Cultural Competency in Auditory Rehabilitation

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 National Early Hearing Detection And Intervention (EDHI) Conference February 2-3, 2006 Renaissance 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.

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

Projected U.S. Population increases (%) by year 2010 & 2050:
Asian Americans: % % Hispanic Americans: % % African Americans: % % Euro Americans: % % Native Americans: % %

Location/Population of Euro-Americans
DIGITAL ATLAS OF THE UNITED STATES Dr. William A. Bowen California Geographical Survey California State University, Northridge

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. Health Resources and Services Administration U.S. Department of Health and Human Services

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 Administration U.S. Department of Health and Human Services

Hearing loss and its rehabilitation

Incidence per 10,000 of Congenital Defects/Diseases

Prevalence of Hearing Impairment in the U.S. by Age Group and Race
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 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:
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

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

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

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

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

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.

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

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

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

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

Internalized oppression
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

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

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

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

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

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

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

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

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

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

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
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, p.271 (with permission)

Aural Rehabilitation Plan with infusion of 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, p.271 (with permission)

Aural rehabilitation plan with infusion of cultural considerations during client evaluation

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 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, p.271 (with permission)

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 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, p.271 (with permission)

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.

Aural rehabilitation plan with insertion of cultural considerations in communication training

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

Statement |___|___|___|___|___|___|___|___|Statement
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. Very Strong Very Strong Statement |___|___|___|___|___|___|___|___|Statement Mastery over nature Personal control Doing Time dominates Human equality Individualism/privacy Youth Self sufficiency Competition Future orientation Informality Directness Practicality/efficiency Materialism Harmony with nature Fate Being Personal needs dominate Hierarchy/rank/status Group Elders Birthright/inheritance Cooperation Past or present orientation Formality Indirectness Idealism Spiritualism Adapted from Schilling & Brannon, 1986

Euro- American Ethnic minority American Mastery over nature
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 Mastery over nature Personal control Doing Time dominates Human equality Individualism/privacy Youth Self sufficiency Competition Future orientation Informality Directness Practicality/efficiency Materialism Harmony with nature Fate Being Personal needs dominate Hierarchy/rank/status Group Elders Birthright/inheritance Cooperation Past or present orientation Formality Indirectness Idealism Spiritualism Adapted from Schilling & Brannon, 1986

Cultural Pattern #1 – Alignment with Euro-centric American cultural values Adapted from Schilling & Brannon, 1986 Very Strong Very Strong Statement |___|___|___|___|___|___|___|___|Statement Mastery over nature Personal control Doing Time dominates Human equality Individualism/privacy Youth Self sufficiency Competition Future orientation Informality Directness Practicality/efficiency Materialism Harmony with nature Fate Being Personal needs dominate Hierarchy/rank/status Group Elders Birthright/inheritance Cooperation Past or present orientation Formality Indirectness Idealism Spiritualism X

Cultural pattern #2 – Alignment with Ethnocentric American cultural values Very Strong Very Strong Statement |___|___|___|___|___|___|___|___|Statement Mastery over nature Personal control Doing Time dominates Human equality Individualism/privacy Youth Self sufficiency Competition Future orientation Informality Directness Practicality/efficiency Materialism Harmony with nature Fate Being Personal needs dominate Hierarchy/rank/status Group Elders Birthright/inheritance Cooperation Past or present orientation Formality Indirectness Idealism Spiritualism X Adapted from Schilling & Brannon, 1986

Cultural pattern #3 – Non-Alignment, culturally neutral; in state of cultural transition between Euro-centric and Ethno-centric values Very Strong Very Strong Statement |___|___|___|___|___|___|___|___|Statement Mastery over nature Personal control Doing Time dominates Human equality Individualism/privacy Youth Self sufficiency Competition Future orientation Informality Directness Practicality/efficiency Materialism Harmony with nature Fate Being Personal needs dominate Hierarchy/rank/status Group Elders Birthright/inheritance Cooperation Past or present orientation Formality Indirectness Idealism Spiritualism X Adapted from Schilling & Brannon, 1986

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 Very Strong Very Strong Statement |___|___|___|___|___|___|___|___|Statement Mastery over nature Personal control Doing Time dominates Human equality Individualism/privacy Youth Self sufficiency Competition Future orientation Informality Directness Practicality/efficiency Materialism Harmony with nature Fate Being Personal needs dominate Hierarchy/rank/status Group Elders Birthright/inheritance Cooperation Past or present orientation Formality Indirectness Idealism Spiritualism X Adapted from Schilling & Brannon, 1986

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:

Bally’s Aural Rehabilitation Model
Personal Factors Psychological Factors Biological Behavioral Spiritual Affective Cognitive Assessments Micro-Systems Rehabilitation Meso-Systems Contextual Systems Accommodation Macro-Systems Time

Bally’s Personal Factors
Biological Spiritual 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.

Bally’s Psychological Factors
Cognitive Behavioral Affective 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 management of their hearing problems Affective refers to the emotional reactions a person experiences from being hearing impaired

Factors Connected Personal Factors Psychological Factors Biological
Spiritual Cognitive Behavioral Affective Psychological Systems Time Micro-Systems Conceptually, all of these factors develop over a period of time 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.

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)

(A focus on Rehabilitation)
The Meso-Systems (A focus on Rehabilitation) Personal Factors Psychological Factors Biological Cognitive Behavioral Spiritual Affective Assessments Psychological Systems Micro-Systems Rehabilitation Biological Cognitive Affective Behavioral Spiritual Time Contextual Systems* Meso-Systems *Contextual systems refer to how the personal and psychological factors interact at various levels in the model.

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)

(A focus on Adaptations)
The Macro-Systems (A focus on Adaptations) Personal Factors Psychological Factors Biological Cognitive Affective Behavioral Spiritual Assessments Psychological Systems Micro-Systems Rehabilitation Biological Cognitive Affective Behavioral Spiritual Contextual Systems Accommodation Meso-Systems Time Macro-Systems

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).

Bally’s Model Cognition Spiritual Behaviors Biological Affective
Personal Factors Psychological Factors Bally’s Model Cognition Spiritual Behaviors Biological Affective Micro-Systems Micro-System Identifiers: Starting point for rehabilitation processes Hearing disability is identified using conventional a assessment techniques and devices (i.e., pure tone, SRT, SD, etc.) Hearing aid evaluations are conducted Speech reading assessments are conducted Hearing handicap inventories and scales help identify: Personal or individual resilience factors Concerns regarding loss of hearing Effects on interpersonal communication Other interpersonal effects (i.e., self esteem, etc.) Meso-Systems Meso-System Identifiers: Availability of services and practitioners in the community Family support and support groups Educational support for hearing impaired children Parent support groups for hearing impaired children Macro-Systems Macro-System Identifiers: Science/Technology The major influences on economics, social accessibility, quality of life issues Social security Medicare/Medicaid Welfare (welfare reform) Federal laws (i.e., ADA)

Another look at Bally, with cultural perspectives identified.

Modified Aural Rehabilitation Model
with Cultural Factors Cultural Factors Behaviors Cognition Affective Biological Spiritual Micro-Systems Meso-Systems Macro-Systems 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 citizens
Non-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:
Biological Spiritual Cognitive Behavioral Emotional Micro-Systems 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 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:
Biological Spiritual Cognitive Behavioral Affective Meso-Systems 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 . 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 Jones & Richardson-Jones 1989

Regarding the Macro-Systems, “ Minorities” tend to have:
Biological Spiritual Cognitive Behavioral Affective Macro-Systems 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 Jones & Richardson-Jones, 1989 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 Jones & Richardson-Jones 1989

A Demonstration

An effective rehabilitation model
Biological Spiritual Cognitive Behavioral Affective

Hearing impairment is discovered
Client’s Response

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 to see an audiologist.
Response

Follows audiologist’s recommendations to
try a hearing aid and aural rehabilitation Response

Fears, concerns, worries, etc. are reduced
because of effective management of hearing loss. 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
Biological Spiritual Cognitive Behavioral Affective

Hearing loss is identified
Client’s Response

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

Client Prays Response

Continues to worry about problem
Response

Prays some more! Response

Person fails to take more direct action
Response

May not have all the information needed
to appreciate the significance of the problem 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 base throughout process
Hearing status continues to change Still worrying about it. Unsubstantial knowledge and misinformation about hearing loss continues. Response Never takes effective action, and lives with the condition.

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 exploration in 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.

Continuum of Cultural Competency
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.

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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