Beyond lip service: Towards human rights-driven guidelines for South African speech-language pathologists

Abstract

Developed with a strong awareness of past injustices, South Africa’s progressive constitution emphasises a full spectrum of human rights. While the constitution celebrates many languages and cultures, speech-language pathologists (SLPs) face challenges in translating these values into practice with a diverse clientele. Similarly, Article 19 of the Universal Declaration of Human Rights focuses on freedom of expression in one’s language of choice, but is often perceived as a “Cinderella” right (i.e. one that is frequently neglected). This paper presents a literature review undertaken in association with the Health Professions Council of South Africa to produce guidelines to support SLPs in their practice with diverse linguistic and cultural groups. The aim was to identify key points for inclusion in a set of human rights-driven guidelines. Specific objectives were to critique: (1) current guidelines for SLPs working with diverse cultural and linguistic groups; and (2) equivalent guidelines for related professions. Content analysis of the datasets revealed key themes which formed the basis of an initial skeleton, to be further developed through a consultative process and discussion, ultimately aiming to provide supportive, practical guidelines to better equip South African SLPs to serve all the people of the country.

Keywords:

• Article 19
• Universal Declaration of Human Rights
• United Nations
• linguistic and cultural diversity
• guideline development

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Correction to: Pascoe et al., Beyond lip service: Towards human rights-driven guidelines for South African speech-language pathologists

Introduction

The 70th anniversary of the Universal Declaration of Human Rights (United Nations, 1948) is an appropriate time to reflect on Article 19 and its application in a linguistically and culturally diverse country like South Africa. Focusing on freedom of expression in one’s language of choice, South Africans have much to celebrate, for example, our 11 official languages (isiZulu, isiXhosa, Sepedi, Setswana, Sesotho, Xitsonga, siSwati, Tshivenda, isiNdebele, English and Afrikaans) which the constitution states must all enjoy parity of esteem and equal treatment (Constitution of the Republic of South Africa, 1996). In addition to the official languages, a host of other languages are spoken. These include Siphuthi, Khilobedu and Sindebele (Northern Ndebele) as well as South African Sign Language, sometimes (although not yet officially) referred to as South Africa’s twelfth official language. South Africa is home to many people from other countries in Africa where Portuguese and French are spoken, so these languages are also widely used along with other Southern African languages such as Shona, Shangaan and Chichewa.

In South Africa, English is prominent in political, educational and social settings (van der Walt & Evans, 2017), but most people will have a home language of one (or more) of the indigenous languages. IsiZulu is the first language of the majority of the population (22.7%), followed by isiXhosa (16%) and Afrikaans (13.5%). English is estimated to be the fourth most widely spoken language with less than 10% of the population claiming it as their home language (Statistics South Africa, 2016; van der Walt & Evans, 2017). Although South Africa is not unique in its cultural and linguistic diversity, it is unusual because its indigenous people do not constitute a minority, and the role of English here is complex with some viewing it as the language of power and prestige (Evans & Cleghorn, 2014; Mashiyi, 2014) and others disputing its place as the lingua franca, based on a mismatch between perceived status and actual usage (van der Walt & Evans, 2017).

Speech-language pathologists (SLPs) working in South Africa are tasked with providing a high quality, evidence-based service to all these people – irrespective of their language/s and culture. This is a challenge for a number of reasons detailed by Barratt, Khoza-Shangase, and Msimang (2012), Mdlalo, Flack, and Joubert (2016), Smit, van den Berg, Seedat, and Stein (2006), Southwood and Van Dulm (2015), and van der Merwe and Le Roux (2014). In brief, SLPs comprise a small group poorly equipped to serve the needs of the population due to a homogenous composition (largely female, white, English or Afrikaans speaking) and a lack of data about local people and their languages and cultures, together with few resources appropriate for use with the population. This occurs in a resource-constrained environment characterised by a quadruple burden of disease: the HIV/AIDS epidemic together with a high burden of tuberculosis; high maternal and child mortality; high levels of violence and injuries; and a growing burden of non-communicable diseases (Swanepoel, 2006).

SLPs in South Africa will most likely be aware of the legal framework in which they practice: They will know about the country’s constitution (Constitution of the Republic of South Africa, 1996) and the value that it places on languages and culture; the Universal Declaration of Human Rights (United Nations, 1948) and the emphasis that is placed on freedom of expression; and the Health Professions Council of South Africa’s scope of practice for SLPs (HPCSA, 1988) and code of ethics (HPCSA, 2007). Despite these frameworks, they may experience day-to-day challenges in their practice not knowing how to work with clients with whom they do not share a common language and/or cultural frame of reference. May (2011) described language rights as the “Cinderella” right (i.e. one that is frequently neglected), an apt descriptor when considering the situation for South African SLPs. The situation is not unique to SLPs but it may be a more pressing issue for our profession since language lies at the heart of our work: communication is not merely the tool needed to address a problem, it is the area that we wish to address. While linguistic diversity and challenges related to language use should be central for SLPs, what of cultural diversity and the role of human rights? In the following section, we describe what we mean by “human rights-driven guidelines” and the way in which we understand the relationship between human rights, language and culture.

Definitions of culture vary widely and much has been written about the nature of culture and the different levels at which it can be considered (i.e. individual, social, political and legal) (Irina, 2011). We define culture broadly as a people’s way of life, “the sum total of norms and values espoused and cherished by a particular people” (Iraki, 2004, p. 1). Culture is closely tied to identity, with specific cultural practices serving to demonstrate and enhance this identity (Nabudere, 2005). Language, a system of signs (verbal or otherwise) intended for communication, may be seen as one component of culture, a cultural resource or what Irina (2011) refers to as “cultural equipment” (p. 32). Based on this framework, language and culture are closely related but different, with language being one of the many ways in which culture and identity are affirmed. Having the freedom to identify with a particular culture through communication in a specific language/s and performance of particular cultural practices is an intrinsic human right. The United Nations recognises the universality of human rights: they are for everyone irrespective of culture, and everyone has the right to their culture. Rights to culture (including language) must be considered in the same way people have rights to housing, water and nutrition. Language is thus central to the work of SLPs, but can be viewed as part of a bigger picture: a resource or manifestation of belonging to a culture, which in turn is a fundamental human right.

Mental Health America (MHA, 2016) produced a position statement regarding cultural and linguistic competency which noted that organisations wishing to improve the ability to serve all people should develop a formalised, written, cultural and linguistic competency plan with clearly specified outcomes. Recognising the urgent need to support SLPs in the provision of services for all their clients, and thus make the profession more relevant for the people of South Africa, the HPCSA convened a “Language and Culture Task Team” requested to draft guidelines to support SLPs working with a linguistically and culturally diverse population. To our knowledge, none of the other registered health professions in South Africa have developed such guidelines. Our work with culturally and linguistically diverse groups is challenging but places us at the forefront of addressing these complex issues.

This paper describes our first step in formulating guidelines for South African SLPs to support their work with clients from linguistically and culturally diverse backgrounds: A scoping review of guidelines for SLPs (and other related professions) working with culturally and linguistically diverse populations. We approached the task with a human rights perspective, wanting to document a way in which the rights – especially those pertaining to language and freedom of expression, seen as a manifestation of culture – of all individuals might be better realised in our society.

Method

Aims and objectives

The main aim was to identify key points for inclusion in a set of human rights-driven guidelines written for SLPs practising in the linguistically and culturally diverse South African context. Specific objectives were to describe and critique:

1. Current guidelines for SLPs working with diverse cultural and linguistic groups;

2. Equivalent guidelines for related professions.

Scope of the review

We searched for documents that had been published or updated in the last 10 years (i.e. from 2006). Policy documents, position statements and clinical guidelines all serve different functions. We searched using each of these terms to identify a full range of documents focussing on linguistic and cultural diversity. Relevant documents were identified through a Google Scholar search and by directly accessing websites of SLP associations and other regulatory bodies. Our initial search revealed a total of 21 documents specific to SLPs, and 34 documents for other professions.

Criteria for inclusion

We applied the following inclusion criteria. Documents

1. that were freely available on the internet in full, in English;

2. focussing primarily on linguistic and/or cultural diversity. Several documents included this topic as part of a broader document. These were excluded since the level of detail provided was usually minimal.

Analysis

We undertook qualitative content analysis of each document, aiming to distil key themes from each in relation to language and culture. We then made comparisons across papers within each dataset and looked across the datasets to make sense of what we had read. We followed the content analysis approach described by Terre Blanche, Durrheim, and Kelly (2006), viz. familiarisation/immersion, inducing themes, coding, checking and interpreting. Comparison of findings from the two separate datasets added rigour to the final set of results which formed the basis of an initial skeleton, to be further developed through a consultative process and discussion into a guideline document for South African SLPs.

Results and discussion

Overview: Fifteen documents formed the focus of our guideline review: seven that pertained specifically to SLPs (ASHA, 2017; IASLT, 2006; IEPMCS, 2012; RCSLT, 2014; SAC, 2011; SPA, 2016; Virginia Department of Education, 2011) and eight for other professional associations including two for occupational therapists (CAOT, 2011; WFOT, 2009), one for general medical practitioners (RACGP, 2011); one for mental health practitioners (MHA, 2016); and the remaining three for multidisciplinary groups working in organisations focussed on early childhood (Division for Early Childhood, 2010), care of the elderly (Helping Hand Aged Care, 2010), child safety (Child Safety, 2010) and a health board (Waitemata District Health Board, 2015). Eight main themes emerged from these two datasets. Themes 1–3 focus on basic description of the documents, while themes 4–8 encapsulate key content of the documents reviewed.

Theme 1: Purpose of the documents

Our review was undertaken bearing in mind the different purpose and nature of the documents. In the first dataset, three of the documents were position statements (IEPMCS, 2012; SAC, 2011; SPA, 2016), while the others are guidelines. The ASHA guidelines consisted of two linked documents: a guideline detailing the knowledge and skills needed by SLPs to provide culturally and linguistically appropriate services (ASHA, 2004), and an ethics document focussing on cultural and linguistic competence (ASHA, 2017). While the ethics paper sets out standards for practice, the guideline document offers support to SLPs in detailing how they might achieve the standards. Having a clear understanding of the purpose of a document is important, along with an understanding of other policy documents that relate to it. Our work will involve writing a guideline containing detailed practical information for SLPs. The document could be used to formalise the position of the profession on the issue of cultural and linguistic diversity since this is assumed but not well-documented. Positioning the document in relation to the Universal Declaration of Human Rights (United Nations, 1948) and Constitution of the Republic of South Africa (1996) would be valuable.

Theme 2: Context

Most of the documents focussed on professionals working in a specific country with their content speaking directly to that milieu. For example, SAC (2011) focussed on French-English bilingualism while the RCSLT document specifically mentioned minority languages of the UK. Many of the documents were written with an assumption of English as the dominant language and the need to include other minority languages, although in some cases this was acknowledged as not always being the case (RCSLT, 2014). Many of the professional bodies explicitly acknowledged the mismatch that exists between culture and languages of clinicians and the cultural background and languages of the people they serve (e.g. IEPMCS, 2012; SPA, 2016). SAC (2011) emphasised the need for more bilingual-bicultural clinicians as a way of addressing this problem in their country. The two occupational therapy documents (CAOT, 2011; WFOT, 2009) both see an important place for enabling justice, and understanding power relations between individuals and groups. Linked to this is the Child Safety (2010) document which specified the need for practitioners to understand the impact of racism and discrimination. For our guidelines, it will be important to consider regional variation of languages and dialects, past injustices, power relations (Durrheim, Mtose, & Brown, 2011) challenges in education, debates regarding language policy (Kioko, Ndung’u, Njoroge, & Mutiga, 2014) and, in contrast to many of the guidelines reviewed, that local languages are majority languages in terms of number of speakers although not necessarily in terms of resources.

Theme 3: Terminology

Each document favoured different terminology in relation to language and culture. Most included a glossary or definition of terms. For language, key terms were language dominance, bi/multilingualism, minority languages, dialects, language difference vs language disorder. For culture, these included cultural competence, cultural and linguistic diversity, cultural safety, and cultural sensitivity. RACGP (2011), Child Safety (2010) and Helping Hand Aged Care (2010) focussed on cultural competence, each defining this term in slightly different ways, while CAOT (2011) refers to cultural safety defined as involving lifelong learning and continuing competence, a respectful approach to nationality, culture, age, sex, gender and sexual orientation, political and religious beliefs. MHA (2016) included cultural humility, incorporating “a lifelong commitment to self-evaluation and self-critique, to redressing imbalances in the patient–physician dynamic, and to developing mutually-beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations” (Tervalon & Murray-Garcia, 1998, p. 117). The RACGP (2011) did not mention cultural humility as part of its terminology, but expressed a similar sentiment when stating the need for practitioners to: “Tolerate ambiguity, suspend judgement and develop empathy when meeting the health needs of patients from different cultures.” (p. 156). The relationship between language and culture was also considered in our analysis. As SLPs focus on language as a core area of their scope of practice, this aspect often received more attention than culture. Some of the documents focussed more heavily on language than culture, although this often appeared to have been the remit of the authors, e.g. Virginia Department of Education (2011); IASLT (2006) and RCSLT (2014). The ASHA guidelines made clear links and distinctions between culture and language, and the Virginia Department of Education gave some excellent examples of the effect of both language and culture that can be seen in the narratives produced by children, together with suggestions for how to elicit and analyse these in culturally and linguistically appropriate ways. Positioning culture and language in a human rights framework may be helpful for SLPs in understanding the importance and challenges of this work.

Theme 4: Valuing diversity

Each document placed a strong and unequivocal value on multilingualism and embracing a diverse range of languages and dialects. Some gave specific examples of the benefits of diversity for individuals and society. For example, IEPMCS (2012, p. 3) spoke of the “development of cultural identity,” and broader legal frameworks such as the Human Rights Equal Opportunity Commission Act (Office of Legislative Drafting and Publishing, 2006) were referred to by SPA (2016). Authors such as Irina (2011) and Nabudere (2005) point to such frameworks as key drivers in promoting appreciation of cultural diversity, but cautioned that valuing diversity does not necessarily equate to knowing how to respond to issues related to diversity. Southwood and van Dulm’s (2015) survey of SLPs illustrated this point, and the work of McLeod, Verdon, and the IEPMCS (2017) responds to this need in the case of multilingual children with speech difficulties.

Valuing diversity is not necessarily straightforward. Nabudere (2005) describes situations in which a tension occurs between human rights and cultural practices. Using the case of female genital mutilation, he describes the conflict between universally espoused human rights and at the same time, the right to one’s culture and associated practices, suggesting that open dialogues may offer solutions to such difficulties. What we can take from this for our work, is a caution that “valuing diversity” is easy to include in guideline documents but upholding this and offering practical support in doing so may require more thought, effort and resources – linking with our seventh theme below.

Theme 5: Equity and accessibility

All documents emphasised the importance of treating clients in a fair and non-discriminatory manner, despite challenges of cultural and linguistic diversity. Not surprisingly the second dataset placed less emphasis on language when compared to the SLP dataset. The Division for Early Childhood (2010) made specific mention of children learning more than one language, speakers of different dialects and the need for fair assessment practices. Many focussed on equity and access for users of all languages and specifically mentioned interpreters and translators in ensuring that these ideals are met. MHA (2016) placed emphasis on making communication accessible for all, specifically detailing a need for signing professionals, sign language interpreters and the use of braille as needed. Interestingly, the emphasis on sign and braille was not so explicit in the first dataset. Some of the documents went beyond issues of accessibility. For example, WFOT (2009) included a section in which the power of words was considered in relation to terminology used by the profession, together with a call for occupational therapists to be more conscious of the language they use. In South Africa, issues of equity and access must be linked to our context (theme 2) of historical disparity and constitutional rights, and our document should include practical suggestions for ensuring equity and access for all people.

Theme 6: Life-long learning

The documents reviewed unanimously referred to an ongoing process through which the necessary skills for working with diverse client groups would be developed. Life-long learning was frequently mentioned (e.g. ASHA, 2017; SPA, 2016). Training of students, life-long learning (both informally through self-reflection) and continuing professional development (CPD) were core parts of many of the documents. SPA (2016) described a “continuous process of learning and adapting to the needs of others” (p. 11). Several documents mentioned the need to undertake research relevant to culturally and linguistically diverse populations that will help the professions to better serve all clients. Training must also consider recruitment and retention of staff who have language skills that complement the languages used by the communities being served (MHA, 2016). Our document will emphasise learning throughout the professional lifespan from student training to experienced professionals, and make links with cultural humility. Including a section on student training and CPD activities/reflective logs will be ways in which we can offer practical support to SLPs.

Theme 7: Creating the space/valuing the task

SPA (2016) and IEPMCS (2012) both emphasised that working with a diverse clientele will typically take longer (e.g. assessment in multiple languages) and require more resources (e.g. need to develop/have access to multiple assessments; pay an interpreter). This extra time and resourcing is key to achieving a high standard of service and signals the value that should be placed on such efforts. Linked to this point is the need for SLPs to advocate for these extra resources and drive forward a research agenda in this regard. All the documents mentioned the need to draw upon all resources available and make links with interpreters, community members and support personnel to achieve the highest standards of care. The ASHA documents (2017) were helpful in not only emphasising the need to seek help from other personnel but also cautioning that to rely too heavily on such assistance would be a failing since SLPs must take responsibility for their clients and ensure that interpreters are well trained for their roles. In South Africa, there is much work to be done in relation to this theme. Setting specific targets that relate to this theme may be a useful starting point.

Theme 8: Being data-driven and using theory as a guide

Some documents made explicit mention of theoretical frameworks which they use to navigate challenges of working with a diverse population. SPA (2016) used six principles of culturally competent practice (Verdon, McLeod, & Wong, 2015); IEPMCS (2012) used the International Classification of Functioning, Disability and Health (WHO, 2007) as their guiding framework. Although some of the other documents were less explicit about their frameworks, the importance of research evidence as an underpinning of best practice came across strongly in many. For example IASLT (2006) and Virginia Department of Education (2011) based many of their recommendations on a review of recent research regarding bilingualism. Several emphasised the importance of knowledge as a tool for bringing about meaningful change. For example, WFOT (2009) urges occupational therapists to collect demographic data about the populations they serve. Knowing facts, figures and disparities is key to being able to successfully advocate for underserved populations. Similarly, knowledge was seen as key by RACGP (2011) in knowing about how different cultures attach meaning to different parts of the body and illness. This may result in clients presenting in different ways, following treatments in different ways, their attitude to medication and diet. The Child Safety (2010) document mentioned the need to develop a working knowledge of differences in child rearing practices. As noted for theme 4, knowledge of particular cultural practices may lead to tensions with human rights, and require careful negotiation and dialogue to ensure that human rights are not compromised and cultural differences are valued.

Implications

Our main aim was to identify key points for inclusion in a set of human rights-driven guidelines for SLPs working in South Africa with a culturally and linguistically diverse population. Analysis of the datasets enabled us to identify eight key themes around which we will start to structure our guidelines, while undertaking further literature review. The themes and specific implications for our document arising from each one are summarised in Table I.

Table I. Implications for speech-language pathology guidelines from the literature review.

Theme	Implication for our speech-language pathology guideline document
Theme 1: Purpose of the documents	We need: clear understanding of the nature/purpose of the document; understanding of other policies and guidelines that relate to it.We will: write a guideline which offers support for SLPs through detailed practical information currently lacking. The document could be used to formalise the position of the profession on the issue of cultural and linguistic diversity since this is assumed but not necessarily documented. Positioning the document in relation to the Universal Declaration of Human Rights (United Nations, 1948) and Constitution of the Republic of South Africa (1996) may be helpful.Exemplars/References: WFOT (2009); CAOT (2011).
Theme 2: Context	We need: to speak directly to our context (e.g. specific languages and multiple official languages).We will: consider regional variation, past injustices, power relations, that local languages are majority languages in terms of number of speakers but not necessarily in terms of resources.Exemplars/References: Waitemata District Health Board (2015).
Theme 3: Terminology	We need: to define terminology used.We will: debate use of appropriate terms. There is scope for use of multiple terms. Cultural competence is a controversial term; cultural safety and humility may be preferable.Exemplars/References: WFOT (2009); MHA (2016).
Theme 4: Valuing diversity	We need: to ensure valuing diversity is explicitly stated.We will: emphasise as a main underpinning and explain why; try to go beyond emphasising the value to show practical ways of how this can be done.Exemplars/References: WFOT (2009); MHA (2016). IEPMCS offer good examples of this, not only in their 2012 position paper but through follow-up papers with a tutorial focus (e.g. see McLeod, Verdon, & IEPMCS, 2017).
Theme 5: Equity and accessibility	We need: to ensure that issues around equity and access are explicitly considered.We will: emphasise as a main underpinning, link to context (historical disparity; constitutional rights) and explain practical guidelines and pointers for achieving this.Exemplars/References: WFOT (2009); MHA (2016).
Theme 6: Life-long learning	We need: to ensure this is emphasised throughout the professional lifespan from student training to experienced professionals, and makes links with cultural humility.We will: incorporate a section on student training, CPD activities/reflective logs.Exemplars/References: SPA (2016); ASHA (2017).
Theme 7: Creating the space/valuing the task	We need: recognition of work done; more time, funding and research; SLPs to adopt an advocacy role.We will: set targets for this type of work.Exemplars/References: SPA (2016); IEPMCS (2012); MHA (2016).
Theme 8: Being data-driven and using theory as a guide	We need: to encourage collection and sharing of data.We will: draw on available theoretical models and evidence-base in writing the document.Exemplars/References: IEPMCS (2012); RCSLT (2014); WFOT (2009).

Limitations and future work

The work described here was used as a starting point for a larger project, and we acknowledge that the review has several limitations. First, we focussed on published guidelines that were available online and in English. We acknowledge that these criteria impacted on the results obtained, and that there may be bias in our findings as a result. Second, we focussed on guidelines written or updated in the past 10 years. This may have led to exclusion of documents that may have contributed to a more comprehensive review. Third, none of the guidelines reviewed were from Africa, and it will therefore be important in our future work to ensure that African values and context are explicitly taken into account. Additional themes may be added based on this literature, and our initial ideas presented here may be modified. There is a large body of work focussing on cultural and linguistic diversity in South Africa and it will be important to ensure that a review of this literature is woven into the data already obtained and used to inform our work. This speaks closely to our themes 2 and 8 in which we emphasise the importance of context, and the importance of available knowledge as an underpinning for practice.

The eight themes highlighted by our review will be used as initial headings, and references cited here will guide, but not limit, our discussions. The task team will now debate and detail guidelines that are a combination of local and international literature and best practice while at the same time being appropriate for our specific context. Our draft guidelines will ultimately be circulated widely to local stakeholders and international experts for further comment and revision, aiming to provide supportive, practical guidelines to better equip South African SLPs to serve all the people of the country and ensure that Article 19 of the Universal Declaration of Human Rights, the basic human right to express oneself in one’s language of choice, can be upheld.

Declaration of interest

There are no real or potential conflicts of interest related to the manuscript.

Acknowledgements

This paper was written in preparation for the authors’ participation in the Language and Culture Task Team convened by the Health Professions Council of South Africa (Speech Language and Hearing Professions), whose support is acknowledged.