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142

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)