As audiologists continue the much-needed and long-awaited discussion about ways we can improve service provision to a culturally diverse patient population, we have an obligation to include the unique needs of our pediatric patients and their families. This consideration is critical because, if we don’t connect with parents in a way that supports them along their journey, it can disrupt the audiologist-parent relationship that is so crucial to the success of children with hearing loss.
This article offers an overview of cultural diversity in health care (generally) and audiology (specifically), a discussion of the needs of children and their families from an array of backgrounds, and a list of suggestions and resources for audiologists working with a culturally diverse pediatric population.
Defining Cultural Diversity
Cultural diversity relates to the heterogeneity within a given group of people, including a range of beliefs, values, traditions, languages, religions, political ideals, education levels, physical abilities and disabilities, ages, sexual orientations, genders, races, and ethnicities. In recent decades, many Americans have moved away from the idea of the American melting pot, with its implications of assimilation and acculturation, and instead have moved toward the idea of the American salad bowl, in which people from diverse backgrounds retain the customs and qualities that make them unique.
As the population of the United States becomes increasingly diverse—currently 40 percent of all Americans identify as a category other than white, non-Hispanic—there is an increasing need for educators and health-care professionals to be able to effectively support students, patients, and families who come from a wide array of backgrounds, traditions, and belief systems.
The Need in Health Care and in Audiology for Cultural Competence
It has long been known that physicians do not accurately reflect the ethnic, racial, and cultural backgrounds of the Americans they serve. As recently as 2019, the Association of American Medical Colleges reported that only six percent of active physicians identified as Hispanic (compared to 18 percent of the general population) and only five percent of physicians identified as Black (compared to 13 percent of the general population).
In the realm of audiology, the differences between providers and patients appear equally stark. According to government statistics compiled by online aggregator Data USA, only eight percent of audiologists identify as Hispanic/Latino and less than four percent identify as Black. Given that, according to the information published by Data USA, only 18 percent of audiologists identify as something other than “white, non-Hispanic,” it is likely that there are many encounters in which the patient’s background is quite different than that of the audiologist.
This disparity between the ethnic, cultural, and racial background of audiologists compared to that of our patients may contribute to a lack of effective care for people in need of hearing and balance help.
What Is Unique About the Needs of Children as Related to Cultural Diversity?
One of the biggest joys of working with children is the opportunity to work with their parents and, often, with extended family. It is also one of the biggest challenges, as our youngest patients are completely reliant on their families for all aspects of their care.
For children with hearing loss, much of their language, cognitive, and social growth over time can be attributed to the family’s adherence to their chosen intervention, whether that’s listening and spoken language (which typically requires 10+ hours per day of hearing aid or cochlear implant use) or manual communication (which requires robust exposure to sign language or cued speech). For families to be successful with an intervention plan, they must first understand it, understand why it’s important, and identify tools to help them incorporate the intervention into their daily lives.
Given the increasing presence of diverse racial, ethnic, and cultural backgrounds in the children who need care from audiologists, it’s quite likely that the parents and families seeking care in our clinics and practices will have different cultural backgrounds than ours and that their daily lives might look very different than that of their audiologist. For this reason, it is absolutely essential that audiologists who work with children have an approach to patient care that includes respect, empathy, and responsiveness.
Guidelines for Audiologists Working with a Culturally Diverse Pediatric Population
There are many ways to meet families where they are:
Language: Audiologists should make every effort to interact with children and their families in the language preferred by the family. If the audiologist is not fluent in that language, an interpreter can be arranged. Online or phone-based interpreters are a cost-effective way to address the needs of your non-English speaking patients. Audiologists should remember that it is never appropriate to use children and adolescents as interpreters for their parents and family members.
Communication style: Families from cultural backgrounds that differ from that of the audiologist may have culturally linked behaviors that influence the audiologist-patient/family interaction, including eye contact and body language. The provider should follow the parent’s lead with regard to communication style. When possible, learn about the family’s cultural background so that your communication style can be more carefully adapted to help the family feel more comfortable.
Representation: Make sure that the materials and examples you use in your practice reflect a diverse array of skin tones, ethnicities, and cultures. Families will feel more comfortable if they see that you respect and appreciate the contributions of a wide range of people. In addition, children will feel more empowered if they see that your practice celebrates diversity in a way that includes children and adults who look like them.
Collaboration: Coordinate resources and services for patients and families with community groups including agencies, businesses, cultural and civic organizations, colleges and universities, and local physicians’ practices.
Respect: Listen to parents’ concerns and reserve judgment. Remind yourself that things you perceive as barriers to care (such as a lack of punctuality or limited engagement) may have a basis in cultural differences that reflect a different value system than the one automatically (and often unconsciously) applied to the situation by the audiologist. Know that, regardless of cultural differences, your goal for your pediatric patient is the same as the parent’s goal for their child: the opportunity for growth, learning, and success.
Awareness of implicit biases: Many factors can affect interactions across cultures, including the biases each person in the interaction has toward the other. This is true even for well-meaning audiologists whose goal is to help children achieve better hearing and balance. We all have deeply internalized ideas and views of the world and the people we may encounter. By working to become aware of your biases and learning to take a step back when your biases might be affecting the support you’re providing to the parents and family of a child with hearing loss, you’ll become a better audiologist and care provider for all of your patients.
Information sharing: It is common for people of all backgrounds, but particularly for people who have been marginalized in the health-care system, to be reluctant to admit that they do not understand what is going on. If you follow up your explanation with Does that make sense? or Did you understand all of that?, they may tell you yes, regardless of the extent to which they actually understood what you shared with them. Instead, have them demonstrate the action you’ve described (changing the battery, inserting/removing the child’s hearing aid) or have them tell you about some language-stimulating activities that might fit into their daily routine. Close the appointment with an open-ended request that they ask you at least one other question before they leave, rather than just asking them Do you have any questions?, which often leads parents to respond with No.
There are many resources online to help develop your cultural competence. Below, I’ve listed a few that I found particularly helpful.
The Cleveland Clinic Foundation (2017) has a Diversity Toolkit resource that provides information about 70+ cultural backgrounds to help health-care practitioners improve the care and support they provide to patients and families from diverse backgrounds.
The Pacer Center (2015) in Minneapolis has an excellent list of suggestions for “Getting off to a good start: Positive interactions with diverse families” that was written for educators, but applies to health-care providers as well. Their recommendations include:
- Set the stage for positive and productive appointments by having interpreters available and involved from the earliest points of contact with families. Call the family in advance of the appointment to clearly explain the purpose of the appointment and what the child and parent should expect.
- Build trust by sharing some information about yourself, including why you went into audiology and what you enjoy about working with children and their families. Direct your comments and questions to both parents and respect the family structure, even when it is not your own experience or value system. Recognize the importance of extended family members, community elders, and spiritual leaders.
- Consider differences in literacy levels. Many families from diverse backgrounds may struggle to read written information, particularly if it is written at a higher reading level. In a sensitive and indirect way, check frequently for understanding and provide information in a variety of formats (verbal, written, pictorial).
- Incorporate differences in culture as you work to understand your pediatric patients and their families. Consider the following:
- In many Asian and African cultures, it is better not to initiate a handshake unless the individual extends their hand to you first.
- Families from Asian, African, South American, and indigenous backgrounds may use a combination of traditional or tribal medicine along with Western medical approaches. It may be helpful to learn more about the other practices the family is incorporating into the child’s care so you might include them in your recommendations.
- Many non-Western cultures have different standards for eye contact and physical distance. Follow the family’s lead in these areas.
- If immigration status is a concern, the family may be cautious in disclosing information or they may take longer to develop a trusting relationship with you.
- At the conclusion of your appointment or meeting, end on a positive note by praising the child and thanking the parents for their input and participation.
The American Academy of Pediatrics (Cora-Bramble, 2020) has a Providing Culturally Effective Care Toolkit that can easily be adapted for audiologists working with children and families from diverse backgrounds. Their suggestions include the four pillars outlined in TABLE 1.
Demonstrate, by attitude and behavior, an openness to different cultures.
Adjust clinical practice, when possible, to acknowledge patient and family/caregiver culture.
Demonstrate a commitment to professional development aimed at acquiring new cultural-competence knowledge and skills.
Consider that often the variability within cultures may be more pronounced than the variability among cultures and that there is also significant variability among recent immigrants and those who have been in the United States for one or more generations.
As many audiologists are working toward a better understanding of their culturally diverse patients, it is important to remember that children and their families may have unique needs that are significantly affected by their family’s background, traditions, culture, and beliefs. By demonstrating an attitude of openness, respect, and collaboration, we can show our patients and their families how much we value them and wish to support them on their unique journey with hearing loss.