Cultural competence involves understanding and appropriately responding to the unique
combination of cultural variables and the full range of dimensions of diversity that the
professional and client/patient/family bring to interactions.
“Culture and cultural diversity can incorporate a variety of factors, including but not limited to
age, disability, ethnicity, gender identity (encompasses gender expression), national origin
(encompasses related aspects e.g., ancestry, culture, language, dialect, citizenship, and
immigration status), race, religion, sex, sexual orientation, and veteran status. Linguistic
diversity can accompany cultural diversity.” (ASHA, 2017)
The client/patient population reflects a wide array of differences and similarities across cultural
variables. Professional competence requires that audiologists and speech-language pathologists
(SLPs) practice in a manner that considers each client’s/patient’s/family’s cultural and linguistic
characteristics and unique values so that the most effective assessment and intervention services
can be provided (ASHA, 2004, 2006).
Developing cultural competence is a dynamic and complex process requiring ongoing selfassessment and continuous expansion of one’s cultural knowledge. It evolves over time,
beginning with an understanding of one’s own culture, continuing through interactions with
individuals from various cultures, and extending through one’s own lifelong learning.
Clinical approaches—such as interview style, assessment tools, and therapeutic techniques—that
are appropriate for one individual may not be appropriate for another. It is important to recognize
that the unique influence of an individual’s cultural and linguistic background may change over
time and according to circumstance (e.g., interactions in the workplace, with authority figures,
within a social context), necessitating adjustments in clinical approaches.
Cultural competence in service delivery is increasingly important to
respond to demographic changes in the United States;
eliminate long-standing disparities in the health status of people based on racial, ethnic,
and cultural backgrounds;
improve the quality of services and health outcomes; and
meet legislative, regulatory, and accreditation mandates.
In addition, cultural competence can contribute to a competitive edge in the marketplace and
decrease the likelihood of liability/malpractice claims.
Roles and Responsibilities
Professional competence requires that audiologists and SLPs practice in a manner that considers
the impact of cultural variables as well as language exposure and acquisition on their
clients/patients and their family. ASHA-certified practitioners have met rigorous academic and
professional standards, including knowledge of cultural variables and how they may influence
communication.. Clinicians are responsible for providing competent services, including cultural
responsiveness to clients/patients/families during all clinical interaction. Responsiveness to the
cultural and linguistic differences that affect identification, assessment, treatment, and
management includes the following:
Completing self-assessment to consider the influence of one’s own biases and beliefs and
the potential impact on service delivery
Identifying and acknowledging limitations in education, training, and knowledge and
seeking additional resources and education to develop cultural competence via continuing
education, networking with community members, and so forth
Seeking funding for and engaging in ongoing professional development of cultural
competence throughout one’s career
Demonstrating respect for an individual’s age, disability, ethnicity, gender identity,
national/regional origin, race, religion, sex, sexual orientation, and veteran status
Integrating clients’/patients’/families’ traditions, customs, values, and beliefs in service
Identifying the impact of assimilation and acculturation on communication patterns
during identification, assessment, treatment, and management of a communication
Assessing/treating each client/patient/family as an individual and responding to his/her
unique needs, as opposed to anticipating cultural variables based on assumptions
Identifying appropriate intervention and assessment strategies and materials that do not
violate the client’s/patient’s/family’s unique values and/or create a chasm between the
clinician and client/patient/family and his/her community
Using culturally appropriate communication with clients/patients, caregivers, and family
so that information presented during counseling is provided in a health literate format
consistent with clients’/patients’ cultural values
Referring to/consulting with other service providers with appropriate cultural and
linguistic proficiency, including using a cultural informant or broker
Upholding ethical responsibilities during the provision of clinically appropriate services
Clinicians also have a responsibility to advocate on behalf of consumers, families, and
communities at risk for or with communication disorders and differences, swallowing, and/or
balance disorders. Advocacy specific to cultural competence includes the following:
Collaborating with professionals across disciplines and with local and national
organizations to gain knowledge of, develop, and disseminate educational, health, and
medical information pertinent to particular communities
Gaining knowledge and education of high risk factors (e.g., hypertension, heart disease,
diabetes, fetal alcohol syndrome) in particular communities and the incidence and
prevalence of these risk factors that can result in greater likelihood for
Providing education regarding prevention strategies for
communication/swallowing/balance disorders in particular communities
Providing appropriate and culturally relevant consumer information and marketing
materials/tools for outreach, service provision, and education, with consideration of the
health literacy, values, and preferences of communities taken into consideration
Identifying and educating communities regarding the impact of state and federal
legislation on service delivery
Cultural and linguistic competence is as important to the successful provision of services as are
scientific, technical, and clinical knowledge and skills. The ASHA Code of Ethics (ASHA, 2016)
contains the fundamentals of ethical conduct, which are described by Principles of Ethics and by
Rules of Ethics. Rules of Ethics are specific statements of minimally acceptable as well as
unacceptable professional conduct. The Code of Ethics speaks directly to the need for culturally
and linguistically competent services and research, specifically:
Individuals shall provide all clinical services and scientific activities competently
(Principle I, Rule A).
Individuals shall use every resource, including referral and/or interprofessional
collaboration when appropriate, to ensure that quality service is provided (Principle I,
Individuals shall not discriminate in the delivery of professional services or in the
conduct of research and scholarly activities on the basis of race, ethnicity, sex, gender
identity/gender expression, sexual orientation, age, religion, national origin, disability,
culture, language, or dialect (Principle I, Rule C).
Individuals who hold the Certificate of Clinical Competence shall engage in only those
aspects of the professions that are within the scope of their professional practice and
competence, considering their certification status, education, training, and experience
(Principle II, Rule A).
Individuals shall not engage in any form of conduct that adversely reflects on the
professions or on the individual’s fitness to serve persons professionally (Principle IV,
Individuals shall not discriminate in their relationships with colleagues, assistants,
students, support personnel, and members of other professions and disciplines on the
basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age,
religion, national origin, disability, culture, language, dialect, or socioeconomic status
(Principle IV, Rule L).
Principles of Ethics and Rules of Ethics are not intended to serve as justification for the denial of
services nor as the basis for discrimination in the delivery of professional services or the conduct
of research and scholarly activities. Rather, “individuals shall enhance and refine their
professional competence and expertise through engagement in lifelong learning applicable to
their professional activities and skills” (Principle II, Rule D). Care should not vary in quality
based on factors such as ethnicity, age, or socioeconomic status. Discrimination in any
professional arena and against any individual, whether subtle or overt, ultimately dishonors the
professions and harms all those within the practice.
Clinicians have an obligation to seek the information and expertise required to provide culturally
competent services and are asked to carefully consider the basis for determining their need to
refer and/or deny services. ASHA’s Office of Multicultural Affairs can provide assistance and
resources in making this determination and in identifying resources to continually enhance
cultural competence. The Board of Ethics’ Issues in Ethics Statement: Cultural and Linguistic
Competence (ASHA, 2017) is designed to provide guidance to members, applicants, and
certified individuals as they make these types of professional decisions.
Developing Cultural Competence
Developing cultural competence is an ongoing process. It involves self-awareness and cultural
humility, and it may require audiologists and SLPs to recognize what they do not know about the
languages and cultures of the individuals, families, and communities they serve. As a result, they
may seek out culture-specific knowledge and experience in these areas. The culturally competent
clinician has the ability to
simultaneously appreciate cultural patterns and individual variation;
engage in cultural self-scrutiny to assess cultural biases and improve self-awareness;
utilize evidence-based practice to include client/patient/family characteristics, clinician
expertise, and empirical evidence in clinical decisions; and
understand the communication contexts and needs of clients/patients and their families by
considering communication disorders within a social context (Kohnert, 2008).
Developing cultural competence includes
self-assessment, including a review of the clinician’s personal history, values, beliefs, and
an understanding of how these factors might influence perceptions of communication
abilities and patterns; and
an understanding of how personal perceptions might influence interactions and service
delivery to a variety of clients/patients/families.
The continuum of cultural competence (Cross, Bazron, Dennis, & Isaacs, 1989) includes the
Cultural Destructiveness —in which “attitudes, policies, and practices that are destructive to
cultures and consequently to the individuals within the culture” (p. 29) are exhibited.
Cultural Incapacity —in which individuals and agencies do not seek to be “culturally
destructive, but lack the capacity to help . . .” (p. 30).
Cultural Blindness —in which “the system and its agencies provide services with the expressed
philosophy of being unbiased . . . and function with the belief that color or culture make no
difference and that all people are the same” (p. 30).
Cultural Pre-Competence —in which there is awareness and an attempt to “improve some
aspect of services to a specific population” (p. 31) and clinicians are aware of perceptions,
values, and other elements of their own culture and of cultures different from their own.
Cultural Competency —a stage of “acceptance and respect for difference, continuing selfassessment regarding culture, careful attention to the dynamics of difference, continuous
expansion of cultural knowledge and resources, and a variety of adaptations to service models”
(p. 31). At this stage, clinicians are able to effectively use their cultural knowledge during
interviewing, assessment, and treatment.
Cultural Proficiency —in which agencies hold “culture in high esteem . . . and seek to add to
the knowledge base of culturally competent practice by conducting research, developing new
therapeutic approaches based on culture, and publishing and disseminating the results of
demonstration projects” (p. 31). In this stage, clinicians champion cultural competence in
practice by training others in cultural competence, recruiting personnel from diverse cultures,
and conducting research that adds to the knowledge base.
Self-assessment may reveal where a clinician is along the continuum of cultural competence.
Specific steps in the development of cultural competence are identified based on a clinician’s
location along the cultural competence continuum, the essential characteristics of the culturally
competent clinician, and a reflection on individual needs. These steps are as follows:
Learning about a client’s/patient’s/family’s culture(s), language, experience, history,
alternative sources of care, and power differentials.
Developing a dynamic definition of what constitutes culture that allows for possible
change, or redefinition, as clients/patients and clinicians grow.
Demonstrating respect for the cultural background of clients/patients/families by
integrating the client’s/patient’s/family’s personal preferences and cultural practices into
assessment and treatment, including recognizing the influence of culture on linguistic
variations, which may result in variations in communication patterns due to the context,
communication intent, and communication partner.
Recognizing that power in the clinical situation is reciprocal and that
clients/patients/families have the power or capacity to make choices and changes in their
lives and to participate in service delivery as appropriate for their culture and personal
Identifying both explicit cultural variables discernible on the surface—such as external
symbols, food, and language—and implicit variables, including religious practices and
beliefs, spiritual beliefs, educational values, age and gender roles, child-rearing practices,
and fears and perceptions.
Developing an ethnogenetic viewpoint that recognizes that groups, cultures, and the
individuals within them are fluid and complex in their identities and relationships;
Moving away from ethnocentrism , the belief that one’s way of life and view of the world
are inherently superior to others’ and are more desirable.
Moving away from essentialism, which defines groups as “essentially” different, with
characteristics “natural” to a group (Fuller, 2002, p. 199). Essentialism does not take into
account variation within a culture and can lead health care professionals to stereotype
their patients. As such, their clinical practice focuses on beliefs about groups instead of
Whereas human nature is inherited, culture is learned; however, individuals within all cultures
vary based on differences, preferences, values, and experiences. Hofstede (2011) identifies
cultural dimensions that are globally applicable and are reflected in all aspects of life, including
health care practices.
Hofstede (2011) identifies the following as the broadest and most encompassing dimensions of
Long- and short-term orientation
Indulgence versus restraint
Additional dimensions include the following:
Cultural value orientations (e.g., time orientation)
Verbal communications (e.g., turn-taking expectations, amount of talking allowed among
Nonverbal communication (e.g., eye contact, personal space use)
Relational communication Norms (e.g., greeting rituals, conversational expectations for
various types of individuals)
Cultural dimensions occur along a continuum, and an individual may demonstrate behavior that
falls anywhere along the spectrum. A wide variety of factors may influence how cultural
dimensions are manifested by each individual, including
assimilation —the process of someone in a new environment totally embracing the host
culture (Riquelme, 2013); and
acculturation —the integration of the host culture with the native culture to varying
degrees (Riquelme, 2013).
Implications of Cultural Dimensions
Cultural dimensions influence verbal and nonverbal behaviors in communicative interactions.
They affect how individuals convey trust or distrust and what they interpret as friendly,
unfriendly, interested, or bored behaviors. For example, friendliness is conveyed by
polite listening in a high power distance culture;
formal and specific language in a strong uncertainty avoidance culture;
verbal disclosure of information in an individualistic culture; and
an assertive style of communication in a highly masculine culture.
Failure to recognize these variations in interactions can result in crucial miscommunications.
The impact of cultural dimensions should be considered within the environment and within
clinical interactions. An audiologist or SLP whose cultural beliefs are consistent with
independence and active experimentation may face conflicts with families whose cultural beliefs
support dependence and compliance if there is a lack of awareness of these cultural differences
(Kalyanpur & Harry, 1999).
Professionals educated in U.S. schools typically value a low power distance and attempt to treat
students, clients/patients, and families as equals, encouraging them to participate in the
development of therapeutic goals and objectives. Persons from high power distance cultures may
question the competence of a professional who attempts to include them in the development of
the interventions (Hwa-Froelich & Westby, 2003). Research suggests that when clients/patients
view themselves as similar to their health care providers in terms of cultural and linguistic
background, the health care provider–patient relationship is strengthened. Patient-centered
communication is one factor noted to affect perceived personal similarity (Street, O’Malley,
Cooper, & Haidet, 2008).
Cultural Competence Versus Stereotyping
Cultural competence requires audiologists and SLPs to consider how values and norms are
uniquely shaped. Even when individuals share similar cultural backgrounds, their values are
shaped by their own experiences and interpretations of these experiences. Stereotyping uses
preconceptions of a particular population and may result in inappropriate clinical judgments and
decisions for a given client/patient and the client’s/patient’s family.
For example, cultural competence in dysphagia services includes the identification of the
individual’s personal food history and preferences. Stereotyping in dysphagia services could lead
to recommendations based solely on the food preferences most often associated with the
individual’s cultural background.
Dynamic Assessment and Response to Intervention
Early intervening services are used to determine which children have intrinsic learning problems
that cannot be attributed to lack of experience with the tasks. Response to
Intervention and Dynamic Assessment are both early intervening processes that help to decrease
unnecessary referral to special education for children who can benefit from modified
instructional techn …
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