Culturally safe speech-language supports for First Nations children: Achieving Sustainable Development Goals 3, 4, 8 and 10

Abstract

Purpose

Self-determination is foundational to health and well-being for First Nations people. Colonisation has undermined self-determination and widespread effects are observed as disparities in health and well-being. Chronic middle ear disease is more highly prevalent in First Nations children, is associated with delays in speech and language and lower levels of educational readiness. However, there is a paucity of culturally and linguistically sensitive speech-language assessments and habilitation services globally. Focussing on high-income colonial-settler countries (including United States, Canada, Australia and New Zealand), where health disparities are significant, we aim to discuss the importance of and the challenges in providing culturally safe care to First Nations children with communication disabilities.

Result

To be effective, both cultural and linguistic diversity and cultural safety must be considered in all aspects of assessment and intervention. Furthermore, speech-language pathologists must be equipped to work with First Nations children with communication disorders.

Conclusion

To optimally support First Nations’ children with communication disabilities, services need to be culturally safe, family-centred and strengths-based. This commentary focuses on the United Nations Sustainable Development Goals (SDGs)3, 4, 8 and 10.

Keywords:

• Sustainable Development Goals (SDGs)
• good health and well-being (SDG 3)
• quality education (SDG 4)
• decent work and economic growth (SDG 8)
• reduced inequalities (SDG 10)
• communication disability
• First Nations

Introduction

The United Nations 17 Sustainable Development Goals (SDGs; United Nations, 2015) target global issues such as poverty, hunger, climate change, peace, health and well-being. This commentary considers how the development of speech and language are foundational for quality education (SDG 4) and decent work and economic growth (SDG 8) and subsequently influences good health and well-being (SDG 3) and reduced inequalities (SDG 10). First Nations communities (collectively used here to respectfully describe the original inhabitants of Australia, Canada, New Zealand and the USA before colonisation) demonstrate continued resilience and connection to culture and country in spite of widespread intergenerational effects of colonisation. Colonisation has resulted in significant disparities in health and quality of life. This includes chronic middle ear disease which is more severe, lasts significantly longer and occurs more frequently in First Nations children than in non-Indigenous children (Bhutta, 2015). Middle ear disease often leads to hearing loss. While typically only mild and fluctuating, the intersectionality between any hearing loss (particularly in the early years) and socio-economic disadvantage can reduce school readiness and access to high quality education (SDG 4), reduce employment opportunities (SDG 8) and increase inequalities (SDG 10) (Williams & Jacobs, 2009). Speech-language programs are critical to addressing delays and mitigating longer-term impacts (e.g. communication disability), enabling children to reach their full potential. SDG 3 target 3.8, recommends that all people must have access to quality essential healthcare services to achieve equitable health (Figure 1). Yet there is a cultural service gap in speech-language programs. This is made further inaccessible to First Nations peoples due to a critical lack of cultural safety (Zingelman, Pearce, & Saxton, 2021). Speech-language programs in high-income colonial-settler countries are frequently developed from a pervasive monolingual mindset that strongly promotes standard English. Sadly, this perspective is to the detriment of distinguishing between language disorders and cultural and linguistic language diversity (Vining, Long, Inglebret, & Brendal, 2017). Recognising this is foundational to considering how such programs should be reimagined, designed and delivered. Therefore, the aim of this commentary is to: (a) explore the key factors which influence literacy, speech and language development, (b) discuss how to develop culturally safe and strengths-based speech and language assessments, interventions and services and provide recommendations for speech-language pathologists (SLPs) that will help overcome existing system and structural barriers that reduce opportunities for First Nations children to develop a foundation of strong literacy, speech and language skills and consider how this contributes to achieving the SDGs. While the focus here is on First Nations children, factors discussed within this commentary are broadly relevant to all culturally and linguistically diverse children and families.

Figure 1. Scaffolding speech-language skills to achieve Sustainable Development Goals (SDGs) in First Nations children.

Literacy, speech and language development amongst first nations peoples

For First Nations People, communication and literacy skills enable the development and sharing of culture and a sense of belonging, foster ownership of their own history, enable storytelling to share information of their families and ancestors. Control over language is central to self-governance and self-determination, which are important in addressing the historic and deeply embedded impacts of colonialism. On the other hand, low literacy leads to disempowerment, and a resultant cascade of impacts on social aspects, health (including access to health services), education and employment (Williamson & Boughton, 2020). There is overwhelming evidence to suggest that early oral language skills - developed through interactions with family, community and early childhood educators, lay the foundation for literacy development (e.g. Larney, 2002). A strong interconnectedness exists between language and culture, particularly in First Nations oral traditions where language is used as a tool to understand concepts of the world through a cultural lens and forms the basis of one’s cultural identity and heritage. There is significant linguistic diversity within First Nations communities. Often, First Nations families are bilingual or multilingual, learning their Indigenous language as the dominant language, while also acquiring social cues that dictate the type and quantity of verbalisation deemed culturally appropriate (Ball & Lewis, 2014). The language acquisition environment and expected trajectories of a child’s language development and the way in which they express language may be different in First Nations communities compared to Western society norms that assessments are commonly based on. Children primarily receive oral language input grounded in the tradition of storytelling and are not expected to provide immediate responses – standard ways of measuring development using Western milestones (Ball, 2012). Language development for First Nations children aligns with the theories of multiliteracies (Gillispie, 2016) and multimodalities, i.e. communication is not limited to words, but can occur via multiple modes/senses like visual arts and kinesthetics (Mills & Dooley, 2019). The recognition that language development is different should be considered a strength rather than assessed as a deficit. Culture-specific language development trajectories should form the basis of assessments of speech and language competence and abilities.

There is a well-recognised, disproportionate burden of socio-economic and political factors deeply rooted in colonialism which has led to higher prevalence and greater severity of literacy, speech and language delays in First Nations populations than non-Indigenous populations. Many colonial-settler countries are developing strategies to address equity in accessing care and education for First Nations people, for example “Closing the Gap” in Australia and “He Ara Hauora Māori” in New Zealand. However, to date, many initiatives have had limited success. Programs to address this are typically fragmented, and the root cause of the disproportionate burden relating to the complex interplay of socio-economic factors and culturally unsafe services and pathways is often overlooked (DeLacy et al., 2020).

Maintaining good ear and hearing health is important to the development of speech and language. Children with recurring and prolonged ear infections and hearing loss with speech-language delays often struggle to catch up in the later years, affecting school completion and future employment prospects (Bell et al., 2021). To provide foundational language and literacy skills in children who are at-risk of middle ear disease, system and service transformation is needed to ensure programs are culturally safe, family-centred and strengths-based. Curtis et al. (2019) identified that cultural safety is a requirement of achieving health equity, stating “Cultural safety requires healthcare professionals and their associated healthcare organisations to examine themselves and the potential impact of their own culture on clinical interactions and healthcare service delivery” (p. 14). Here we explore how this can be achieved through examination of assessment tools and approaches to speech and language interventions for First Nations children.

Culturally safe services and systems

Western and First Nations cultures view health and disability differently (Ineese-Nash et al., 2018; King et al., 2009). A systematic scoping review in 2018, identified that culture was at the heart of all characteristics of Indigenous primary health services (Harfield et al., 2018), highlighting its importance in system design and service delivery. Several recommendations within Harfield et al.’s (2018) review can be adapted for other health services for First Nations people.

Short-term solutions

Local Indigenous health workers could be employed to work alongside speech pathologists to support a culturally safe, family-centred approach and align the service with local cultural beliefs and values. Cultural safety training should be conducted for all health workers to obtain knowledge of languages and culture, identify culturally appropriate goals, use culturally appropriate resources, consider socio-political and cultural contexts, develop partnerships with families, communities and other professionals (Verdon et al., 2015). Case history taking should include questions of language preference, cultural background and community perspectives of language development which can be supported by the health worker’s experience and knowledge. Test administration must be flexible to accommodate cultural (e.g. eye contact patterns, short responses to show respect) and linguistic differences (e.g. phonological and syntactic differences of Indigenous English within and between First Nations communities). Assessment of First Nations children typically continues to be with tools that have been developed for and normed on non-Indigenous children. Therefore, a local cultural expert could support the SLP to identify errors which result from a language difference rather than a deficit. They also could support the family and community to implement program recommendations for the individual and other children within the community.

Interventions must be culturally congruent, developed collaboratively and in line with the needs and expectations of the family, culture and heritage of the child. Scheduling of sessions must allow flexibility to fulfil cultural obligations and geographically accessible (Williams, 2012). Four quality areas for best practice in early childhood intervention (Early Childhood Intervention Australia, 2016), are globally relevant and important for First Nations children and families. These include: (a) Family: practitioners must be knowledgeable and respectful of cultural values of the family. Family are best placed to support the child’s language development and must be provided all the support to do so; (b) Inclusion: providing additional communication facilitates the child’s full participation in family and community life which optimises learning and social development; (c) Teamwork: family and professionals form an integrated team led by a key worker to focus on building family capacity to support child’s learning and (d) Universal principles: evidence-based practice must inform all aspects of the service, which must focus on targeting and measuring outcomes important for the child, family and community.

Longer-term sustainable solutions

Services need to be redesigned in a manner that is aligned with the principle of self-determination and with what First Nations families and communities value. Systems-thinking approaches and co-design provides an opportunity to achieve this, empowering communities to work with service organisations and collectively design an approach that aligns with their values and beliefs and which is culturally safe. There is an urgent need to invest in the development of culturally and linguistically appropriate assessment tools (e.g. tools with themes and pictures relevant to community) to allow practitioners to differentially diagnose a speech-language difference from disorder (Williams & McLeod, 2012). The development of new assessment measures stems from an understanding of the developmental trajectories of speech and language for First Nations people and recognising variations that can influence this. Materials must be culturally appropriate which can be achieved through authentic co-design approaches with First Nations communities. Implementation requires an understanding of the types and nature of responses that are appropriate for children. In conjunction, non-standardised assessments (e.g. dynamic and portfolio assessment, narrative) and home-language assessments need to be administered to ascertain the true functioning and capabilities of the child and design programs to match individual needs (Ball, 2012; Gould, 2008; McLeod et al., 2014). Certainly, communication disorder needs to be defined from an evidence-base and a cultural lens. Table I provides an overview of key short-term and longer-term recommendations and how this is aligned with the four key principles.

Table I. Short- and long-term solutions to deliver a culturally safe service.

Needs	Short-term solutions	Long-term sustainable solutions
Family
Speech-language assessments	Embed local cultural liaison within service to identify local linguistic and cultural differences that might influence the child’s assessment outcomes on standard Western measures.	Co-design culturally and linguistically appropriate assessments with communities, taking a strengths-based approach; Validate and develop the evidence-base to demonstrate effectiveness (SDG 4, 10)
Teamwork
Interventions	Work with local cultural liaison to support a family-centred approach and to support the family and community to implement recommendations; Provide cultural safety training for all.	Develop policies to make the short-term solution sustainable (SDG 4).
Inclusion
Community capacity-building	Co-design and deliver community-based programs to strengthen local knowledge of speech-language development and the importance of early language stimulation; or provide early identification. Support community to identify children “at-risk” of speech-language delays early.	Provide opportunities for literacy and language development to be scaffolded early (for example, support language reawakening programs; SDG 4).
Universal principles
Redesign systems and services	Use systems-thinking to identify what communities value and co-design services and pathways to deliver this. Develop culturally and linguistically appropriate outcome measures that align with concepts of value.	Modify and evaluate educational practices and assessments to support linguistic and cultural diversity as a strength of childhood development (SDG 4).
Services and workforce
Increase access to SLP services	Reduce financial disincentives for families to travel to services; Develop mobile health clinics to increase access for communities; Design and implement telehealth approaches to support assessment and intervention	Grow the First Nations SLP workforce to deliver interventions and ensure policies support opportunities for them to work locally (SDG 8).

Summary and conclusion

Culturally and linguistically sensitive speech-language supports must be co-designed with First Nations communities to enable development of optimal speech-language skills. The recommendations provided within this commentary link to the United Nations SDGs. Specifically, embedding a cultural liaison and developing culturally sensitive assessments and interventions will assist in reducing inequalities (SDG 10), community capacity-building and development of a First Nations speech-language pathology workforce will promote access to early intervention and quality education (SDG 4), which can support decent work and economic growth (SDG 8). The overall outcome of these recommendations will be good health and well-being (SDG 3) for First Nations peoples. This will create a pathway to achieve the global transformational vision outlined in the United Nations 2030 Agenda for Sustainable Development.

Disclosure statement

No potential conflict of interest was reported by the author(s).