Cultural Considerations for Communication and Swallowing Disorders

In the 1960s African Americans were diagnosed with disorders because of the way they spoke. Professionals assessed cultural differences in their speech as conditions to be treated.

As a result, the American Speech-Language Hearing Association (ASHA) created a Multicultural Affairs office. In time, it sparked conversations about how speech-language pathologists (SLPs) evaluate and intervene with diverse clients’ speech.

“[Language] is so uniquely connected to who people are, their identity, how they behave, what they value, and what’s important to them,” said Vicki Deal-Williams, who has overseen ASHA’s Multicultural Affairs office for the last two decades.

In that time, she has watched as attitudes and realities around culturally sensitive treatment changed: By 2045, the majority of the U.S. population will be people of color and children increasingly speak multiple languages.

Like all providers, SLPs are surrounded by language and culture. But they are also treating it: how do clients speak, what do they hear, and what can they eat? To evaluate and treat these issues, SLPs need to also understand how culture affects them.

The term “culture” is purposefully vague. It encompasses the norms, values, and attitudes shared by groups of people, many of whom are strangers to one another. Shared beliefs rooted in race, ethnicity, religion and more influence perceptions and actions. It affects every aspect of life, including how patients and clients interact with healthcare providers.

Speech-language pathologists work with culture constantly: clients’ values influence what they’re saying, hearing, and eating. The sound of someone’s voice is linked to their upbringing and group norms. The foods eaten on holidays are rooted in tradition. Television, movie, and music preferences and references are all shaped by cultural identity.

Speech-language pathologists (SLPs); audiologists; and speech, language, and hearing scientists are generally less diverse than the overall U.S. population. For example, 4.5% of the profession identifies as Hispanic or Latino compared to 18.3% of the U.S. population. Approximately 3% of SLPs, audiologists, and speech, language, and hearing scientists are black or African American, while more than 13% of the general population is black. However, about 12% of the profession did not specify their race.

Go to a tabular version at the bottom of this page comparing the racial and ethnic composition of ASHA members and the U.S. population.

When SLPs are working with diverse populations, they’re also working with diverse assessments and treatments. However, just a quarter of SLPs said they felt confident serving English Language Learners, according to Bilinguistics.

That’s why cultural competence is so important. Cultural competence, according to the Centers for Disease Control and Prevention, is a combination of behaviors, attitudes, and policies that facilitate effective patient care in cross-cultural interactions.

But “competence” tends to imply the terminal point where a healthcare provider is completely culturally aware. In practice, it’s an ongoing process that requires constant work, attention and reciprocal partnerships.

“It’s the ability to ask questions, be respectful, to engage with individuals, to get a sense of what’s important to them,” Deal-Williams said. “It’s using empathy and trying to help an individual see that in order for you to be effective in helping them, they are going to have to be an active participant.”

When assessing foundational components of clients’ culture, like language, it is vital to understand the line between a “difference” and a “disorder.” To begin, SLPs need to understand their own preferences and attitudes.

For example, when evaluating communication disorders in multilingual speakers, SLPs should ask: How persistent is the issue across all language? If the issue doesn’t appear in every language the client speaks, it’s not a disorder. Instead, it’s a difference that is unique to that language and how they utter it.

But cultural differences also influence treatment goals and plans. Someone who has a tea ceremony with their family every week may prioritize their ability to drink hot liquids. Another person who reads passages at church could care most about diction. It’s important to remember that it’s not up to the provider to make those determinations based on their client’s beliefs, although it is important to understand and appreciate what those beliefs are.

Deal-Williams says we all have biases. “It doesn’t make us bad people. It makes us human. Recognizing where that bias is going to impact my ability to provide services makes me that much more conscious about what I’m saying and doing,” she said.

ASHA Personal Reflection tool

This tool asks providers to reflect on how they view their clients and what kinds of considerations they make for a diverse population. This relies completely on self-awareness and honesty. Use the tool as a starting point to understand your blind spots and opportunities for learning.

National Culturally and Linguistically Appropriate Services Standards

The National CLAS Standards from the U.S. Department of Health & Human Services outline policies for health organizations to implement that ensure the most equitable treatment of patients and clients. Refer to the standards regularly to confirm best practice.

Primary Health Competency Checklist (PDF, 79 KB)

Designated for primary healthcare providers, this checklist covers the physical environment of a clinician’s practice, communication styles, values and attitudes. Use this to create a more detailed level of awareness in your work about how you serve all clients.

Project Implicit

Implicit bias is unconsciously-held beliefs or preferences that can sway our treatment of people. Use these speed-based tests to find your level of bias towards different groups based on race, weight, disability and more.

SPEECH

What are some ways speech, culture, and SLPs interact?:

• Language barriers
• Multilingualism
• Accents
• Differences in dialects

Try This: Venn Diagram Activity

Dr. Ellen Kester, founder of Bilinguistics, works with multilingual children in her practice. She reiterated the importance of understanding a difference versus a disorder, but admitted that it’s difficult when most SLPs can only speak one language. Where do they begin?

Kester recommends comparing the client’s native language with yours using a Venn Diagram. Which sounds are common? That’s where you begin intervention.

“When we see errors in sounds that are in English and not [the client’s] native language, that’s an indication that it’s an influence from their native language and not an impairment,” Kester said. “When we see errors in the middle of the Venn diagram and on the side associated with their native language, then we’re concerned.” 

Phoneme examples courtesy of Bilinguistics Speech Therapy

More tools for cultural considerations about speech:

• The Speech Accent Archive
• Tutorial: Speech Assessment for Multilingual Children Who Do Not Speak the Same Language(s) as the Speech-Language Pathologist (PDF, 227 KB)
• Bilinguistics Speech Therapy Materials

HEARING

What are some ways hearing, culture, and SLPs interact?:

• Head coverings that obstruct the eyes or mouth
• Language of the audio
• Appropriate messaging in music and sample audio

Try This: Recording Sessions

For those that are losing their hearing, a difficult experience can be the feeling of isolation or not being able to meaningfully participate in traditions. Provide an opportunity for your client to share the experiences they want to fully hear—whether it be a prayer before dinner, their favorite song their spouse sings, or the sound of a bedtime story being read to a grandchild. Give clients the tools they need to record those things in a format they can hold on and listen to in a more controlled setting.

More tools:

What are some ways hearing, culture, and SLPs interact?:

• Head coverings that obstruct the eyes or mouth
• Language of the audio
• Appropriate messaging in music and sample audio

Try This: Recording Sessions

For those that are losing their hearing, a difficult experience can be the feeling of isolation or not being able to meaningfully participate in traditions. Provide an opportunity for your client to share the experiences they want to fully hear—whether it be a prayer before dinner, their favorite song their spouse sings, or the sound of a bedtime story being read to a grandchild. Give clients the tools they need to record those things in a format they can hold on and listen to in a more controlled setting.

More tools:

• Religious Head Coverings Across the Globe

SWALLOWING

What are some ways swallowing, culture, and SLPs interact?:

• Fasting requirements
• Traditional holiday meals
• Vegetarian or vegan requirements
• Religious restrictions like keeping kosher or communion
• Routines, such as tea ceremonies

Try This: Menu Activity

A client’s level of adherence to specific religious restrictions or their commitment to family norms is impossible to guess. Instead of making assumptions, give the client the opportunity to describe their lifestyle and preferences.

Ask clients to make a modified menu to use during their treatment. Outlining their restrictions and needs can help guide a plan that meets their goals and set realistic expectations from the beginning. Refer back to it throughout treatment to stay on track.

More tools:

• Guidance on Food for Religious Faiths (PDF, 749 KB)
• Vegetarian vs. Vegan vs. Pescatarian vs. Flexitarian

CLIENT INTERACTIONS

What are some other ways clients, their culture, and SLPs interact?:

• Patient punctuality
• Opinions toward traditional or western healthcare practices
• Acceptance of certain diagnoses
• Eye contact
• Physical contact

Try This: 9 Questions to Learn More About a Patient’s Culture and Values

Take opportunities with clients to ask open-ended questions about their lifestyle and how it may affect treatment. Learning what a client expects from a process is the best way to gain an understanding of how to move forward sensitively.

“You don’t have to go in knowing everything,” Kester said. “But you do have to go in and be respectful of differences.”

1. Is there anything I should know about your values that would make you comfortable?

2. How would you like your family to be involved in your care?

3. What do you like to do in your spare time?

4. What are your favorite foods and when do you like to eat them?

5. What is your daily routine like?

6. What holidays do you celebrate?

7. What traditions are important to you and your family?

8. Does this treatment plan work for you?

9. What are your biggest concerns regarding your diagnosis?

More tools:

• EthnoMed community culture profiles 
• Think Cultural Health resource library 

Providing tailored treatments that align with specific client goals may take time, but the outcome is better for everyone. That’s why effective SLPs view cultural considerations and competency as an opportunity, not an obstacle.

Deal-Williams likened the profession of SLP to being a detective.

“We have a set of information, and we’ve got a client who we should automatically assume is different than we are. And we try to figure out,” she said. “Based on my observations, what they’ve told me, and what I know—what’s really happening here? Being a culturally competent speech-language pathologist provides a unique opportunity to look at the diversity of human beings and how we do things. We can improve the quality of life.”

This section contains tabular data from the graphic in this post.

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Citation for this content: The online speech pathology program from Baylor University’s Robbins College of Health and Human Sciences.