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JCPSLP
Volume 18, Number 3 2016
Journal of Clinical Practice in Speech-Language Pathology
explain communication difficulties in accessible
and appropriate ways, are able to give locally
contextualised examples and explanations in local
languages, and use sustainable materials to make
appropriate resources.
Cultural sensitivity is, arguably, the most salient part of
the Papadopolous et al. (1998) model. The concept of
cultural sensitivity resonates with that of cultural humility. It
reaches beyond knowledge and deeper into the awareness
that there is more to a person’s culture than is, or can be,
articulated (Hall, 1984; Levi, 2009). This implicit cultural
information is rarely accessible to outsiders (Papadopolous
et al., 1998) and that is a primary reason why it is
imperative to work with local partners who do have access
to, and are accepted at, these implicit cultural levels. It is
therefore crucial that speech-language pathologists work
with, and through, local practitioners who bring expertise
beyond clinical skills and are uniquely positioned to access
the communities to which they belong (see Hickey et al.,
2014).
Summary
The concept of culture is continually evolving and it is
therefore crucial that theoretical frameworks develop to
reflect this change. However, the analysis provided
suggests that the current frameworks of clinical cultural
competence do not yet adequately reflect the multifaceted
attributes required to work effectively with people from a
range of backgrounds and require reconceptualisation.
The above reflection and analysis illustrates that
cultural competence in clinical practice encompasses
multidirectional interactions between individuals with
multiple identities and their practitioners, with the
awareness, knowledge and skills to offer effective and
ethical services. In order to develop appropriate skills,
cultural humility must underpin the development of
awareness and knowledge of, and sensitivity towards, one’s
own, and other, cultures (including individual interpretations
of these). As discussed, the theory of cultural humility
dictates that competence is not an endpoint, but an
evolving phenomenon (see Figure 2). In order for speech-
language pathologists to deliver culturally appropriate,
In east Africa, explanatory models of disability are often
deficit-focused, though this is gradually changing. A
biopsychosocial understanding of disability (WHO, 2001)
is prevalent in the minority world and speech-language
pathology professional culture and practice has developed
in line with this model (Leadbeater & Litosseliti, 2014).
External speech-language pathologists’ biopsychosocially
derived skills are therefore at risk of being in juxtaposition
with both the conceptualisation of disability and health care
delivery models predominant in east Africa. My experience
has taught me that it takes time, skill, patience, flexibility
and relationship-building, alongside reflection on both
personal and professional beliefs and knowledge about
explanatory models of disability, to work between the two
paradigms. This relationship between knowledge and skill
development is, again, bidirectional but is not represented
as such in the models.
Understanding of the need to build local capacity is also
critical to culturally competent practice (Barrett et al., 2016;
Hickey et al., 2014; IAHA, 2015) – sustainability is key. In
countries where local speech-language pathologists are
either not available or in short supply, other professionals
may benefit from skill-sharing
4
to enhance their practice
with people with communication disabilities (Hartley, Murira,
Mwangoma, Carter, & Newton, 2009). Consideration
of communication disability as a broader public health
issue, potentially best addressed with a population-based
approach to service delivery, may be a potential solution
to the skill deficit (Wylie, McAllister, Davidson, Marshall, &
Law, 2014). This longer term approach requires advocacy
from service users and providers, political will, and strategic
planning from within to achieve change. It is therefore
crucial that external speech-language pathologists have
the appropriate understanding of the context, and resultant
skills, to support local service users, providers, and
advocates in this process.
Theme 4. Sensitivity
Reflection: In Kenya, Uganda and Rwanda, working
with local organisations has allowed teams of
local partners to build internal capacity and reach
out to people in remote communities who would
not otherwise access services. The partners
Relevant, appropriate and effective
clinical skills and practices
Awareness of own and
other cultures
Knowledge of own and
other cultures
Sensitivity to
other cultures
Cultural humility
Figure 2. Towards an integrated model of cultural competence. Cultural humility underpins the development of awareness and
knowledge of, and sensitivity towards, one’s own and other cultures and the subsequent development of effective clinical skills.
(Integrated model based on Sue et al., 1992; Papadopolous et al., 1998; and Walters, 2015)