Abstract
This study explored the demonstration of culturally responsive service provision when planning intervention by speech-language pathologists (SLPs). A fifteen-item survey revealed (a) SLPs consider culture when choosing therapeutic materials, and (b) family structure was the cultural factor selected by the most SLPs, followed closely by race and/or ethnicity. Religion was the least commonly selected cultural factor. Knowledge of multiple factors of culture should be considered to provide culturally competent intervention.
While most speech-language pathologists (SLPs) continue to be White middle-class females (American Speech-Language-Hearing Association [ASHA], 2020; Morrell, 2010), the cultural composition of the clients they serve continues to change. As such, it is the ethical responsibility of an SLP to demonstrate respect for an individual’s cultural composition (ASHA, n.d.-a). The U.S. Census Bureau (2017) predicted that by 2060, over half of the population will be composed of children who are part of a racial or ethnic group other than White. Due to this growth in diversity, it is likely that an SLP will be working with an individual whose cultural and linguistic background is different than their own. In their survey, Guiberson and Atkins (2012) found that 83% of the respondents’ caseloads involved racially diverse clients and families. Only 17% of respondents reported working with primarily White individuals (Guiberson & Atkins, 2012). According to Kritikos (2003), 95% of SLPs reported working with at least one client from a different cultural and linguistic background than their own. This information provides an idea of the prevalence of working with culturally and linguistically diverse (CLD) individuals despite a lack of literature on SLPs’ use of culturally competent practices.
Culture
While some may limit their consideration of cultural factors to race, ethnicity, gender, sex, and origin, cultural components include an abundance of additional factors. Cultural diversity incorporates, but is not limited to, age, disability, ethnicity, gender identity, national origin, dialect, race, religion, sex, sexual orientation, and veteran status. “Culture” itself refers to “integrated patterns for human behavior that include language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or other groups (e.g., gender identity/gender expression, age, national origin, sexual orientation, disability)” (ASHA Issues in Ethics, 2017). It is pertinent to understand that language and communication are not separate from one’s culture. Instead, they are embedded into one’s culture as ways of expressing oneself and mediating learning through experiences.
Cultural Competence
Cultural competence is composed of behaviors, attitudes, and policies coming together in a system, agency, or interprofessional interaction that successfully work in cross-cultural conditions (ASHA, 2017). The promotion of cultural competence and culturally responsive service provision is a topic of critical importance to the field of speech-language pathology, as well as related fields, such as nursing, occupational therapy, and physical therapy (McKivigan, 2021; Riley et al., 2012; Wray & Mortenson, 2011). Cultural considerations are vital to effective practice in health care. Not only should SLPs and other health care professionals work toward cultural competence because of ethical reasons, but there are also legal reasons why consideration of a client’s culture is imperative, such as mandates by Medicare and Medicaid (U.S. Department of Health and Human Services, 2001), and the Individuals With Disabilities Education Act (IDEA; 2004). ASHA explains that cultural competence is important to improve overall quality of services and health outcomes; meet legislative, regulatory, and accreditation mandates; answer to changes of demographics in the United States; and more importantly, disregard long-standing biases in the health status of people based on race, culture, or ethnicity (ASHA, 2017).
Cultural Factors
Although there are an abundance of cultural factors that should be considered when discussing cultural competence, very few of these have been addressed in the literature. Many studies address cultural factors based on language and, by association, race and ethnicity (Craig-Unkefer & Camarata, 2010; Pickering & McAllister, 2000). Race and ethnicity can be indirect factors studied, as they frequently align with use of certain linguistic features, be this within a language or a language variation. For example, Craig-Unkefer and Camarata (2010) discuss how clinicians must consider lexical, grammatical, and cultural differences when working with clients who are learning African American English (AAE) as their primary dialect and have a language impairment. They studied two different intervention methods that have been supported for speakers of mainstream American English (MAE) and used them with four children who speak AAE. These intervention methods included conversational recast and imitation. Results from the study showed a positive effect in treating the language disorders of the AAE-speaking children after the two intervention methods were used. More research is needed to determine the relationship between other intervention interventions strategies used with MAE speakers and their potential uses for AAE speakers. While language, race, and ethnicity are very important cultural factors to consider, cultural domains are vast and include more variety than solely these components.
The influence of socioeconomic status (SES) on an individual’s performance on some expressive and receptive language assessment tasks is an area that should also be considered by SLPs. If the child has no exposure to certain objects and experiences in their culture, it might be unfamiliar to the client, thereby making the task culturally inappropriate. In Maul’s qualitative study (2015), perceptions of nine SLPs and their interactions while working with CLD populations were investigated. Several SLPs reported diversity based on their clients’ cultures as well as their SES and educational levels. These findings suggest that CLD individuals come from vastly diverse backgrounds that include their family upbringing and socioeconomic standing. Still, there are few studies that discuss cultural components like socioeconomic status along with additional areas such as religion, gender, and family structure.
Culturally Responsive Intervention
While far less research has been done on the demonstration of cultural competence in intervention compared with that of assessment, becoming a more culturally competent clinician while providing intervention is equally critical because it impacts an SLP’s effectiveness in interacting, building rapport, and working with CLD students (Grandpierre et al., 2018; Hook et al., 2013; Kang et al., 2016). This is an increasingly important concept as the population of culturally diverse individuals continuously increases. While culturally responsive assessment practices are steadily being adapted (e.g., Gatlin-Nash et al., 2021; Moland & Oetting, 2021), there is a lack of research demonstrating how SLPs are choosing therapy materials to target intervention goals with CLD individuals. To develop culturally responsive materials, SLPs must engage in many thoughtful activities, such as paying attention to the races of the people in the picture, paying attention to pronoun use, and making sure multiple identities of differing cultural backgrounds are represented. The current research provides information on common definitions of cultural competence and how SLPs are assessing and intervening with CLD individuals. The literature also addresses how other helping professions (e.g., physical therapy, occupational therapy, nursing) are implementing culturally responsive practices in their fields and associated benefits (McKivigan, 2021; e.g., improved outcomes, enhanced learning environment, improved willingness to work in underserved areas). However, there is a gap in the literature providing information on the use of culturally appropriate/responsive materials in therapy. As part of a broader inquiry into aspects of clinical care for CLD populations, the primary aim of this research study was to survey practicing SLPs regarding consideration of culture in the selection of intervention planning. As race/ethnicity are the most frequently investigated cultural factors in the current literature base (Craig-Unkefer & Camarata, 2010; Pickering & McAllister, 2000), SLPs will have had the most opportunity to learn from current evidence on these factors. Therefore, it was hypothesized that race/ethnicity would be the most considered cultural factor in the selection of therapy materials.
Method
Participants
One hundred thirty-three participants completed the survey and met inclusion criteria: clinicians who work/have worked with preschool to school-age children in the past year and graduated with their master’s degree in speech-language pathology.
Procedures
Survey Distribution. After obtaining approval from the Auburn University Institutional Review Board (IRB), participants were recruited three ways. The first method of recruitment was through two ASHA Special Interest Groups (SIGs): Cultural and Linguistic Diversity (14) and Language Learning and Education (1). An information letter containing a link to the survey and consent was sent via email to group coordinators then posted online. These SIGs were chosen because their members were likely to work with children. In addition, a brief description of the survey was posted on the ASHA Community website and several SLP Facebook groups of which the primary investigator and/or faculty advisor were members. The post included the embedded link for potential participants to click to be directed to the survey. The post was made public and shareable to the Facebook community. Once potential participants clicked on the link, the information letter and permission of consent was present. Participants were able to provide consent by responding with “yes” or “no” to participate.
Survey Development
The investigators created a web-based, 45-item survey via Qualtrics as a part of a larger investigation on cultural competence in speech-language pathology. Fifteen questions related to the aim of the current study addressed the following areas: (I) Demographics and (II) SLP consideration of cultural factors in intervention planning. See Appendix for the survey.
Part I of the survey collected demographic data of the participating SLPs via Qualtrics using a questionnaire. The demographic questionnaire collected data from participants regarding their age, race, ethnicity, gender identity, religion, sexual identity, language, and geographical region where they have lived majority of their lives. Questions regarding race, ethnicity, gender identification, sexual orientation, and religion had a response option as “prefer not to answer” if they did not feel comfortable answering the question.
Part II of the survey presented one embedded stimulus picture that contained representations of different cultural factors including race, gender, religion, socioeconomic status, and family structure (i.e., the makeup of people who live together and form a family), such as the nuclear and extended family. The stimulus picture was selected following a review of the literature on the topic (Black & Stone, 2005; Letiecq, 2019). Three faculty members with expertise in cultural and linguistic diversity agreed that it represented the cultural facets being queried in the current investigation and that it embodied multiple privileged cultural identities: the White, heterosexual, Christian, nuclear family.
The stimulus selected was an image of a White Barbie doll family that included a woman, a man, and two girls. Barbie is wearing a wedding dress, Ken is wearing a tuxedo, the two girls are wearing dresses, and the family is standing in front of a wedding chapel. To understand cultural competence, it is important to know that the SLP understands that someone’s cultural identity may not align with their privilege so that also needs to be considered when selecting therapy materials. In addition, as the majority of SLPs are White (83.7%, U.S. Census Bureau, 2017), Ken and Barbie were specifically selected as a representation of the predominant race of the profession.
Results
Data Analysis
Responses from the survey were filtered for completion. Responses of any participants who abandoned the survey at any point were not included in the analysis. After closing the survey on Qualtrics, data were extracted to an Excel spreadsheet for descriptive analyses. To determine a mean response for each survey item, responses from participants who responded were averaged. If participants did not respond to an item, averages were obtained using the number of respondents who answered that item rather than the number of individuals who completed the survey.
Demographics
Respondents represented all regions of the United States (Midwest, Northeast, South, and West); most participants being from the South. Concerning race, White was reported as the majority race (75%; n = 103), followed by Black (15%; n = 21). Regarding languages spoken by respondents, 132 participants answered this question. The largest percentage of participants reported that they spoke one primary language (67%; n = 89) while 33% (n = 43) responded that they speak two or more languages. Participants were also asked to report the dialect(s) that they speak. While only 62 respondents answered this question, 32% (n = 20) reported to speak more than one dialect. Table 1 presents dialects spoken by participants.
Reported Dialects Spoken by Study Participants.
Note. n = number of participants, % = percentage of participants, N/A = not applicable. Due to some respondents speaking more than one dialect, the number of participants (n) exceeded the sample size of 62.
Research Question: Is Race/Ethnicity the Most Considered Cultural Factor in the Selection of Therapy Materials When Provided With a Target Stimulus?
One hundred-thirty participants responded to this portion of the survey. Analysis of selected cultural factors revealed that almost all participants selected the cultural factors of family structure (95%; n = 124) and race and/or ethnicity (93%; n = 121). The least chosen factor was religion (72%, n = 93). Four participants chose “other (please specify)” which were not included in the list of choices. These responses included other cultural factors that participants reported should be considered prior to using the stimuli in therapy and included “family and child preferences,” “disability,” “familial expectations,” and “sexual orientation.” Table 2 presents the n’s and percentages associated with each cultural factor.
Cultural Factors Chosen by Study Participants.
Note. n = number of participants, % = percentage of participants. SES = socioeconomic status.
Discussion
The purpose of this study was to explore SLPs’ demonstration of culturally competent service provision during the intervention process. This was done by investigating what cultural factors SLPs selected when choosing therapy materials. As reviewed by Pickering and McAllister (2000), most studies address cultural factors based on language with a focus on race and ethnicity. While the hypothesis of this study was not evidence-supported, it should be noted that this study was over two decades ago, and the difference may be reflective of an increase in the cultural responsiveness of SLPs over time. While not the most selected option, race and/or ethnicity was still the second most chosen cultural factor. This finding is important, since many SLPs work with clients from a different racial/ethnic background. It should be noted that each participant’s unique cultural identity and resulting experiences likely impacts their consideration of culture when planning intervention, in addition to other factors that influence decision making such as reason and emotion (Damasio, 1994).
This study adds to the literature by revealing another cultural factor that SLPs are considering prior to intervention, family structure. This is a positive finding as an appreciation and consideration of different family structures will likely help to build a stronger therapeutic relationship, which is found to contribute to client success (Plexico et al., 2010). While it is an encouraging result that almost all SLPs considered family structure, it is possible that family structure was selected by so many participants due to the nature of the stimulus. Since over 30% of participants reported to speak more than one language, it may be that the personal culture of the participant group was biased toward those in cultures that value family structure differently.
While there is scarce literature focusing on family structure as a cultural consideration, this implies there is a need for research on other cultural factors than race and/or ethnicity. For example, religion was the least considered factor when choosing therapy materials. This finding highlights the need for SLPs to consider religion as a cultural factor when planning interventions. Areas of consideration include refraining from incorporating thematic activities that center around holidays that not all cultures celebrate (e.g., Christmas, Halloween) or using foods that some religious cultures may prohibit (e.g., pork). Williams and McLeod (2012) found in their questionnaire that many respondents made their own materials to use with CLD individuals to represent their diverse caseload. This is reflective of a greater need by producers of therapy materials to ensure representation of a wide variety of cultural backgrounds when developing intervention resources for SLPs. It was not specified in their study which factors of culture were considered; however, it was a specific step in their process of intervention planning to consider the cultural composition of the CLD individual. This could be implied as participants considering the most common cultural factors such as age, gender, occupation, sexual orientation, disability, socioeconomic status, religion, ethnicity, and more (ASHA, n.d.-b). The study by Moodley and colleagues (2005) that explored 10-year-olds’ reactions to folktales representing each of their culture, gender, or physical characteristics helps demonstrate the significance of considering multiple cultural factors for use in therapy materials. The folktales that reflected these aspects of the participants’ lives better captured their interest and encouraged more participation. Moodley’s findings highlight the critical importance of clients seeing themselves in therapy materials, a fact of which SLPs must remain cognizant.
Strengths, Limitations, and Future Directions
This research adds to our knowledge base on SLPs’ consideration of culture during intervention practices. Gaining an understanding of SLPs’ knowledge regarding cultural factors that may form one’s cultural identity is an important step; however, an important question remains. To what degree does SLP knowledge ultimately influence the decision making in planning culturally responsive intervention? This is also a necessary question as other factors are known to influence ones’ decision-making process, including reason and emotion (Damasio, 1994).
With the diversity of family structures present in society, it is a positive finding that most SLPs identified family structure as a cultural factor to be considered in planning intervention. There are many families that do not look like the privileged identity of family structure (e.g., a nuclear family with a mother, father, and children). Many families have a single caregiver, partners who are not married, or two mothers or fathers, for example. Not making assumptions about what a family should look like is an important aspect of cultural competence. However, it is important to note that the social construct of “family” goes beyond the family structure. In the current investigation, the stimulus item provided did not allow for assessment of SLPs’ consideration of the “Family System” in which the family is viewed as a complex social system in which an individual cannot be viewed independently from the system. Rather, family members are interconnected and interdependent (Pfeiffer & In-Albon, 2022). Also, of interest is how family values (e.g., faith, career, commitment), which could not be measured through the current use of Ken and Barbie as stimulus items, can be considered and integrated into intervention planning as supports in communication intervention. Therefore, qualitative investigations into these topics are important future directions. An additional limitation of the current investigation is the possibility that only SLPs interested in multicultural competence may have participated in the survey. Participants who took the survey may have an increased knowledge on working with multicultural populations due to an increased interest in the subject. Another limitation is that the question asked may have been leading. Consequently, participants may have felt forced to choose at least one of the cultural factors listed versus none. Future work in this area may benefit from more detailed examination of the participants’ cultural background themselves through focus groups and one-on-one interviews of participants, and inclusion of more and varied stimuli.
Conclusion and Clinical Implications
The current investigation offers insight into the demonstration of SLPs’ cultural competence during intervention and their consideration of cultural factors embedded in therapy materials. The results showed that while culture is being considered, certain cultural factors are focused on more than others. One may use the findings from this study to support investigating their student’s cultural composition and spending extra time on the factors likely not considered. Professors and other educational leaders may better prepare SLPs to provide culturally responsive services by incorporating multicultural education into their curriculum and inviting their students to think of culture in a more in-depth way with multiple factors. During session planning, clinicians should be intentional to consider not only family structure and race/ethnicity as cultural factors, but to also consider the diversity of cultural factors in each of their students. While this study focused on pediatric service provision, the provision of culturally responsive intervention is critical across the lifespan. Professors and other educational leaders in the field of speech-language pathology may use the findings of this study to gain an understanding of the importance of considering the client’s cultural background in evidence-based practice. By teaching future SLPs to consider different cultural factors in their therapy materials, the journey to becoming a more culturally competent clinician can extend into our intervention practices for both children and adults.
Footnotes
Appendix
Authors’ Note
The work presented in this article is novel and the sole responsibility of the authors.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
