Portal de Periódicos da CAPES

Finding Success in Cultural Competence

2015; Lippincott Williams & Wilkins; Volume: 68; Issue: 11 Linguagem: Inglês

10.1097/01.hj.0000473653.54858.81

2333-6218

Gina Shaw,

Interpreting and Communication in Healthcare

Figure.Several years ago, an American traveled to Zambia with big plans for starting an audiology training program there. Although he had never traveled to Africa before, the American managed to meet with Zambia's minister of health to outline the plan. “But what that American didn't know was that in Zambia, nodding and saying ‘Uh-huh,’ doesn't really mean agreement,” said Jackie Clark, PhD, a clinical professor at the University of Texas at Dallas School of Brain and Behavioral Sciences, who also serves as a research scholar at the University of the Witwatersrand in Johannesburg, South Africa, and collaborates with several other universities in Africa and Asia. “So the professional from the United States ran with it, and was very surprised, upon returning to Zambia, when the lone Zambian audiologist said, ‘No, this won't work,’” Dr. Clark said. “That Zambian audiologist had studied in the United States and learned about assertiveness.” Whether you are working with patients or other professionals overseas, or in the United States, cultural competence is something that every audiologist should develop, according to Dr. Clark. The actual term, ‘cultural competence,’ however, is misleading. “I will never be culturally competent,” Dr. Clark said. “I continue to strive, but my whole being is shaped around my culture. I grew up very poor in a multicultural area, and I am still constantly kicking and trying to monitor myself, but I will never be completely competent. The best we can hope for is to be culturally aware.” Whether you call it cultural competence or cultural awareness, what it means in health care is being responsive to the cultural and linguistic differences that affect the identification, assessment, and treatment of your patients’ needs. “Cultural and linguistic competence is as important to the successful provision of services as are scientific, technical, and clinical knowledge and skills,” according to a section on cultural competence on the American Speech–Language–Hearing Association (ASHA) website. Fifteen years ago, the U.S. Department of Health and Human Services’ Office of Minority Health published the first National Standards for Culturally and Linguistically Appropriate Services in Health Care (National CLAS Standards) in an effort to better serve the nation's increasingly diverse communities. These 15 standards, which have since been revised and enhanced, can be found online along with an array of fact sheets, video guides, and implementation strategies.1 Several states, including New Mexico, New Jersey, and California, have legislation mandating cultural competence training for physicians, and others are considering it, although no legislation is currently on the books that specifically applies to hearing health care professionals. TEST YOURSELF Just how culturally competent is your hearing health care practice? That can be a hard question to answer. We all like to think that we are open and responsive to the needs and backgrounds of people who are different from us, but sometimes it's hard to see our own blind spots. You can assess your own personal attitudes toward clients from diverse populations, your practice's policies, and how well you're delivering services to these populations using assessment checklists provided by ASHA.2 This section of the site also offers an interactive, web-based tool specifically designed to evaluate cultural competence in hearing health care. Once you have a better sense of how culturally competent (or aware) you and your practice are, how can you best serve a diverse population? It starts with a community assessment, said Robert Novak, PhD, the director of the Center of Excellence in Communication Sciences and Disorders (CECSD) in the Department of Otolaryngology–Head and Neck Surgery at the University of Texas Health Science Center. “We all need to be generally culturally sensitive, but it's impossible to be culturally competent in every culture,” Dr. Novak said. “Look at the community you practice in as leading the dance in terms of how you develop your practice. What are the unique cultural subgroups in your community, and how do they look at hearing health care?” For example, if you practice in Fresno, CA, St. Paul, MN, or Wausau, WI, it's a very good idea for you to educate yourself on the beliefs and health practices of the Hmong people, natives of Southeast Asia. (More than nine percent of Wausau's population of just under 40,000 is of Hmong descent.) Audiologists practicing in Minneapolis–St. Paul would also do well to learn about the culture of Somali Americans, who reside in Columbus, OH, Seattle, and San Diego. One of the biggest issues in cultural competency, of course, is language proficiency. Many first- and second-generation immigrants have limited English proficiency. Approximately 61.6 million individuals, both foreign and born in the United States, spoke a language other than English at home, according to a 2013 report from the Migration Policy Institute. Find out the primary languages spoken by the immigrant communities in your area, and determine what you can do to provide interpretation and translation services for them. Some of your options may include bilingual staffs, staff interpreters, outside interpreter services, volunteer community interpreters, and/or telephone services. If you are using bilingual staff members rather than trained medical interpreters, however, make sure that those staff members have the skill and fluency to accurately convey hearing health care concepts to the patient. When in doubt, contact the International Medical Interpreters Association3 or Language Line Solutions.4 How else can cultural differences affect hearing health care? Dr. Clark has spent 18 years traveling to sub-Saharan Africa to provide ear and hearing care outreach in rural areas. “One group I had contact with became very incensed when they returned and found that the hearing aids they had dispensed kind of ‘migrated’ to other people they weren't dispensed to,” she recalled. “But that community is a much more collectivist society. If you dispense a hearing aid, it is going to be shared within the community. ‘My neighbor needs a hearing aid, I have one, so I'm going to share mine with him.’ You have to work with people specifically to get them to understand that this is your hearing loss, and your hearing aid custom fit for you and programmed for your needs. You need to offer as much counseling as possible to help them understand that the aid won't work for other people, and that they don't want to ruin their community members’ ears or destroy what hearing they have left.” In some Asian cultures, a degree of shame may be associated with having a child with some sort of physical disability, said King Chung, PhD, an associate professor of audiology at Northern Illinois University and co-editor with Dr. Clark of HJ’s Audiology Without Borders column. “This may mean that the family does not go out to get help for a child with a hearing loss, which puts that child in a very disadvantaged position,” she said. “It's important to help them understand their options and overcome that stereotype, and let them know that they are not alone.” In many Asian and African countries, family decision making about health care choices does not follow the typical American model. “You may be talking to the parents of a child with hearing loss and believe that they are the ultimate decision makers, but you have to do your due diligence and find out who's actually the final arbiter of the decision and connect with them. In many Asian cultures, for example, that's Grandma,” Dr. Chung said. BECOMING CULTURALLY COMPETENT Dr. Clark frequently takes students with her on her trips to Africa, which helps them become educated about other cultures and approaching the differences in hearing health care. “One thing I require they do is go through the Peace Corps manuals for the countries we are visiting,” she said. That can be useful even if you're not traveling overseas, but rather providing hearing health care here in the United States to people from other cultures. Typing in “Peace Corps manual” and the name of the country or countries into Google should yield a document called “The Peace Corps Welcomes You to [Country Name].” These manuals focus primarily on the experience of volunteering in that country, but they will give you a sense of the traditions, beliefs, and etiquette that may influence your patients’ decisions. Dr. Chung strongly recommends travel as the best promoter of cultural competence. “Go out and serve in humanitarian programs; I think that is the best. We can look at books all the time, but unless you're in the country and see things differently and understand that people may do things differently, you don't really understand.” In your own backyard, Dr. Novak recommends teaming with local refugee centers, health clinics, and churches that directly serve particular cultural groups. Cultural competence can also help you build your practice, Dr. Novak said. “Many of the people in some of the immigrant and underserved communities in the United States have untreated middle ear disorders that have evolved into mixed and sensorineural hearing losses, and they need help. This is a patient population you can serve,” he said. The business model for caring for these communities may have to change, however. “You'll have to figure out a new model of hearing aid sales delivery that makes up in volume what you may lose in unit cost, setting up a practice that's accessible in terms of how you're marking up your units and unbundling it from service delivery,” Dr. Novak said. “What many of these populations need is good, family-centered rehabilitation that maximizes the potential for good outcomes: keeping hearing aids, wearing them, and benefiting from them. Hearing loss can really impair things for people who are trying to learn English, get a job, and go to the next level in this country, and often the person doesn't realize just how much it's holding them back.”