these as they arise.

2) Once the clinician recognizes a potential core issue, it can be explored further by inquiring about the patient’s own belief or preference. Each patient’s situation is unique and is influenced by personal and social factors as well as by culture. Direct questioning and discovery of core issues can avoid cultural pitfalls and help guide further explorationin cross-cultural encounters.

Audiologist’s Professional Responsibilities

To provide competent and professional services and to assure the hearing impaired person attains these goals:

Acceptance of and adjustment to hearing impairment

Acceptance of and adjustment to amplification use

Effective communicability

Cultural Responsibilities

Provide empathetic concern which: Draws upon person’s interpersonal

resources Calls upon social support system(s) Reflects person’s cultural interests

and perspectives

Cultural Competence Checklist for Success

Make the environment more welcoming and attractive based on clients cultural mores.

Avoid stereotyping and misapplication of scientific knowledge.

Include community input at the planning and development stage.

Use educational approaches and materials that will capture the attention of your intended audience.

Adapted from material developed by the National Center for Cultural Competence, Georgetown University Child Development Center.

Cultural Competence Checklist (cont’d) Hire staff that reflect client population. Understand cultural competency is

continually evolving. Be creative in finding ways to

communicate with population groups that have cultural differences and/or limited English-speaking proficiency.

Adapted from material developed by the National Center for Cultural Competence, Georgetown University Child Development Center.

Projected benefits of including cultural competency into aural rehabilitation

For underserved populations, enhanced understanding of hearing loss and its effects on communication

Better self-disclosure and self-acceptance Greater knowledge about how to manage

communication difficulties Reduced stress and discouragement Improved advocacy of hearing healthcare Increased satisfaction with aural rehabilitation

services Increased motivation to minimize listening problems Stronger adherence/compliance with the aural

rehabilitation plan, including use of amplification

Erdman, 1993

Individual’s Path to Cultural Competency

Ethnocentricity – This is a state of relying on our own, and only our own, paradigms based on our cultural heritage. We view the world through narrow filters, and we will only accept information that fits our paradigms. We resist and/or discard others.

Awareness – This is the point at which we begin to realize that there are things that exist which fall outside the realm of our cultural paradigms.

Understanding- This is the point at which we are not only aware that there are things that fall outside our cultural paradigms, but we see the reason for their existence.

Individual’s Path to Cultural Competency

Acceptance/Respect - This is when we begin allowing those from other cultures to just be who they are, and that it is OKAY for things to not always fit into our paradigms.

Appreciation/Value- This is the point where we begin seeing the worth in the things that fall outside our own cultural paradigms.

Selective Adoption - This is the point at which, we begin using things that were initially outside our own cultural paradigms.

Multiculturation- This is when we have begun integrating our lives with our experiences from a variety of cultural experiences.

Cultural Destructiveness is the most negative. It is the attitudes, policies, and practices that are destructive to cultures and the individuals within these cultures. A system that adheres to a destructive extreme assumes that one race or culture is superior and eradicates lesser cultures because of their perceived sub-human condition. Bigotry coupled with vast power allows the dominant group to disenfranchise, control, exploit, or systemically destroys the less powerful population.

Cultural Incapacity occurs when agencies do not intentionally seek to be culturally destructive, but rather have no capacity to help people from other cultures. This system remains extremely biased, and believes in the superiority of the dominant group. It assumes a paternal posture towards “lesser” groups.

Continuum of Cultural CompetencyContinuum of Cultural Competency

Cultural Blindness is characterized by a well intended philosophy; however, the consequence of such a belief can often camouflage the reality of ethnocentrism. This system suffers from a deficit of information and often lack the avenues through which they can obtain needed information.

While these agencies often view themselves as unbiased and responsive to the needs of minority people, their ability to effectively work with a diverse population maybe severely limited.

Cultural Pre-competence implies movement towards reaching out to other cultures. The pre-competent agency realizes its weaknesses in working with people of other cultures and attempts to improve that relationship with a specific population.


Cultural Competence is characterized by acceptance of and respect for differences, continuing self assessment regarding culture, careful attention to the dynamics of differences, and continuous expansion of cultural knowledge and resources.

Cultural Proficiency is the culmination point on the continuum is characterized by holding culture in high esteem. These agencies actively seek to hire a diverse workforce.


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