This part of the discussion is divided into two subsections to elaborate on the communication challenges in diverse contexts and how SLTs solve the problem of limited resources. Studies
on doctor–patient communication have found that problematic communication leads to reduced health outcomes and poor compliance by patients (Levin, 2005: MacDonald, Carnevale & Razack, 2007a). The profession of SLT faces similar challenges to those in the medical field in their attempt to improve communication with their clients (Ferguson & Armstrong, 2004). In the context of health care provision, communication is important for the provision of excellent service. Research by Travaline, Ruchinskas and D'Alonzo (2005)
indicates that patient–HCP communication matters, because it allows for patients’ healing and reconnection. Therefore, in situations where communication is not signified, health care provision cannot be adequately provided. Thus it was surprising to find that in a context of diverse languages, service providers in the area of speech do not speak or understand the languages of those they serve.
The communication challenge that is common for both doctors and SLTs is that of unequal
encounters in doctor–patient communication (Thomas, 2006). Salma reported some of the challenges in communicating with clients who have a different belief regarding causality and medicine:
Salma: … and that just is it. I had one patient who said the lady at Dischem said she
must come to get the pills to make the child talk and like after the two minutes of
stunned silence, I said to her like, “umm start from the beginning that your child does not talk” and then ... so I try also to make them see for themselves where the logic is. So it’s pills to make them talk, and another thing is very odd is the tongue type. It’s always the tongue is short and the tongue needs to be cut, that’s why their children can’t speak, and you find that if they come from the locations, that’s the common thinking that if your child is not talking, then you need to have their tongue cut. (Interview, December, 2012)
In the above quote, Salma does not share the caregiver’s cultural beliefs, and struggles to get the caregiver to think the way she does. SLTs need to note that clients are “culturally unique individuals and as such are products of past experiences, cultural beliefs and cultural norms” (Tjale & De Villiers, 2004). Salma’s statement of like after the two minutes of stunned silence is problematic, because it comprises an element of judgment of the logic that is used by the caregivers regarding the causality of speech disorders in children. In addition, she appears to have a limited understanding of this prevalent frame of reference that she ascribes to people she says come from the locations. The understanding of causality of disease and illness varies from culture to culture (Nkosi, 2012). In most Western countries, disease is explained in empirical or scientific terms, whereas most African cultures believe in supernatural beings and powers such as gods or spirits (Tjale & De Villiers, 2004). Cultural beliefs are complex and need to be treated with caution and little or no judgement at all. Speaking or understanding the language of the community is not sufficient knowledge of their culture and cultural beliefs.
Although it is commendable that SLTs find other ways of coping with the diverse languages and cultures, they should be required to learn these languages or have interpreters that speak these languages fluently. Below is a transcript of Nozipho, who was the only African therapist at CMJAH. She discusses the problems that occur due to the lack of interpreters and the misdiagnosis that occurred.
Nozipho: I don’t think it’s fair on the patients; they are not getting full service; there is something that needs to be done. There can be misdiagnosis done in the wards. You will go and find that this patient has expressive aphasia, but when you go, you find out that they speak Zulu, and you speak in their home language, they can actually
respond. The problem was maybe they didn’t understand English, so maybe they just looked at someone, whatever assessed them first, and just assumed they are, they had issues. (Interview, December, 2012).
Nozipho was speaking from experience that patients receive unequal and unfair treatment if they do not speak English. This disparity in health care for people who have limited English proficiency is also documented in other countries such as the US (Balsa & McGuire, 2002). Nozipho felt that something needs to be done but appeared not to have a solution. The human
and language rights of patients have been violated for many decades – since before and after the new democratic government – and still no action has been taken, politically or legally. The professional and regulatory bodies have policies on the provision of equitable health care and rehabilitation services; however, the challenge lies in implementing these policies.
Misdiagnosis of patients is a serious ethical and clinical malpractice, which appears to continue unreported by the professionals and researchers. In most cases this is unintentional misdiagnosis, but it is still a misdiagnosis. The difficulty regarding such disclosures is that they are scarcely reported in research, because researchers have to choose between maintaining confidentiality and protecting the public (Skweyiya & Jewkes, 2011). Similar findings are reported in other countries such as the US, where it was found that many hospitals were not providing language services for patients not proficient in English in compliance with their federal law on National Standards for Culturally and Linguistically
Appropriate Services in Health Care (CLAS standards) (Diamond, Wilson-Stronks & Jacobs, 2010). In this US study, the majority of hospitals stated that they use family members or untrained staff as interpreters. Only 13% of hospitals in this study met the criteria of the CLAS standards, while 19% met none of them.
Salma reported that they face serious challenges when they have to consult clients and record their case histories. Like Nozipho, she also recognises the challenges that they
experience when they have to consult with a client. She states that clients’ basic conversational English skills make it easy during brief interactions when clients come in to make an appointment only. However, when they have to take a case history, the language problems become evident.
Salma : Umm, because it’s a referral hospital, a lot of the patients are referred either from outside doctors or hospitals or clinics here. We don’t always know what the language is ’cause they come here with the referral letter, they come here to make an appointment, and you know, that basic conversation we are able to have at the front desk, when must you come back and all the documentation you need to bring. It’s just that when you are sitting here, you are delving into the deeper case history, that sometimes things just get lost. (Interview, December, 2012).
Even though Salma reports that in her consultations “things get lost” due to communication barriers, she continues her work and seems to have no solution to the problem. Despite the common communication challenges due to diverse populations in the Gauteng province, the SLTs appeared to be keen on delivering their services respectfully. The researcher observed ethical behaviour in most situations. Families and caregivers of young children were
collaborated with, and seen as team members. Devi’s attempts at collaboration seem to be limited to caregivers being interpreters of their child. However, Salma’s approach is very different, as it involves asking open-ended questions and making the environment hospitable. The following quote indicates these different approaches:
Devi: Uhm, personally I use the parents as the main person and I do everything through the parents. So if there’s anything that I’m doing, then I make sure that the parents know what it is that I want and what we need in this session and they do all
the interpreting. So everything that I’m saying, they’re interpreting to their child. (Interview, December, 2012).
Salma: Umm I always sit on the smaller chair, face-to-face, I never sit behind the desk, ok, and I always say to the moms, “why are you here? What is it that you want? I am worried about the moms, I am not interested in the child in the first visit and I always say to the moms, “today it is about you and me. When we are done here I will speak to the child” …. (Interview, December, 2012).
Both Salma and Devi seem to be aware of the importance of parental involvement when
working with young children. Nonetheless, they have completely different approaches – one at the level of assisting the SLT to give intervention to the child through the parents, and the
other, inclusive and expecting participation in decision making. Salma’s approach is aligned with the guidelines for best practice in early childhood intervention services, which state that the service should be individualised and relevant for families. In addition, the early childhood services should ensure that parents are actively involved in planning the services for their child and themselves. This strategy requires SLTs to implement services that recognise the value and support of this collaborative team approach (Bailey, Curtis & Nuna, 2001).
6.4 Conclusion
In answering the question about how SLTs perceive their effectiveness during consultations with clients from diverse cultures and languages, the five SLTs and one interpreter that participated were analysed according to themes. Four themes emerged from the analysis of
the transcriptions: adaptation to the situation; the benefit of cultural background in adapting to diversity; the role of the interpreter in adapting to a lack of professionally trained mediators; and communication challenges in diverse contexts and how SLTs solve the problem of limited resources.
The findings also confirm the culture of planisa that seems to be operating in the profession and it is suggested that this is a good strategy. However, on its own, planisa is not effective because it has negative consequences for social justice, resulting in poor health provision for people who have limited English proficiency in SA. Although there was limited evidence that the experience and cultural understanding of some SLTs had a facilitatory effect on the health care provision for families of children with communication disabilities, there is a need for further research on the barriers to effective strategies for SLTs that work in a multicultural and multilingual context.
Finally, it appears that the redress of admission policies and the radical inclusion of service learning and multicultural competency in the curriculum of speech pathology can significantly influence and assist in transforming the professional training of SLTs at South African universities. Transformation of the curriculum, profession and practice of SLTs will require immense commitment and understanding and unpacking of critical diversity literacy and decolonization concepts not at a theoretical level only but also in how to implement it. The following chapter will address the recommendations related to research, policy and practice.
CHAPTER 7: Conclusion and Recommendations