JCPSLP November 2016

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

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,

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)

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JCPSLP Volume 18, Number 3 2016

Journal of Clinical Practice in Speech-Language Pathology