Introduction
Somewhere around mid-century, non-Hispanic whites will become a minority group in the United States (Curry, 2005). As racial and ethnic groups such as Hispanics, African-Americans, Asians, Native Americans, and Pacific Islanders increase in number and move into all regions of the U.S., they carry along their cultural identities and values. As cultural diversity increases, so does the need for cultural sensitivity and understanding among audiologists toward their patients.
Audiologists provide hearing healthcare services to millions of Americans with hearing loss. From the identification of hearing loss in newborns to the provision of hearing aids to older adults, audiologists often encounter cultural values and traditions that are different from their own. Some patients speak a different language: "How can I help someone if I can't talk with them?" Other patients communicate differently or in a way that creates discomfort: "Why won't the patient look me in the eye?" "Why does he get so close when he talks to me?" Others learn differently: "I wish I knew why she doesn't use what I've told her over and over again," or have a different time perspective: "The patient never comes on time for hearing aid follow-ups. How can he expect to use his new aids?"
Stereotypes
The original use of the word "stereotype" came from printing. When type was prepared for printing from a metal plate cast from a matrix, the result was the ability to reproduce many printed pages that appeared virtually identical, or stereotyped. Similarly, when all members of a group are viewed as much the same, as if they were stamped from the same mold, the word "stereotype" applies.
As early as l922, Walter Lippman in his book Public Opinion identified four characteristics of stereotypes as applied to people: They are simple, acquired secondhand, erroneous, and resistant to change. The word "stereotype" continues to suggest that individuals of a particular category share many or most characteristics in common, often in a negative sense. Such categories may include national groups such as English, Nigerian, Tibetan, Peruvian; regional categories such as northerners, southerners, westerners; and additional categories such as religious affiliation, skin color, gender, age, profession, sexual orientation, size, income, physical and mental disabilities, and others.
When we hear someone refer to "those people," it often relates to a stereotyped view of a group. Accompanying the group is often a list of assumptions about how "those people" behave. When we assume the individuals in a group have the same characteristics, even when we have not yet met and come to know the individuals, we are making a "pre-judgment." From this we get the term "prejudice," or a "judging before knowing."
What Comes to Mind?
What group or groups comes to mind when you read the following statements about "those people?"
"Those people are never arrive on time; they are always late."
"Those people are all absent-minded."
"Those people are all hair stylists and landscapers."
"Those people are all members of the Mafia."
"Those people live on reservations and are all drunks."
"Those people are all senile and live in nursing homes."
When audiologists react to individuals according to preconceived notions rather than to the real persons before them, the diagnostic and rehabilitative process can be hindered. Becoming aware of stereotyping and pre-judging can help to avoid their hurtful effects on audiological services.
Avoid Stereotyping and Prejudging
Audiologists can avoid stereotyping and pre-judging by looking for similarities and common bonds between themselves and their patients, as well as for differences. For example, Maslow's classic hierarchy of needs (Boeree, 1988), including physiological, safety, acceptance, esteem, and self-actualization, are characteristic of most humans. The universal importance of family and community bonds throughout all groups is another good place to begin the communication process so critical to tailoring audiological services to the needs of each patient.
Aaron Hougham of the Oregon State Daily Barometer Online, in an article entitled "Stomping Out Racial Stereotypes," rightly concludes that we should "scratch out stereotypes and replace them with two words that describe people from all cultural backgrounds: Unique person" (Hougham, 2004).
Culture
Culture is broadly defined as a "system of shared ideas and meanings, explicit and implicit, which a people use to interpret the world and which serve to pattern their behavior" (Halsall, 1995). The word itself has Latin roots meaning to inhabit, honor, or cultivate. Humans are members of literally thousands of cultural groups, which are based on socially transmitted values, traditions, and beliefs. According to Anthropologist Edward T. Hall (1976), "there is not one aspect of human life that is not touched and altered by culture." The tendency to stereotype people from other cultures is one of the major barriers to communication. In this light, it is instructive to turn the tables and look at American cultural stereotypes from an international perspective.
Stereotypes of American Culture
Stereotypes of American culture are presented by eduPass (Cultural Differences, 2005), a website for international students presented as the "SmartStudent Guide to Studying in the USA." Under Cultural Differences, the section on Stereotypes advises:
"Don't believe all of the stereotypes you may have heard about Americans. Even the ones that are true in general may not be true about specific individuals or a large segment of the population. For example, although Americans tend to be louder and more boisterous than people from other cultures (especially at athletic events), many of the people you meet will be quiet and polite. Some people may be intolerant and xenophobic, but most will be pleasant and welcoming. Remember that American films and television exaggerate in order to generate excitement, and so present a rather distorted picture of what life in the United States is really like. Likewise, tourists are not always on their best behavior."
Other sections under "Cultural Differences" present American views on topics such as personal space, forms of address, demeanor, toilets, tipping, telephone etiquette, dining, gift giving, gestures, and noises. Under Noises, for example, the guide advises the student that it is "not polite to burp in public or to slurp your soup."
Under "Business Clothing" the student is to "Ask your American friends or professors for help in selecting a good set of business clothes. You can also ask the sales staff at the more expensive stores, such as Ann Taylor, Brooks Brothers, or Saks 5th Avenue, for advice. Even if you later buy your clothing at Sears or Caldor, it will give you a good sense of what is appropriate attire."
If all else fails, students are to employ the Reasonable Person Principle, which is to "do what a reasonable person would do" under the circumstances."
Although the website is a serious attempt to help international students understand the eccentricities of Americans, it is a good example of the difficulties in any attempts to generalize and categorize the behavior of any group of individuals under a single label. Ultimately, such generalizations however well-intentioned become stereotypes which are dispelled only by meeting and interacting with a variety of Americans in their everyday lives.
Stereotypes of Aging
What are some common stereotypes of aging that might affect the audiologist in the delivery of audiological services? Older adults are an important patient base, with 3 out of 4 hearing aids dispensed to persons aged 65 or more. How many of the following aging "myths"/stereotypes presented by Shenk and Dancer (2005) do you believe?
Older adults:
- are incapable of learning new information
- are depressed
- live in nursing homes
- are crabby, cantankerous, grouchy, and rigid
- are angry or irritated
- show declines in cognition and intelligence
- are abandoned by their children
- are pretty much alike
- live in poverty
- don't care about communication
Shenk and Dancer point out that the myths of aging are a "double-edged sword, affecting the attitudes and behaviors of both older adults and audiologists...If an older patient believes that old dogs can't learn new tricks, then why bother with hearing aids. If the audiologist believes that older patients are set in their ways, then why bother with rehab services." The authors advise that we banish such destructive myths of aging to our "Nevermore!" file by seeing patients as unique individuals, identifying myths, learning the facts, and applying them to our everyday routines.
Test your knowledge about aging by taking the online Aging Quiz by Woolf (2005). Learning the facts on aging and rejecting the stereotypes are the first steps in treating each older patient as a unique individual rather than as a category. Getting personally acquainted with each patient through asking questions about their lives, their hearing loss, and their hearing needs is also an important step, so getting to know a patient better can pay dividends in future interactions.
Cultures in Context
The effects of culture are pervasive to the everyday lives and histories of its members, affecting factors such as time perception and use, family life, social relationships, economics, food, clothing, shelter, transportation, communication, language, government, politics, arts, recreation, beliefs, values, traditions, religion, and education. Learning the specifics of even a single culture is a daunting task.
A useful starting point for audiologists is the concept of "high" context versus "low" context cultures (Timbrook, 2001). The higher the context, the more it is expected than an individual in the culture will simply know, implicitly, what to do and how to do it, without being told. The context suggests what customs, rituals, and procedures to follow.
In contrast, in low context cultures, each situation needs its own explicit set of instructions and directions. In the low context, the individual is distanced from the behavior. Not knowing how to do something relates to information supplied, not to the worth of the individual. In high context, the individual and the behavior are more closely linked, so that failure to behave in a socially or professionally prescribed manner is perceived not just as a failure to know the rules, but as a personal failure as well.
For example, if an audiologist gives directions about the use and care of hearing aids to a patient from a low context society, the patient could readily accept and use the new instructions as something separate from self-evaluation. However, a patient from a high context background might feel that he/she should have known what to do, and the instructions are a personal criticism labeling the patient as a failure, who then brings shame to the group.
The low context patient might feel free to return for follow-up services and call back for further instructions as needed. The high context person, on the other hand, might never appear again, in order to avoid further failure that would damage the reputation of the family.
The following fictional accounts highlight differences in an audiologist's attempts to help persons from high and low context cultures and, conversely, of the patients' perspectives on the encounters. Note how the high context encounter challenges both the audiologist and the patient, while both parties enjoy the low context encounter.
High Context Cultural Encounter
Audiologist's Report:
"Mrs. Y arrived over an hour late for the diagnostic testing of her baby for possible hearing loss. She had a number of family members with her, who had to remain in the waiting area. Fortunately, I had enough time to work the baby into my busy schedule. The mother spoke English well enough to answer my questions, but she kept her eyes downcast and appeared subdued in demeanor. The baby had a mild-to-moderate bilateral hearing loss, and after testing I explained to the mother the need for early intervention services, including hearing aids, to foster speech, language, and learning skills. Despite my encouragement, she had no questions for me about the findings and appeared uncomfortable with my follow-up questions. I made an appointment for a hearing aid fitting, but somehow I doubt she will keep it. She just didn't seem to understand the importance of habilitation services for her child's future success."
Patient's Perspective:
The mother is not sure why the audiologist acts annoyed when she arrives for her baby's appointment on the designated day. The exact time is not so important. She is uncomfortable with the audiologist's explicit questions about her family life, and she feels disrespected when the audiologist constantly stares at her. When she tries to move closer, the audiologist further insults her by moving away. After the hearing test, the mother is shamed by the news of her baby's hearing loss, feeling she is somehow to blame, and she fears telling her waiting family the bad news. She is no longer listening to the audiologist; she just wants to leave as soon as possible, taking her guilt with her.
Low Context Cultural Encounter
Audiologist's Report:
"Mr. X was early for his hearing aid fitting and he was already asking the receptionist questions about hearing aids. As I greeted him, he looked me straight in the eye and said in a humorous way that he wanted the best hearing aids money could buy, as long as he got a good deal on the price. He was curious about all aspects of the fitting, including the purpose and need for the special features I had included in his aids. As I explained the use and care of the aids, he listened intently and asked numerous questions. It took him awhile to insert and remove the aids, but with my encouragement he kept at it until he succeeded. As he was leaving, he told me he was looking forward to his next appointment and would call if he had questions in the meantime. I'm looking forward to his return."
Patient's Perspective:
The patient arrived early and appreciated the friendliness and outgoing manner of the audiologist and other staff at the clinic. He was curious about the care and use of his aids, and enjoyed the explicit information he was getting. He came alone, preferring to deal with his hearing loss as an individual. As the meeting progressed, he felt good about what he was learning, and he agreed with the audiologist that he should involve his family in achieving his goal of successful communication. He left with the hearing aids in his ears and is looking forward to the next session, where he can learn even more.
The Context of Audiology
Just as cultures can be described as high or low context, so can specific situations or events. Regardless of the culture, a formal dinner party could be described as a high context situation where participants must know and follow prescribed and unvarying rules to avoid embarrassment. In contrast, an informal classroom setting can be seen as a low context situation with the free give-and-take of ideas encouraged from all participants.
The provision of audiological services in the U.S. generally occurs within a low context setting where direct, explicit communication is valued over indirect, implicit communication. Audiologists in busy practice settings need specific and detailed answers to questions about the patient's hearing loss, lifestyle, and family dynamics in a short amount of time. The audiological process is structured around diagnosis and rehabilitation, which requires the give-and-take of information, primarily verbal, between the audiologist and the patient. The loss of communication between the audiologist and the patient, regardless of the reason, hinders the patient's progress in overcoming the hearing loss through audiologic re/habilitation and stymies the audiologist's rehab plan. Learning to communicate beyond one's cultural boundaries is an on-going process, which requires both time and effort but pays off with increased patient satisfaction.
A TRIBUTE to Diversity
Communication is a two-way process, which involves cooperation between the audiologist and the patient. Audiologists can foster communication through using the seven steps of the TRIBUTE protocol to respond to all patients, regardless of culture:
Treat
*T - Treat each patient as an individual with unique hearing and personal needs. Although we can graph a person's hearing loss on an audiogram and obtain scores on standard hearing outcome measures such as the Hearing Handicap Inventory for the Elderly (HHIE), we can only find out about each patient's perspective by asking open-ended questions about their lives and actively listening to their answers.
Respect
*R - Respect cultural differences through your verbal and non-verbal interactions with patients. What you say is important, but how you act is even more important. Nothing says "I respect you" more than a caring and concerned attitude that begins with your initial greeting of a patient and continues throughout the provision of diagnostic and re/habilitative services.
Identify
*I - Identify the personality and learning preferences of each patient, including their time orientation. Personality preferences, such as introversion/extroversion, are found in people of all cultures, and Ward and Dancer (2004) point out that such preferences are stable throughout our lives and determine how we learn best. For example, introverts tend to learn by listening while extroverts tend to learn by talking. Remember that high context cultures often treat time as a less structured event, so stress to each patient the importance of showing up on time for each appointment.
Begin
*B - Begin with learning some basic information about cultural differences through formal coursework and informal interactions with persons from different cultural backgrounds. Although you can't know everything about all cultures, you can learn more by reading about and observing with interest and curiosity the diversity of patients who seek your help. Picking up on subtle cultural rituals, such as the need to touch a baby you have complimented to avoid giving the "evil eye," is something best learned indirectly, through explanation.
Use
*Use professional and cultural translators when necessary to overcome or explain language and cultural differences. Some cultures have a structured family hierarchy which precludes having children serve as language translators to older family members, so find out before you use anyone other than a professional translator. If you are mystified by a particular behavior that disrupts the diagnostic or re/hab process, you might consult with the International Visitors Association in your community or with the international student's club at your local university.
Tell
*Tell the patient about their hearing needs and hearing options in plain everyday language, avoiding audiologic jargon. Effective communication starts on your end.
Explain
*Explain the process of obtaining hearing aids and re/habilitative services as a family event. Involving the family is a good idea regardless of the cultural context. Family members provide encouragement and support and need to know and apply simple but effective rules for better communication. Involving patients and their families in a group setting is a good way to get persons from different cultural groups to get to know and to learn from one another. In some cultures, group learning is preferred over individual learning, so give your patients the opportunity to participate in both.
Conclusion
Effective communication is the key to success in audiology, so practice these skills at every opportunity. Meeting and helping patients from different cultures is both challenging and rewarding. By treating each patient as unique, we pay TRIBUTE to our cultural differences as well as to our human similarities.
Works Cited
Boeree, C.G. (l998). Abraham Maslow. Retrieved 10/19/05 from www.ship.edu/~cgboeree/maslow.htm
Cultural Differences. (2005). The SmartStudent Guide to Studying in the USA. Retrieved 10/19/05 from www.edupass.org.
Curry, G. The Business Case for Diversity. Retrieved 10/19/05 from www.blackpressusa.com/News/Article_Search.asp?NewsID=3592
Hall, E.T. (l976). Beyond Culture. Garden City, New York: Anchor Books.
Halsall, P. (l995). Chinese Cultural Studies: Understanding "Culture." Retrieved 10/19/05 from acc6.its.brooklyn.cuny.edu/~phalsall/texts/culture.html
Hougham, A. (2004). Stomping Out Racial Stereotypes, The Daily Barometer. Retrieved 10/19/05 from barometer.orst.edu/vnews/display.v/ART/2004/03/08/404ca9530e9f4
Lippman, W. (l922). Public Opinion. New York: MacMillan.
Shenk, H. and Dancer J. (2005). The Nevermore File. Retrieved 10/19/05 from Advance for Audiologists, www.advanceforaud.com.
Timbrook, L. (2001). High/Low Context Cultures. Retrieved 10/19/05 from www.colostate.edu/Depts/Speech/rccs/theory63.htm.
Ward, A. and Dancer, J. (2004). Rx for Challenging Personalities. Retrieved 10/19/05 from Advance for Audiologists, www.advanceforaud.com.
Woolf, L. Test Your Knowledge About Aging. Retrieved 10/19/05 from www.webster.edu/~woolflm/myth.html.
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Jess Dancer is Professor Emeritus of Audiology at the University of Arkansas at Little Rock
Allan Ward is Professor Emeritus of Speech Communication at the University of Arkansas at Little Rock
