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Culturally Responsive Practices for Improved Speech-language Pathology and Audiology Interventions in South Africa
Abstract
Cultural and linguistic diversity poses significant challenges in diagnosing and treating speech, language, and hearing disorders. This short communication underscores the necessity of integrating culturally responsive practices within the South African National Health Insurance (NHI) framework, utilizing implementation science to promote equitable care. We outline a framework for developing and implementing culturally sensitive interventions, training programs for healthcare providers, and strategies to ensure inclusivity in patient care. Insights from pilot programs and the implications for health policy and practice within the NHI context are also discussed.
1. INTRODUCTION
It is crucial to recognize cultural and linguistic diversity when providing Speech-language Pathology and Audiology (SLPA) services [1]. Speech-language Patho- logists and Audiologists (SLPAs), who specialize in evaluating and treating individuals across all ages for disorders related to communication, swallowing, and hearing, are uniquely positioned to spearhead discussions on the impact of language and culture on service delivery [2]. Interestingly, the current demographics of South African SLPAs do not mirror the country’s rich linguistic and cultural diversity, with the majority of graduates being English or Afrikaans speaking with only about 23% of registered practitioners being Black African [3-5].
Culture and language play a nuanced and integral role in both the assessment and therapeutic interactions in SLPA [6]. Recognizing cultural and linguistic diversity in SLPA contributes to more accurate diagnoses, effective treatments, and equitable care, ultimately enhancing outcomes for all patients [7]. Moreover, assessments within the cultural context ensure a comprehensive understanding of how communication difficulties impact daily life and relationships while understanding a patient's language proficiency guides the development of appropriate intervention strategies [8]. Khoza-Shangase and Mophosho conceded that it is crucial not to overlook or superficially address these factors [2].
In 2019, the Health Professions Council for South Africa (HPCSA) Board for SLPA professions issued Guidelines for Practice in a Culturally and Linguistically Diverse (CLD) South Africa [9]. These guidelines underscored five principles aimed at advancing the SLPA profession: 1) contextual relevance for effective management of communication difficulties through appropriate clinical processes and protocols; 2) assessment and intervention that challenge traditional knowledge sources; 3) valuing local knowledge to enhance professional practice; 4) improving clinical training within the South African context; and 5) committing to lifelong professional development and critical consciousness. As SLPAs navigate the complexities of the 21st century and transition into the era of service delivery within the framework of the National Health Insurance (NHI), they must adeptly balance acknowledging cultural and linguistic similarities with respecting differences that significantly influence service delivery and professional relationships [10, 11].
Integrating culturally and linguistically appropriate practices within South Africa's NHI is crucial for achieving universal healthcare coverage and ensuring access to high-quality health services for all [11]. These practices ensure that diverse populations receive speech-language and hearing services that respect their cultural beliefs and language preferences, thereby promoting equitable access to NHI services [12]. Providing information and services in patients' preferred languages enhances comprehension and adherence to health advice, critical for the NHI's effectiveness. Culturally sensitive care builds trust between healthcare providers and patients, enhancing satisfaction and health outcomes, which aligns with the goals of NHI to improve overall health [12, 13]. A practical health systems approach for the NHI in South Africa must prioritize these considerations to effectively meet the diverse needs of the population.
1.1. Challenges of Cultural and Linguistic Diversity in Speech, Language, and Hearing Care
According to Statistics South Africa [14], the country's population is estimated at 62 million, reflecting a rich diversity of cultures and languages. Of this population, 81.4% are Black Africans, with isiZulu being the most commonly spoken home language (24.4%), while only 8.7% speak English at home. It is thus vital for SLPAs to consider the patients' proficiency and home language during interventions with bilingual or multilingual individuals [7, 10, 15]. However, the shortage of clinicians fluent in multiple languages limits access to care for those from diverse linguistic backgrounds [5, 16]. Moreover, rel-ying on untrained interpreters presents additional issues, as they may struggle to accurately interpret patients' physical and verbal cues for social relevance and may not have an understanding of the terms used [17, 18].
Standardized tests are often unavailable in every language, leading to inaccurate assessments. Many assessment tools are developed based on Western cultural norms and the English language, making them potentially unsuitable for individuals from diverse backgrounds [1, 2]. For example, while isiZulu is one of the most widely spoken languages in South Africa, there are few diagnostic tools specifically adapted for isiZulu speakers. Most standardized tests are available only in English or Afrikaans, making it challenging for clinicians to accurately assess language disorders without unintentionally introducing linguistic bias [17]. This can result in a risk of either over-diagnosing or under-diagnosing conditions in these populations, as linguistic differences may be mistakenly interpreted as language impairments.
Assessing speech sound disorders without culturally appropriate materials can be challenging, as many tests do not account for the phonetic and phonological structure of indigenous languages, like Setswana or Sepedi [1, 17]. This gap often leads to misdiagnosis or incomplete assessments, particularly in rural areas. Audiologists face similar challenges, as individuals who primarily speak languages, like Tshivenda or Xitsonga, may not fully understand instructions in English or Afrikaans. Without interpreters or translated resources, patients may struggle to comprehend follow-up care, device usage, or hearing conservation practices, impacting their long-term outcomes [7].
Insufficient culturally appropriate resources can hinder the success of interventions [19]. Furthermore, there is a scarcity of culturally and linguistically appropriate research in the field of SLPA, leading to a reliance on data that may not be applicable to diverse groups [6, 20]. However, the challenges posed by linguis-tic and cultural diversity are not unique to the South African context, but are ubiquitous in various countries, such as India, the United Kingdom, Australia, the USA, and Denmark [6, 21].
1.2. Framework for Implementing Culturally and Linguistically Responsive Practices within Health Systems
The current authors advocate for several culturally and linguistically responsive practices within the South African health system, which are aligned with the narratives of researchers in the field. A proposed framework, covering patient intake to monitoring and evaluation, is presented in Table 1. This framework should involve conducting systematic assessments to identify the cultural and linguistic needs of patients and the communities served by the health system. It should also include ongoing training for SLPAs to improve their understanding and skills in working with diverse cultural and linguistic backgrounds, ensuring language access through translated materials and qualified interpreters, and implementing protocols that incorporate cultural beliefs, values, and practices into treatment plans while respecting individual preferences [17, 21, 22]. To address the shortage of SLPAs who speak indigenous languages, partnerships with local universities could focus on recruiting bilingual graduates, particularly those proficient in an African language. Additionally, offering incentives for clinicians to acquire additional language skills could improve service delivery and foster a more linguistically diverse workforce. Furthermore, quality improvement processes are essential for effectively monitoring and adjusting these practices [7].
Culturally and linguistically responsive practices necessitate strong leadership commitment and an organizational culture that prioritizes diversity, equity, and inclusion. This includes dedicating resources and providing support for initiatives focused on cultural and linguistic responsiveness [5]. Leaders must advocate for policies that uphold these practices, such as standards for language services, cultural competence, and patient rights [7]. By integrating these elements into their operations, health systems can effectively meet the diverse needs of their populations, enhance patient-centered care, and achieve improved health outcomes for all individuals they serve (Table 1).
1.3. Role of Implementation Science in Promoting Equitable and Inclusive Care
Implementation science plays a vital role in bridging the gap between research and practice, particularly in promoting equitable and inclusive care for CLD populations [10]. It helps identify and validate effective interventions for different populations, provides ongoing education on best practices for serving CLD groups, encourages community involvement in creating and carrying out interventions, and supports the development of training programs to improve clinicians' cultural competence and language skills [21].
Moreover, implementation science plays a pivotal role in advancing equitable care for CLD populations receiving SLPA services. It establishes guidelines for integrating culturally responsive practices into clinical settings, sets standards for cultural and linguistic competence, and continuously evaluates clinical practices to meet the needs of CLD individuals [9]. Additionally, it provides evidence to support policies that ensure fair care for everyone. By using proven methods, thorough clinician training, integrating policies into everyday practice, and involving the community in decisions based on data, implementation science ensures care that is culturally and linguistically appropriate, ultimately improving health outcomes for diverse populations [9].
1.4. Training Programs and Strategies for Healthcare Providers
Training programs aimed at enhancing cultural and linguistic diversity are indispensable for SLPAs in South Africa [21], as exemplified by the framework outlined in Table 2. These programs should educate on cultural awareness by exploring norms, values, and beliefs, and emphasize respect while mitigating biases and stereotypes [9]. Additionally, encompassing comprehensive knowledge of typical and atypical language development across diverse languages and dialects could be valuable. Moreover, such training should incorporate the use of culturally relevant assessment tools and the creation of intervention materials that resonate with the cultural backgrounds of patients [4].
The implementation of these programs can include workshops, seminars, and courses specifically tailored to cultural and linguistic diversity in SLPA [21]. It is also important to create opportunities for experienced SLPAs to mentor their colleagues in different practices. Moreover, creating ways for SLPAs to share resources, case studies, and best practices can greatly improve their ability to provide culturally sensitive care (Table 2).
1.5. Insights from Pilot Programs and Implications for Broader Health Policy and Practice
To integrate culturally responsive practices into SLPA services within the NHI framework, small-scale pilot programs can be launched in selected NHI-funded institutions, focusing on cultural competencies, like language access and culturally relevant materials. For example, certain health institutions in Gauteng, serving predominantly Black South Africans, employ speech therapy and audiology assistants who also fulfill the role of interpreters, reflecting the community's diverse linguistic needs [17]. This dual role aligns with NHI's goals to improve health outcomes and communication between providers and patients. One of the authors has worked with two such qualified SLPA assistants for over two decades. Their dual role as interpreters has proven highly beneficial, enhancing assessment accuracy, patient comprehension, and therapy effectiveness, congruent with the literature [6, 21]. Importantly, integrating trained and qualified interpreters into healthcare teams aligns with NHI's goals of improving health outcomes and communication between providers and patients [21].
| S.No. | - | - |
|---|---|---|
| 1 | Patient intake and cultural assessment | • Collect information on linguistic background, preferred language(s) for care, and cultural beliefs and values related to health and communication. • Identify any prior exposure to assessment procedures, particularly for individuals from underserved areas. |
| 2 | Selection of culturally relevant assessment tools | • Select assessment tools that align with the patient’s linguistic and cultural background. If unavailable, note potential biases. • Consider informal assessments or dynamic assessments to supplement standardized tools when cultural or linguistic barriers are present. |
| 3 | Engagement of interpreters and culturally competent community members | • Where applicable, involve trained interpreters who are familiar with clinical and cultural nuances. • Collaborate with community members familiar with both the patient’s culture and the clinical context to enhance understanding and build rapport. |
| 4 | Development of culturally adapted intervention plans | • Adapt intervention materials and strategies to the patient’s language, culture, and values, using familiar narratives, symbols, and examples. • Collaborate with family members or caregivers to ensure that intervention strategies align with cultural practices and language preferences. |
| 5 | Follow-up and culturally sensitive outcome evaluation | • Assess outcomes using standardized measures and culturally informed feedback from patients and families. • Adjust interventions based on feedback to ensure they continue to meet cultural and linguistic needs over time. |
| S.No. | - | Core Competencies | Objectives |
|---|---|---|---|
| 1 | Culturally informed communication | Building rapport in culturally respectful ways, using culturally sensitive questioning, and adapting communication styles. | Enable clinicians to engage with patients respectfully and effectively by tailoring communication to cultural preferences and language use. |
| 2 | Language proficiency | Understanding bilingualism and multilingualism dynamics, evaluating language dominance and proficiency, and selecting suitable assessment tools. | Equip clinicians to accurately assess language skills across diverse linguistic backgrounds, avoiding biases tied to language dominance. |
| 3 | Cultural adaptation of treatment materials and interventions | Developing the ability to adapt existing materials to align with cultural contexts by using familiar stories and references and collaborating with patients and families to ensure culturally meaningful interventions. | Enable clinicians to tailor therapy to better resonate with the patient’s cultural and linguistic background while supporting them in seeking patient and family feedback to refine and adapt interventions. |
| 4 | Community engagement and cultural awareness | Building skills in community-based research, partnering with local leaders to enhance service acceptance, and engaging communities in developing and evaluating culturally responsive practices. | Strengthen clinicians’ cultural awareness through community-based learning, foster trust through cultural leader involvement, and align services with community health priorities and values. |
| 5 | Ethical considerations in cultural competence | Recognizing and addressing cultural bias, upholding patient rights, and respecting cultural values and health beliefs. | Guide clinicians in delivering equitable care by adhering to ethical standards that respect patient autonomy and cultural identity. |
Community Health Workers (CHWs), trained from diverse cultural and linguistic backgrounds, can further enhance healthcare delivery by building trust, improving health education, and supporting treatment adherence [23]. In South Africa, the CHW program, initially designed as part of primary healthcare re-engineering for NHI, currently focuses predominantly on HIV, AIDS, and TB care, treatment, and support due to their high incidence rates, as exemplified in projects, like the Chiawelo community practice project in Soweto, Gauteng [5, 24]. Nevertheless, the recognized benefits of CHWs present an opportunity to expand their role to support services, such as SLPA [23].
Before piloting, baseline data on current practices, patient outcomes, and SLPA competencies should be gathered. Feedback loops involving patients, families, and SLPAs could allow for real-time adjustments to meet cultural and linguistic needs, with clear outcomes, such as patient satisfaction and clinician assessments, used to evaluate effectiveness. Following pilot results, a scale-up plan could be developed to expand successful practices across other NHI institutions, integrating lessons into training, policies, and practices. Sustainability strategies, including continuous professional development and regular monitoring, would ensure long-term success and a culture of continuous improvement.
To support this, clear policy guidelines should mandate culturally responsive training for all SLPAs in NHI-funded institutions, focusing on cultural competencies related to linguistic diversity and cultural beliefs [7]. Continuous professional development, including workshops and webinars, should be required to maintain qualifications and ensure that SLPA professionals remain updated on best practices. This approach can help create a workforce capable of providing culturally competent care, supported by monitoring, patient feedback, and cultural assessments, thereby ensuring equitable healthcare delivery across the NHI framework.
CONCLUSION
In South Africa, as well as in other multilingual nations, over 80% of health provider-patient consultations span language and cultural divides [21]. Delivering SLPA services necessitates a deep grasp of cultural and linguistic diversity to ensure fair healthcare, aligning with NHI objectives for universal health coverage [5]. The SLPA field encounters challenges, like language and cultural disparities, a scarcity of validated materials for diverse populations, and a dearth of pertinent research [5, 20]. To tackle these issues in the South African setting, the authors propose several responsive practices, including professional training, leveraging interpreters, and creating culturally and linguistically fitting materials.
These responsive practices should be rooted in implementation science and disseminated through robust training programs. Anecdotal evidence from healthcare institutions illustrates practice-based insights that can evolve into evidence-based practices through rigorous research. This evidence advocates for integrating these practices into the NHI framework to enrich healthcare delivery in diverse, multilingual communities.
AUTHORS’ CONTRIBUTION
It is hereby acknowledged that all authors have accepted responsibility for the manuscript's content and consented to its submission. They have meticulously reviewed all results and unanimously approved the final version of the manuscript.
LIST OF ABBREVIATIONS
| SLPA | = Speech-Language Pathology And Audiology |
| NHI | = National Health Insurance |
FUNDING
O.O. was partially supported by the Incentive Funding for Rated Researchers’ Grant from the National Research Foundation (No.: 132385). The content is solely the authors' responsibility and does not necessarily reflect the official views of the National Research Foundation or Sefako Makgatho Health Sciences University, South Africa.
ACKNOWLEDGEMENTS
Declared none.
