Presentation on theme: "Cultural Competency in Auditory Rehabilitation"— Presentation transcript:
1Cultural Competency in Auditory Rehabilitation Recognizing that differences make a differencePresented byRonald Jones, Ph.D., CCC-A and Scott Bally, Ph.D., CCC-SLPNorfolk State University Gallaudet UniversityNorfolk, VA Washington, D.CNational Early Hearing DetectionAnd Intervention (EDHI) ConferenceFebruary 2-3, 2006Renaissance Washington D.C. HotelWashington, D.C.
2Faculty 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.
3Introduction 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, andOffer 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.
4U.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%)
5Projected U.S. Population increases (%) by year 2010 & 2050: Asian Americans: % %Hispanic Americans: % %African Americans: % %Euro Americans: % %Native Americans: % %
6Location/Population of Euro-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. BowenCalifornia Geographical Survey California State University, Northridge
7Location/Population of African-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. BowenCalifornia Geographical Survey California State University, Northridge
8Location/Population of Hispanic-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. BowenCalifornia Geographical Survey California State University, Northridge
9Location/Population of Native-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. BowenCalifornia Geographical Survey California State University, Northridge
10Location/Population of Asian-Americans DIGITAL ATLAS OF THE UNITED STATES Dr. William A. BowenCalifornia Geographical Survey California State University, Northridge
11Demographic 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.
12Examples 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
13Cultural 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, andInconvenient and insufficient hours of operation at health facilities.Health Resources and Services Administration U.S. Department of Health and Human Services
14Minority 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 andDirectly 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
16Incidence per 10,000 of Congenital Defects/Diseases
17Prevalence of Hearing Impairment in the U.S. by Age Group and Race Age (yrs.)African American (%)Euro-American (%)3-171.21.918-442.14.945-647.213.465 and older18.730.1Total (ave.)7.312.5Source: 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.
18StatisticsAccording 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 InstituteHolden-Pitt & Diaz, 1998
19Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree ofhearing lossAge at onsetFortunately, the quasi-prescriptive approachesused by audiologists are fairly amenable ataddressing differences between mild, moderate,severe and profound hearing lossesPersonalitySocio-economicsCulture
20Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree ofhearing lossAge at onsetPersonalityDifferent diagnostic and therapeutic approachesAre available to accommodate the behavior andlinguistic needs of clients.Socio-economicsCulture
21Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree ofhearing lossAge at onsetIndividual and/or group therapy approachesUsed to accommodate the personality (i.e.,(introvert, extrovert) characteristicsof clients that tend to impact on the deliveryand reception of therapeutic approaches.PersonalitySocio-economicsCulture
22Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree ofhearing lossAge at onsetFactors into the availability of services andclient’s capacity to purchase high endproductsPersonalitySocio-economicsCulture
23Factors that might affect therapeutic outcomes in audiology/aural rehab: Degree ofhearing lossWhere differences in the values, attitudes, beliefs,behaviors, etc. of certain ethnic minority groupscan affect the interaction between them andpractitioners.Age at onsetPersonalitySocio-economicsCulture
24Culture 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.
25“Cultural Jeopardy” How to play: A definition will be presented and you must determine the appropriate word from the list.
26PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureThe ability to be open to learning about and accepting of different cultural groups.Cultural Sensitivity1
27PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureA belief that racial differences produce an inherent superiority of a particular race.Racism2
28PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureA generalization of characteristics that is applied to all members of a cultural group.Stereotype3
29Internalized oppression PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureA 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 oppression4
30PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureA belief in the inherent superiority of one pattern of loving over all and thereby the right to dominance.Heterosexism5
31PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureTo make a difference in treatment on a basis other than individual character.Discrimination6
32PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureThe 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
33PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureAn attitude, opinion, or feeling formed without adequate prior knowledge, thought, or reason.Prejudice8
34PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureThe belief in the inherent superiority of one sex (gender) over the other and thereby the right to dominance.Sexism9
35PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureA body of learned beliefs, traditions, principles, and guides for behavior that are shared among members of a particular group.Culture10
36PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureTo 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.Ethnocentrism11
37PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureAs a biological concept, it defines groups of people based on a set of genetically transmitted characteristics.race12
38PrejudiceEthnocentrismStereotypeSexismMulticulturalismCultural SensitivityEthnicityRacismRaceInternalized OppressionDiscriminationHeterosexismCultureSharing a strong sense of identity with a particular religious, racial, or national group.Ethnicity13
39Cultural 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
40How can cultural competence be achieved in aural rehabilitation? Begin with the routine aural rehabilitationprocess, but infuse cultural perspectivesinto both diagnostic and therapeuticaspects, particularly in the following areas:
41Aural Rehabilitation Plan with infusion of major cultural considerations PsychosocialAdjustmentHearing AidsRegularFollow-upEvaluationsand ServicesInformationand AffectiveCounselingClientEvaluationAssistiveDevicesCommunicationTrainingNancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, p.271 (with permission)
42Aural Rehabilitation Plan with infusion of marginal cultural considerations PsychosocialAdjustmentHearing AidsRegularFollow-upEvaluationsand ServicesInformationand AffectiveCounselingClientEvaluationAssistiveDevicesCommunicationTrainingMarginalCulturalConsiderationsNancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, p.271 (with permission)
43Aural rehabilitation plan with infusion of cultural considerations during client evaluation PsychosocialAdjustmentHearing AidsRegularFollow-upEvaluationsand ServicesInformationand AffectiveCounselingClientEvaluationAssistiveDevicesCommunicationTrainingNancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, p.271 (with permission)
44Patient EvaluationQuestions 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 viewUse words that come naturally to you, but are meaningful to the client.Avoid questions requiring merely “yes” or “no” responses
45Aural Rehabilitation Plan with insertion of cultural considerations for information and affective counselingPsychosocialAdjustmentHearing AidsRegularFollow-upEvaluationsand ServicesInformationand AffectiveCounselingClientEvaluationAssistiveDevicesCommunicationTrainingNancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, p.271 (with permission)
46Informational 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
47Aural Rehabilitation Plan with insertion of cultural considerations for personal adjustment counselingPsychosocialAdjustmentHearing AidsRegularFollow-upEvaluationsand ServicesInformationand AffectiveCounselingClientEvaluationAssistiveDevicesCommunicationTrainingNancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, p.271 (with permission)
48Psychosocial Adjustment Use cultural referents to establish therapeutic goals and objectivesExplore client’s prior experiences with hearing healthcare servicesExplore client’s support system (i.e., family, community, social services agencies, ) to determine their adequacyRefer client’s whose needs exceed your capacity to assist or to rehabilitate.
49Aural rehabilitation plan with insertion of cultural considerations in communication training PsychosocialAdjustmentHearing AidsRegularFollow-upEvaluationsand ServicesInformationand AffectiveCounselingClientEvaluationAssistiveDevicesCommunicationTrainingNancy Tye-Murray, Foundations of Aural Rehabilitation, Singular Publishing Group, p.271 (with permission)
50Communication 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.
52Stage Development of Cultural Awareness Stage 1: Unawareness of cultural/social issuesDescription: Person does not entertain any cultural/social difference hypothesesConsequence: 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 differencesDescription: A person becomes hyper-vigilant in identifying cultural/social factors and is at times confused in determiningthe cultural/social significance of a person’s actions.Consequences: The consideration of cultural/social influences is initially perceived as a distraction, something whichNegatively 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 differencesDescription: 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 developingbehaviors.Stage 4: Cultural/social sensitivityDescription: 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.
54Statement |___|___|___|___|___|___|___|___|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.VeryStrongVeryStrongStatement |___|___|___|___|___|___|___|___|StatementMastery over naturePersonal controlDoingTime dominatesHuman equalityIndividualism/privacyYouthSelf sufficiencyCompetitionFuture orientationInformalityDirectnessPracticality/efficiencyMaterialismHarmony with natureFateBeingPersonal needs dominateHierarchy/rank/statusGroupEldersBirthright/inheritanceCooperationPast or present orientationFormalityIndirectnessIdealismSpiritualismAdapted from Schilling & Brannon, 1986
55Euro- 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-AmericanEthnic minorityAmericanMastery over naturePersonal controlDoingTime dominatesHuman equalityIndividualism/privacyYouthSelf sufficiencyCompetitionFuture orientationInformalityDirectnessPracticality/efficiencyMaterialismHarmony with natureFateBeingPersonal needs dominateHierarchy/rank/statusGroupEldersBirthright/inheritanceCooperationPast or present orientationFormalityIndirectnessIdealismSpiritualismAdapted from Schilling & Brannon, 1986
56Statement |___|___|___|___|___|___|___|___|Statement Cultural Pattern #1 – Alignment with Euro-centric American cultural valuesAdapted from Schilling & Brannon, 1986VeryStrongVeryStrongStatement |___|___|___|___|___|___|___|___|StatementMastery over naturePersonal controlDoingTime dominatesHuman equalityIndividualism/privacyYouthSelf sufficiencyCompetitionFuture orientationInformalityDirectnessPracticality/efficiencyMaterialismHarmony with natureFateBeingPersonal needs dominateHierarchy/rank/statusGroupEldersBirthright/inheritanceCooperationPast or present orientationFormalityIndirectnessIdealismSpiritualismX
57Statement |___|___|___|___|___|___|___|___|Statement Cultural pattern #2 – Alignment with Ethnocentric American cultural valuesVeryStrongVeryStrongStatement |___|___|___|___|___|___|___|___|StatementMastery over naturePersonal controlDoingTime dominatesHuman equalityIndividualism/privacyYouthSelf sufficiencyCompetitionFuture orientationInformalityDirectnessPracticality/efficiencyMaterialismHarmony with natureFateBeingPersonal needs dominateHierarchy/rank/statusGroupEldersBirthright/inheritanceCooperationPast or present orientationFormalityIndirectnessIdealismSpiritualismXAdapted from Schilling & Brannon, 1986
58Statement |___|___|___|___|___|___|___|___|Statement Cultural pattern #3 – Non-Alignment, culturally neutral; in state of cultural transition between Euro-centric and Ethno-centric valuesVeryStrongVeryStrongStatement |___|___|___|___|___|___|___|___|StatementMastery over naturePersonal controlDoingTime dominatesHuman equalityIndividualism/privacyYouthSelf sufficiencyCompetitionFuture orientationInformalityDirectnessPracticality/efficiencyMaterialismHarmony with natureFateBeingPersonal needs dominateHierarchy/rank/statusGroupEldersBirthright/inheritanceCooperationPast or present orientationFormalityIndirectnessIdealismSpiritualismXAdapted from Schilling & Brannon, 1986
59Statement |___|___|___|___|___|___|___|___|Statement 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 statementsVeryStrongVeryStrongStatement |___|___|___|___|___|___|___|___|StatementMastery over naturePersonal controlDoingTime dominatesHuman equalityIndividualism/privacyYouthSelf sufficiencyCompetitionFuture orientationInformalityDirectnessPracticality/efficiencyMaterialismHarmony with natureFateBeingPersonal needs dominateHierarchy/rank/statusGroupEldersBirthright/inheritanceCooperationPast or present orientationFormalityIndirectnessIdealismSpiritualismXAdapted from Schilling & Brannon, 1986
61Bally’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.
62Bally’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:
63Bally’s Aural Rehabilitation Model Personal FactorsPsychological FactorsBiologicalBehavioralSpiritualAffectiveCognitiveAssessmentsMicro-SystemsRehabilitationMeso-SystemsContextual SystemsAccommodationMacro-SystemsTime
64Bally’s Personal Factors BiologicalSpiritualIn this model, Biological refers to the functionor in this case a malfunction of the auditorysystemSpiritual refers to the inextricable desire of manyhumans to entreat a “higher power’s” help in theirtime of need.
65Bally’s Psychological Factors CognitiveBehavioralAffectiveCognitive refers to the thought processes and level of understanding a person hasregarding their hearing loss.Behavioral refers to the actions a person takes regarding managementof their hearing problemsAffective refers to the emotional reactions a person experiences from being hearing impaired
66Factors Connected Personal Factors Psychological Factors Biological SpiritualCognitiveBehavioralAffectivePsychological SystemsTimeMicro-SystemsConceptually, all of thesefactors develop over a periodof timeWhen personal and psychological factors are inter-connected, theycomprise Bally’s concept of the Micro-systems. These are those basic factors the client brings to the diagnostic and rehabilitation processes.
67Micro-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 clientHearing “handicap” and hearing aid candidacy is determined.Hearing rehabilitation plan is introduced.Scott Bally (1999)
68Micro-Systems (cont’d) Hearing handicap inventories and scales are used specifically to identify:Personal or individual resilience factor\sClient’s concerns regarding their loss of hearingImmediate effects of hearing loss on interpersonal communicationOther interpersonal effects (i.e., worry, fear, loss of self esteem, etc.).Scott Bally (1999)
69(A focus on Rehabilitation) The Meso-Systems(A focus on Rehabilitation)Personal FactorsPsychological FactorsBiologicalCognitiveBehavioralSpiritualAffectiveAssessmentsPsychological SystemsMicro-SystemsRehabilitationBiologicalCognitiveAffectiveBehavioralSpiritualTimeContextual Systems*Meso-Systems*Contextual systems refer to how the personal and psychological factors interact at various levelsin the model.
70Meso-System Identifiers: Those factors that account for rehabilitation outcomes:Accessibility to hearing healthcare services and practitioners in the client’s communityAvailability to family support and other support groupsAvailability to educational support services for hearing impaired children, and parent groupsScott Bally (1999)
71(A focus on Adaptations) The Macro-Systems(A focus on Adaptations)Personal FactorsPsychological FactorsBiologicalCognitiveAffectiveBehavioralSpiritualAssessmentsPsychological SystemsMicro-SystemsRehabilitationBiologicalCognitiveAffectiveBehavioralSpiritualContextual SystemsAccommodationMeso-SystemsTimeMacro-Systems
72Macro-System Identifiers National-based systems that influence aural rehabilitation services:Science/Technology advancesSocial securityMedicare/MedicaidWelfare (welfare reform)Federal laws (i.e., ADA, IDEA, etc.)Scott Bally (1999).
73Bally’s Model Cognition Spiritual Behaviors Biological Affective Personal FactorsPsychological FactorsBally’s ModelCognitionSpiritualBehaviorsBiologicalAffectiveMicro-SystemsMicro-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 hearingEffects on interpersonal communicationOther interpersonal effects (i.e., self esteem, etc.)Meso-SystemsMeso-System Identifiers:Availability of services and practitioners in the communityFamily support and support groupsEducational support for hearing impaired childrenParent support groups for hearing impaired childrenMacro-SystemsMacro-System Identifiers:Science/TechnologyThe major influences on economics, social accessibility, quality of life issuesSocial securityMedicare/MedicaidWelfare (welfare reform)Federal laws (i.e., ADA)
74Another look at Bally, with cultural perspectives identified.
75Modified Aural Rehabilitation Model with Cultural FactorsCultural FactorsBehaviorsCognitionAffectiveBiologicalSpiritualMicro-SystemsMeso-SystemsMacro-SystemsJones, 2001
76A 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.
77A Minority Perspective (cont’d) Some of their concerns were consistent with those of non-minorities residents. However, most were not.
78Common 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)
79The 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);
80The Minority Perspective (cont’d) their reaction as to what they would do or could do about the hearing loss (behavior), andhow they felt about having to contend with a hearing loss and its associated problems (affective).
81The Minority Perspective (cont’d) 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)
82Summary of differences between non-minority and minority senior citizens Non-Minorities:Likely to have had prior positive experience(s) with hearing aids or assistive devicesHave other family members or friends who have worn hearing aidsExpect to be able to experiment with hearing aid prior to purchasingHave access to more information about hearing aids and other devicesHave positive expectations about the outcome of hearing aid use and aural rehabilitationMinorities:Little to no experience with hearing aids, etc.Not likely to know anyone who has worn a hearing aidHas no expectation of being able to try hearing aids before purchasingDoes not have access to additional information about hearing aids, etc.Has less than positive expectations about the outcome of hearing aid use and aural rehabilitationJones and Richardson-Jones, (1987)
83Regarding the Micro-Systems, “ Minorities” tend to have: BiologicalSpiritualCognitiveBehavioralEmotionalMicro-SystemsRegarding 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 rehabilitationJones & Richardson-Jones, 1989
84Regarding 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).
85Regarding the Meso-Systems, “Minorities” tend to have: BiologicalSpiritualCognitiveBehavioralAffectiveMeso-SystemsRegarding the Meso-Systems, “Minorities” tend to have:Little to no social connection tohealthcare from which to garner personalsupport and “free” informationLess knowledge and experience withamplification devices.Jones & Richardson-Jones 1989
86Regarding 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 lossJones & Richardson-Jones 1989
87Regarding the Macro-Systems, “ Minorities” tend to have: BiologicalSpiritualCognitiveBehavioralAffectiveMacro-SystemsRegarding the Macro-Systems, “ Minorities” tend to have:Limited access to privately managedhealthcare providers; relying instead onsocial service agencies and clinics forhealthcareMore negative experiences withhealthcare delivery which predisposes oneto have negative expectations of outcomeJones & Richardson-Jones, 1989Jones & Richardson-Jones 1989
88Regarding the Macro-Systems, “ Minorities” tend to have: (cont’d) More negative attitudes in general toward government sponsored programs like Medicare and MedicaidJones & Richardson-Jones 1989
109Person fails to take more direct action Response
110May not have all the information needed to appreciate the significance of theproblemResponse
111Doesn’t take necessary steps to get information or appropriate help. Response
112Delays or postpones action until circumstances (e.g., economic, social, etc.)change.Response
113Maintains high spirituality base throughout process Hearing status continuesto changeStill worrying about it.Unsubstantialknowledge andmisinformationabout hearingloss continues.ResponseNever takes effectiveaction, and lives withthe condition.
114The Minority Perspective (cont’d) 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.
115Cultural 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.
116Socio-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, anddistrust of recommendations, andgeneral disintegration of therapeutic relationship.Conflicts may stem from a misinterpretation of…Clinician’s role in relationshipOffense at the authority exuded by clinicianCommunication styles and approachesIntent of physical contactGender and sexuality issuesOther factors
117Strategies1) 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.
118Audiologist’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 impairmentAcceptance of and adjustment to amplification useEffective communicability
119Cultural Responsibilities Provide empathetic concern which:Draws upon person’s interpersonal resourcesCalls upon social support system(s)Reflects person’s cultural interests and perspectives
120Cultural 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.
121Cultural 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.
122Projected benefits of including cultural competency into aural rehabilitation For underserved populations, enhanced understanding of hearing loss and its effects on communicationBetter self-disclosure and self-acceptanceGreater knowledge about how to manage communication difficultiesReduced stress and discouragementImproved advocacy of hearing healthcareIncreased satisfaction with aural rehabilitation servicesIncreased motivation to minimize listening problemsStronger adherence/compliance with the aural rehabilitation plan, including use of amplificationErdman, 1993
123Individual’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.
124Individual’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.
125Continuum 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.
126Continuum 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.
127Continuum of Cultural Competency 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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