Disclosures

Leigh Ann Reel, Candace B. Hicks,
Nathan Ortiz, and Amanda Rodriguez

Have a relevant financial relationship
with the services described in this
presentation.
 We
are co-investigators on an ASHA Office
of Multicultural Affairs grant, which funded
the development of materials discussed in
the current presentation.

Have no relevant nonfinancial
relationships to disclose.
Improving Communication Between
English-Speaking Audiologists
and Spanish-Speaking Patients
Leigh Ann Reel, Au.D., Ph.D.
Candace Bourland Hicks, Ph.D.
Nathan Ortiz, B.S.
Amanda Rodriguez, B.S.
Texas Tech University Health Sciences Center
Need for the Project
Growth of the Hispanic
Population

Hispanic population increased by over
40% between 2000 and 2010, both
for the country as a whole and for the
state of Texas (Humes, Jones, & Ramirez, 2011).

Hispanics now comprise 16.3% of the
total U.S. population and 37.6% of the
population of Texas (Humes et al., 2011).
Cultural and Linguistic Barriers
to Healthcare

Hispanic patients with limited English
proficiency reported less satisfaction
with medical care compared to Englishspeaking patients (Morales, Cunningham, Brown,
Liu, & Hays, 1999).

Even with an interpreter, Spanishspeaking patients rate providers as
being “less friendly, less respectful,
[and] less concerned for the patient as a
person,” as compared to ratings from
patients who speak English (Baker, Hayes, &
Fortier, 1998, p. 1461).
Need for Cultural and Linguistic
Competence in Audiology

Percentage of audiologists who report
being bilingual (ASHA, 2012)



ASHA Code of Ethics (2010)


Texas = 7.1%
U.S. = 4.5%
Principle of Ethics I, Rule C: “…individuals
shall not discriminate in the delivery of
professional services” (para. 10).
Need cultural and linguistic training for
English-only audiologists.

To ensure equal access to care and quality
of service for all patients
Developing Cultural
Competence

Much emphasis on the need for
audiologists to be sensitive to cultural
differences (e.g., ASHA, 2011).

Very little information on how to
accomplish this goal.

Specific examples of aspects of Hispanic
culture

How cultural differences may impact
interaction with Hispanic audiology patients
Developing Linguistic
Competence

Various organizations (e.g., ASHA,
NIDCD) provide Spanish brochures
and other publications for Spanishspeaking patients.

Few published resources available to
assist monolingual English-speaking
audiologists in learning Spanish
terminology needed to effectively test
Spanish-speaking patients.
Spanish Translations for
Balance Testing
Newman-Ryan, Northup, and VillarrealEmery (1995)
Case history
 Pre-test
instructions
 General
questions and
instructions
 Otoscopy

Screening for
cranial nerves 3,
4, and 6
 Cerebellar
function
 Proprioceptive
function
 Gait

Spanish Translations for
Balance Testing
Newman-Ryan, Northup, and VillarrealEmery (1995) - Continued
Overview of test
purpose
 Cleansing
 Calibration
 Gaze
 Sinusoidal
tracking

Optokinetic
testing
 Dix Hallpike
 Positional testing
 Fistula testing
using the
immittance bridge

Spanish Translations for
Balance Testing
Newman-Ryan, Northup, and VillarrealEmery (1995) - Continued
Caloric testing
 Fixation
suppression
 Counting alerting
tasks
 Non-counting
alerting tasks
 Glycerol testing

Rotary chair
 Dynamic
posturography

Spanish Translations for
Balance Testing

Newman-Ryan, Northup, and
Villarreal-Emery (1995) – Continued

Very thorough overall

Does not include: Videonystagmography
(VNG), vestibular evoked myogenic
potentials (VEMPs), dynamic visual
acuity test, hyperventilation nystagmus
test, headshake nystagmus test, and
orthostatic hypotension screening
Spanish Translations for
Standard Audiological Tests
Northup and Jameson (as cited in Roeser,
1996)





Pure-tone testing
(raising a hand)
Pure-tone testing
(pushing a button)
Speech thresholds
Word
discrimination
Masking (puretones only)




Immittance
(tympanometry and
acoustic reflexes)
Uncomfortable
loudness level
Real ear
measurement
Auditory brainstem
response
Limitations of Available
Spanish Translations

Lack translations of test descriptions
and instructions for:

Otoacoustic emissions

Acoustic reflex decay testing

Play audiometry

Visual reinforcement audiometry (VRA)

Behavioral observation audiometry
(BOA)
Limitations of Available
Spanish Translations

Lack translations of test descriptions
and instructions for:

Picture-pointing speech audiometry

Speech awareness threshold (SAT)

Body part identification speech reception
threshold

Bone conduction testing
Limitations of Available
Spanish Translations

Lack of modified test instructions for
standard audiological tests when used with
pediatric patients (e.g., tympanometry)

Brief translated instructions may not
accurately represent test instructions that
audiologists would typically provide to
patients who speak English.

Exception: Translation of balance function
information by Newman-Ryan et al. (1995) is
very thorough.
Limitations of Available
Spanish Translations

Lack of the English version of test
instructions translated into Spanish

Example: Test instructions provided by
Northup and Jameson (as cited in
Roeser, 1996)

English-speaking audiologists need to
know what they are saying to their
Spanish-speaking patients!!!!
Project Objectives

Improve cultural competence of
audiologists by disseminating a learning
module related to cultural issues in the
Hispanic population

Ensure that reliable tests can be conducted
by English-speaking audiologists when
serving Spanish-speaking patients by
providing:


Written Spanish test descriptions/instructions
Video instruction on how to say this information
in Spanish
Project Objectives

Provide Spanish-speaking patients
with easy-to-understand information
(i.e., handouts) about what tests may
be performed before going to an
audiological evaluation

Obtain feedback from Spanishspeaking individuals and from
audiologists to ensure that the
materials are appropriate in different
regions of Texas
Project Objectives

Utilize the results to extend the
project in the future to clinically-based
research projects to better serve the
Spanish-speaking population
Cultural Training
Module
Cultural Competence Training for
Audiologists

What is culture?
 “…language, thoughts, communications, actions,
customs, beliefs, values and institutions of racial,
ethnic, religious, or social groups” (p. 68).

What does it mean to be culturally
competent?
 Understanding and respecting cultural beliefs of
patients, clients, or customers in order to provide
appropriate services.
(Anderson et al., 2003)

Cultural competence in a clinical environment
can be enhanced through use of a patient’s
native language, either through the provider,
an interpreter, or translated materials.

Cultural competence would also include
“training for providers about the culture and
language of the people they serve” (p. 69).
(Anderson et al., 2003)

Between 2000 and 2010, the Hispanic
population increased by over 40 percent in
the United States (Humes, Jones, & Ramirez
2011).

With this growth, Hispanics now comprise
16.3% of the total U. S. population (Humes et
al., 2011).

Hispanic population in the U. S.:
 Over 50 million individuals
 More than 10 million families
 In 2010, three-quarters of the Hispanic population
spoke Spanish in the home.
(U. S. Department of Commerce, 2012)

In working with Spanish-speaking patients,
the audiologist must be competent in what
aspects of culture can impact healthcare.
 Cultural belief systems and values
 Language barriers

Spanish-speaking patients are less likely to
seek medical care (Pearson, Ahluwalia, Ford,
& Mokdad, 2008). This could be related to:
 Distrust of physicians (Boyas & Valera, 2011)
 Question on “integrity” of the provider (Boyas &
Valera, 2011, p. 150)
▪ May feel that medical professionals are focused on
making money/reimbursement and not the overall wellbeing of the patient.
 As compared to English-speakers, may feel that
the provider does not communicate effectively
(e.g., listen to the patient, explain results
effectively, show respect to the patient) (Wallace,
DeVoe, Heintzman, & Fryer, 2009)
 Perception that the provider is “insensitive to
cultural differences” (Anderson et al., 2003, p. 68)

Studies indicate Hispanic patients may also be
less likely to seek audiologic care.

In the Mexican-American population, 34.9% of
females and 46.3% of males aged 55-74 had hearing
loss (Lee, Carlson, Lee, Ray, & Markides, 1991).

One study found 60% of Latino American participants
who reported having problems hearing had not had
their hearing tested (Torre, Moyer, & Haro, 2006).

Spanish-speaking individuals may
demonstrate poor health literacy, with 65%
of Hispanic adults having basic or below basic
health literacy (USDHHS, 2008).
 Health literacy is “the ability to obtain, process,
and understand basic health information and
services to make appropriate health decisions”
(USDHHS, 2008, para 1).

Poor health literacy can impact
healthcare.
 American Medical Association Ad Hoc Committee
on Health Literacy for the Council on Scientific
Affairs (1999) reviewed over 200 articles. They
concluded that poor health literacy can:
▪ Negatively impact a person’s health
▪ Potentially increase medical costs
▪ “Increase the risk of hospitalization” (p. 552).

There are few bilingual medical professionals.
 According to ASHA (2012), only 7.1 % of Texas
audiologists consider themselves bilingual.

Research indicates that Spanish-speaking
patients are more open in discussing certain
medical issues with the physician if the
physician speaks their native language
(Eamranond, Davis, Phillips, & Wee, 2009).

The language barrier that may exist between
a patient and the healthcare provider can
lead to negative health consequences for the
patient.
 When a physician speaks a different language
than the Spanish-speaking patient, 20% of the
patients may not pursue medical care or may not
pursue the medical care in a timely manner
(Robert Woods Johnson Foundation, ND, as cited
in Anderson et al., 2003).
 Related to medical appointments and the
language barrier, translators may be used.
▪ However, patients may not be comfortable with
the translator in the room (Julliard et al., 2008).
▪ Even with a translator, a patient may feel that
“their confidentiality was not protected”
(Julliard et al., 2008, p. 545).

Even with use of translators, it is common for
individuals to be bilingual in Spanish and
another regional dialect.
 These speakers may prefer to communicate in
their dialect versus traditional Spanish.

As such, some patients may not understand
terms used in traditional Spanish.
(Zuniga, 1998)

Often, Spanish-speaking patients and physicians
rely on a third party to translate during an
appointment.

Third-party translators are not formally trained
(Bezuidenhout & Borry, 2011). They may include:
 Family member or friend
 Untrained staff personnel

At least one study indicated physicians’ offices
used untrained staff ~1/4 of the time and
family~1/3 of the time as translators (Hornberger,
Itakura, & Wilson, 1997).

This does not always equate to efficient and effective
communication. Third-party translators may:
 Leave out important information or inaccurately translate the
information (Bezuidenhout & Borry, 2011)
 Violate the privacy of the patient (Baker, Hayes, & Fortier,
1998).
 Exert their own opinions or may answer for the patient instead
of allowing him/her to be an active participant in the medical
appointment, especially if the patient is a family member
(Downing & Tillery, 1992, as cited in Baker et al., 1998)
 Allow the translations to be affected by his/her “social baggage,
beliefs, values, and cultural norms” (Bezuidenhout & Borry,
2011, p. 161).

With use of third-party translators, ¼ to ½ of
information from medical personnel may be
mistranslated or omitted (Ebden et al., 1988,
as cited in Baker et al., 1998).

There are limited published resources available
to assist monolingual English-speaking
audiologists in learning Spanish terminology
needed to communicate with Spanishspeaking patients.

Examples of published resources:

Test instructions in English and Spanish for various
balance tests, as well as a few standard audiological tests
(Newman-Ryan, Northrup, & Villarreal-Emery, 1995)

Test instructions in Spanish for various audiological tests
(Roeser, 1996).

Newman-Ryan, Northrup, & Villarreal-Emery
(1995)
 The English and Spanish versions of the balance
test instructions are quite thorough.
 However, instructions for some balance tests are
not included: Videonystagmography (VNG),
vestibular evoked myogenic potentials (VEMPs),
dynamic visual acuity test, hyperventilation
nystagmus test, headshake nystagmus test, and
orthostatic hypotension screening

Roeser (1996)
 Lack translations of test descriptions and
instructions for:
▪ Otoacoustic emissions
▪ Acoustic reflex decay testing
▪ Play audiometry
▪ Visual reinforcement audiometry (VRA)
▪ Behavioral observation audiometry (BOA)
▪ Picture-pointing speech audiometry

Roeser (1996)
 Also lack translations of test descriptions and
instructions for:
▪ Speech awareness threshold (SAT)
▪ Body part identification speech reception threshold
▪ Bone conduction testing

Problems the two published resources:
 Lack of modified test instructions for standard
audiological tests when used with pediatric
patients (e.g., tympanometry)
 Brief translated instructions may not accurately
represent test instructions that audiologists would
typically provide to patients who speak English.
▪ Exception: Translation of balance function information
by Newman-Ryan et al. (1995) is very thorough.

Lack of the English version of test instructions
translated into Spanish
 Example: Test instructions provided by Northup and
Jameson (as cited in Roeser, 1996)
 English-speaking audiologists need to know what
they are saying to their Spanish-speaking patients!

There are few if any resources that address
variations of Spanish and different regional
dialects an audiologist may encounter.

It is important to use linguistically and culturally
appropriate materials in hearing healthcare.

According to ASHA (2011), bilingual audiologists
reported that “unremarkable histories and
normal hearing results were fairly easy to
translate” or write in a report (p. 12) .

However, there is a lack of Spanish testing materials.

According to the ASHA Code of Ethics (2010)
Principle of Ethics I, Rule C: “individuals shall not
discriminate in the delivery of professional
services…” (para. 10).

Therefore, monolingual English-speaking
audiologists must strive to improve their cultural
and linguistic competence in order to be able to
provide the same access to care and quality of
service to all patients, regardless of their cultural
or language background.

Hispanic population:
 Is considered high-context, with communication
involving “personal delivery that resonated the
affective as well as the factual” (Zuniga, 1998, p. 238).
 Tend to value community and family over the
individual and favor group support.
 Pays attention to non-verbal cues in personal
interactions
 Has a strong sense in tradition and history

The audiologist must understand key aspects of the
culture which can impact hearing healthcare,
including:









Family centered (Familismo)
Child rearing and disabilities
Gender and disabilities
Religion and disabilities
Folk beliefs
Respect (Respeto)
Personal interaction (Personalismo)
Non-verbal cues
Perception of time

In the Hispanic culture, high value is placed on
family (Carteret, 2011; Padilla & Villalobos,
2007; Zuniga, 1998).
 This is includes immediate and extended family
members.
 Family members are obligated to care for and
support one another.

Strong support from family members has been shown
to have a significant positive impact on health for
Hispanic patients (Padilla & Villalobos, 2007).

Sensitivity to role of family
 Spanish-speaking patients may have family members
attend their appointments.
▪ It is important for the clinician to accommodate seating
for all family members, as they may desire to be a part
for the entire appointment process.
 The patient may not be the person communicating
with medical personnel.
▪ The “matriarch/patriarch” or “more acculturated
children” may be the primary person providing
information (p. 29).
(National Alliance for Hispanic Health, 2001)

Sensitivity to role of family
 Hispanic family members are “more likely to be
involved in the treatment and decision-making
process for a patient” (National Alliance for
Hispanic Health, 2001, p. 28).
▪ Clinicians should realize that additional time may be
needed to make a medical decision due to the
patient’s need to discuss the decision with his/her
family members.

Sensitivity to role of family
 “Failure of the clinician to recognize familismo
can lead to conflicts, non-compliance,
dissatisfaction with care and poor continuity of
care” (Carteret, 2011, para. 4).

Compared to Anglo families, Hispanic families
may not place as much importance on children
reaching developmental milestones and learning
to do things independently.

Parents of a child with a disability may be even
more reluctant to discipline the child or push the
child to develop new skills. Therefore, the child
may rely on family members.
(Zuniga, 1998)
 Sensitivity to views on child rearing
 Clinicians should respect how children
are raised in the Latino culture and work
with the family to acknowledge the
priority of developing speech, language
and hearing skills necessary for greater
academic success.

“Machismo (maleness, virility) may contribute to
denial of a disability” (Salas-Provance, Erickson,
& Reed, 2002, p. 152).
 Acknowledging a disability, such as a hearing loss,
and accepting treatment (e.g., hearing aids) may be
viewed by some Hispanic males as a “sign of
weakness” (p. 152).

Due to cultural norms, some Hispanic females
may not acknowledge a health/hearing problem.
 Disabilities are viewed as something you “endure” (p.
152).

Beliefs regarding the cause of a disability may
be tied to religious beliefs (Salas-Provance et
al., 2002).
 Some Hispanic families may believe that a health
problem develops as God’s way of punishing sins
(Zuniga, 1998).
 Others may believe that a disability is the result of
a curse or an evil spirit (Zuniga, 1998).
Some Hispanics may believe in Curanderismo (a form of
folk healing), which includes “the belief that God can
and does heal and that people with a special gift can and
do heal in his name” (Marsh & Hentges, 1988, p. 257).
 Some Hispanics may use curandero(as) (i.e., “natural
faith healers”) to treat physical or mental conditions
(Zuniga, 1998, p. 231), either as a second opinion or in
conjunction with traditional medical treatment (Padilla
& Villalobos, 2007; Zuniga, 1998).

 “Use of natural healers often occurs because they are
geographically accessible, the charges are minimal, and
often families cannot afford or do not have access to
Western resources” (Zuniga, 1998, p. 231).

Sensitivity to religious beliefs regarding
causes and treatments for disabilities
 Clinicians are encouraged to “acknowledge these
belief systems” of the Latino culture (Zuniga,
1998, p. 232).
 If a spiritual healer is used, “the interventionist is
cautioned to respect this fact while at the same
time ensuring that there are no contraindicated
interventions occurring that may harm the
[patient]” (Zuniga, 1998, p. 239).
A 2002 study investigated beliefs about
disabilities (including speech, language, and
hearing) held by four generations of one
Hispanic family.
 Examples of folk beliefs:

 Causes of disabilities
▪ Mal de ojo (evil eye)
▪ Susto (fright sickness)
 Treatments for ear problems
▪ Sweet oil, drinking chamomile, hot wax
(Salas-Provance et al., 2002)

Overall, results of the study showed that:
 “Low income, less educated, and/or older minority
persons [held] folk beliefs regarding causes and cures
of disabilities” (p. 158).
 “Well-educated, young family members more
frequently used medical care for curing disabilities” (p.
158).

However, regardless of education level, both
younger and older participants had at least some
views of disabilities as being medically based,
rather than only based on folk beliefs.
(Salas-Provance et al., 2002)

Sensitivity to folk beliefs
 Audiologists should not assume that all
individuals in the Hispanic culture hold folk
beliefs.
 Direct, close-ended questions may be needed to
determine if the individual has folk beliefs that
could potentially influence their treatment.
(Salas-Provance et al., 2002)

Respect (respeto) should be shown based on “age,
sex, social position, economic status, and authority”
(National Alliance for Hispanic Health, 2001, p. 29).






Young adults should respect older adults.
Children should respect adults.
Women should respect men.
Students should respect teachers.
Workers should respect bosses.
Healthcare providers are typically well-respected.
 As a sign of respect, Hispanic patients may not make eye
contact with the provider.

To show respect for Hispanic patients, healthcare
providers should:
 Make eye contact with the patient, even if an interpreter is
used.
 “Address Hispanic adults as Señor (Mr.), Don (Sir), Señora
(Mrs.), [Señorita (Miss)], or Doña (Madam)” (p. 31).
 Consider greeting the patient in Spanish (e.g., “buenas
dias” or “buenas tardes”), even if you do not speak Spanish
 “Always use the formal usted (you)” when attempting to
converse with the patient in Spanish, unless he/she has
specifically asked you to use the informal tu (you) (p. 31).
(National Alliance for Hispanic Health, 2001)
 Provide complete explanations of all tests and
treatments.
 Encourage patients to ask questions.
▪ “Out of a sense of respeto many Hispanic patients tend
to avoid disagreeing or expressing doubts to their
healthcare provider…They may even be reluctant to ask
questions or admit they are confused about their
medical instructions or treatment” (p. 31).
(National Alliance for Hispanic Health, 2001)

Hispanics value personal relationships.
 Most are more likely to seek medical care from
providers they know in their community.
 They may stop treatment and not seek a new
provider if the health professional they know
moves.
(National Alliance for Hispanic Health, 2001)

Healthcare providers can demonstrate
personalismo by being “warm, friendly, and
personal, and [taking] an active interest in the
patient’s life” (p. 32).
 This lets the patient know that “the provider is
interested in her as a person and will help put the
patient at ease before an exam or medical
procedure” (p. 32).
(National Alliance for Hispanic Health, 2001)

Hispanic individuals may be particularly sensitive to
nonverbal cues, especially when interacting with
individuals in authority (Zuniga, 1998).

Clinicians should be aware their nonverbal language.
 Example: Expressions of surprise, curiosity, or disapproval
may be seen in the body language of the clinician.

Healthcare providers are expected to be attentive,
friendly, and polite.
 If a clinician “seems hurried, detached, and aloof, the
Latino patient/parent may experience resentment and be
dissatisfied with care” (Careteret, 2011, para. 12).

Many Hispanics “treat time as flexible and do
not value punctuality the way their
healthcare providers may expect them to”
(Carteret, 2011, para. 11).
 Being late is viewed as socially acceptable.

Clinicians should be aware of a Hispanic
patient/family’s possible cultural beliefs but
should not make assumptions.

Each patient/family must be considered
individually to determine any cultural beliefs
that may influence his/her healthcare.
(Zuniga, 1998)

In a recent ASHA Leader survey, 20
audiologists, 2 of whom were bilingual,
reported possible solutions to improve the
language barrier between a Spanishspeaking patient and the clinician.

Discussions with these audiologists led to the
following suggestions/resources.
(Abreu, Adriatico & DePierro , 2011)

Common Problem: An accurate and detailed
case history can be difficult to obtain,
especially for pediatric patients.

Possible solution: Assistance from an “ad
hoc” interpreter
 Examples: Family, staff member, and/or
telephone service “language lines,” which are
commercial over-the-phone interpreters
(Abreu et al., 2011)

Drawbacks:
 “All respondents agreed that unremarkable case
histories and normal hearing test results were
fairly easy to translate” (p. 12).
▪ However, information may not be translated correctly
for test results that are not normal.
 Ad hoc interpreters may not understand
audiological or medical terminology, causing
them to make more errors in the translations.
 They are also not trained related to HIPPA.
(Abreu et al., 2011)

Possible solution: use of interpreter services,
either in person or via services over the phone,
computer, etc.
 E.g., telephone interpretation services (see next
slides)

If translators are not available, ad hoc
interpreters are better than nothing.
 However, the audiologist needs to recognize the
potential drawbacks of the use of ad hoc interpreters.
(Abreu et al., 2011)

The healthcare provider and the Spanishspeaking patient are in the same room.

The healthcare provider calls a specific
telephone interpreting service and is
connected to a Spanish-speaking interpreter.

The healthcare provider and the Spanishspeaking patient can communicate via the
interpreter using different telephone setups.
(CyraCom, 2012)

Speakerphone
 The provider and patient communicate with the interpreter via the
speakerphone on a regular telephone.
 Background noise may interfere with signal clarity.

Splitter for attaching an additional handset to a regular phone
 The provider uses one handset, and the patient uses the other
handset.

Dual-handset telephones
 A special telephone with one handset for the provider and one
handset for the patient

Dual-handset cordless phone sets
 A special cordless telephone with one handset for the provider and
one handset for the patient
(CyraCom, 2012)
Dual Handset Telephones
http://www.pacificinterpreters.com/services/telephonicinterpreting/healthcare-and-social-services

There are many telephone interpreting services
available. These are just two examples of
services that specialize in interpreting for
medical/healthcare settings:
 CyraCom
▪ “Interpretation and translation solutions for healthcare"
▪ http://www.cyracom.com
 Pacific Interpreters™
▪ “Medically-qualified interpreters”
▪ http://www.pacificinterpreters.com/services/telephonicinterpreting/healthcare-and-social-services

A recent study of 1201 bilingual families in a pediatric
emergency department compared efficacy of trained
in-person interpreters, telephone interpreter services,
and bilingual physicians.
 Agreement between the family’s understanding of the
diagnosis and the actual diagnosis made by the physician
was similar across the three groups.
 Family satisfaction with the physician and the visit were
“high and similar across groups” (p. e635).
 Suggests that “neither in-person medical interpretation
nor remote telephonic interpretation is less efficacious
than provider fluency in the families’ native language” (p.
e631).
(Crossman, Wiener, Roosevelt, Bajaj, & Hampers, 2010)

Online resources for audiologist and
patient/parent
 ASHA and the National Center for Cultural
Competence
▪ Modules to help clinicians determine their level of cultural
competency.
 Centers for Disease Control and Prevention (CDC)
▪ Hearing and hearing loss information translated in Spanish
 Hearing aid and cochlear implant manufacturers may
have Spanish materials available.
(Abreu et al., 2011)

Translation tools and terminology
 iPad or iPod application, “Medical Spanish”
 Current cultural training module and translations
(see separate file for translations)

Get involved locally
 Ask local organizations or university programs if
they offer medical Spanish, or if they would
consider offering “Spanish for the Audiologist” for
staff and providers.
 Work with local audiologists to develop online
resources and knowledge regarding cultural and
language issues in your area.
(Abreu et al., 2011)

Improve health outcomes for the patient

Result in greater patient satisfaction with services

Promote increased follow-up and overall compliance

“Potential for improving the efficiency of care by
reducing unnecessary diagnostic testing or
inappropriate use of services” (p. 70).
 May reduce healthcare costs

“Close gaps in health status across diverse
populations” (p. 72)
(Anderson et al., 2003)

Audiologists should strive for cultural
competence.

As noted in Quality Health Services for
Hispanics: The Cultural Competency Component
(National Alliance for Hispanic Health, 2001):
 “We cannot afford to let cultural barriers limit our
ability to meet the needs of our patients, or reduce
their opportunity to benefit from the services we can
provide” (p. 3).

Abreu, R. A., Adriatico, T., & DePierro, A. M. (2011). Qué Pasa: “What’s happening” in
overcoming barriers to serving bilingual children? The AHSA Leader, 16(13), 12-16.

American Medical Association Ad Hoc Committee on Health Literacy for the Council on
Scientific Affairs. (1999). Health literacy: Report of the council on scientific affairs.
Journal of the American Medical Association, 281(6), 552-557.

American Speech-Language-Hearing Association [ASHA]. (2010). Code of ethics [Ethics].
doi:10.1044/policy.ET2010-00309

American Speech-Language-Hearing Association [ASHA]. (2011). Cultural competence in
professional service delivery [Professional Issues Statement].
doi:10.1044/policy.PI2011-00326.

American Speech-Language-Hearing Association [ASHA]. (2012). Demographic profile of
ASHA members providing bilingual services August 2012. Retrieved from
http://www.asha.org/uploadedFiles/Demographic-Profile-Bilingual-Spanish-ServiceMembers.pdf

Anderson, L. M., Scrimshaw, S. C., Fullilove, M. T., Fielding, J. E., Normand, J., & Task Force
on Community Preventive Services. (2003). Culturally competent healthcare systems:
A systematic review. American Journal of Preventive Medicine, 24(3S), 68-79.
doi:10.1016/S0749-3797(02)00657-8

Baker, D. W., Hayes, R., & Fortier, J. P. (1998). Interpreter use and satisfaction with
interpersonal aspects of care for Spanish-speaking patients. Medical Care, 36(10), 14611470.

Bezuidenhout, L., & Borry, P. (2011). Examining the role of informal interpretation in medical
interviews. Journal of Medical Ethics, 35, 159-162. doi:10.1136/jme.2008.206286

Boyas, J., & Valera, P. A. (2011). Determinants of trust in medical personnel. Hispanic Health
Care International, 9(3), 144-152. doi:10.1891/1540-4153.9.3.144

Carteret, M. (2011). Cultural values of Latino patients and families. Dimensions of Culture:
Cross-Cultural Communications for Healthcare Professionals. Retrieved from
http://www.dimensionsofculture.com/2011/03/cultural-values-of-latino-patients-andfamilies/

Crossman, K. L., Wiener, E., Roosevelt, G., Bajaj, L., & Hampers, L. C. (2010). Interpreters:
Telephonic, in-person interpretation and bilingual providers. Pediatrics, 125(3), e631e638. doi:10.1542/peds.2009-0769

CyraCom. (2012). Access methods: Multiple access options to quality medical interpretation.
Retrieved from http://www.cyracom.com/Access_Methods/

Eamranond, P. P., Davis, R. B., Phillips, R. S., & Wee, C. C. (2009). Patient-physician
language concordance and lifestyle counseling among Spanish-speaking patients.
Journal of Immigrant Minority Health, 11, 494-498. doi:10.1007/s10903-008-9222-7

Hornberger, J., Itakura, H., & Wilson, S. R. (1997). Bridging language and cultural barriers
between physicians and patients. Public Health Reports, 112, 410-417.

Humes, K. R., Jones, N. A., & Ramirez, R. R. (2011). Overview of race and Hispanic origin:
2010 (C2010BR-02). Retrieved from U. S. Census Bureau website: http://www.census.
gov/prod/cen2010/briefs/c2010br-02.pdf

Julliard, K., Vivar, J., Delgado, C., Cruz, E., Kabak, J., & Sabers, H. (2008). What Latina patients
don’t tell their doctors: A qualitative study. Annals of Family Medicine, 6(6), 543-549.
doi:10.1370/afm.912

Lee, D. J., Carlson, D. L., Lee, H. M., Ray, L. A. & Markides, K. S. (1991). Hearing loss and
hearing aid use in Hispanic adults: Results from the Hispanic health and nutrition
examination survey. American Journal of Public Health, 81(11), 1471-1474.

Marsh, W. W., & Hentges, K. (1988). Mexican folk remedies and conventional medical care.
American Family Physician, 37(3), 257-262.

National Alliance for Hispanic Health. (2001). Quality health services for Hispanics: The
cultural competency component (DHHS Publication No. 99-21). Retrieved from
http://www.hrsa.gov/culturalcompetence/servicesforhispanics.pdf

Newman-Ryan, J., Northrup, B. D., & Villareal-Emery, C. (1995). Testing balance function in
Spanish-speaking patients: Guidelines for non-Spanish-speaking clinicians. American
Journal of Audiology, 4, 15-23.

Padilla, Y. C., & Villalobos, G. (2007). Cultural responses to health among Mexican American
women and their families. Family and Community Health, 30(1S), S24-S33.

Pearson, W. S., Ahluwalia, I. B., Ford, E. S., & Mokdad, A. H. (2008). Language preference as
a predictor of access to and use of healthcare services among Hispanics in the United
States. Ethnicity & Disease, 18, 93-97.

Roeser, R. J. (1996). Roeser’s audiology desk reference. New York, NY: Thieme.

Salas-Provance, M. B., Erickson, J. G., & Reed, J. (2002). Disabilities as viewed by four
generations of one Hispanic family. American Journal of Speech-Language Pathology,
11, 151-162. doi:10.1044/1058-0360(2002/015)

Torre III, P., Moyer, C. J., & Haro, N. R. (2006). The accuracy of self-reported hearing loss in
older Latino-American adults. International Journal of Audiology, 45, 559-562.
doi:10.1080/14992020600860935

U. S. Department of Commerce. (2012). Hispanic heritage month 2012: Sept. 15 – Oct. 15
(CB12-FF.19). Retrieved from U. S. Census Bureau News website:
http://www.census.gov/newsroom/releases/pdf/cb12ff-19_hispanic.pdf

U. S. Department of Health and Human Services [USDHHS]. (2008). America’s health
literacy: Why we need accessible health information (Issue Brief). Retrieved from
http://www.health.gov/communication/literacy/issuebrief/

Wallace, L. S., DeVoe, J. E., Heintzman, J. D., & Fryer, G. E. (2009). Language preference and
perceptions of healthcare providers’ communication and autonomy making behaviors
among Hispanics. Journal of Immigrant Minority Health, 11, 453-459. doi: 10.1007/
s10903-008-9192-9

Zuniga, M. E. (1998). Families with Latino roots. In E. W. Lynch & M. J. Hanson (Eds.),
Developing cross-cultural competence: A guide for working with children and their
families (2nd ed., pp. 209-250). Paul H. Brookes Publishing, Baltimore, MD.
Translations
Translations

Description and instructions for each
test

Standard audiological tests

Instructions for adults and children
 Children
– Additional instructions for the
parent

Balance function testing

Instructions for ENG (electrodes) and
VNG (goggles) for each test
Translations – Standard
Audiological Tests
Otoscopy
 Tympanometry
 Acoustic reflexes
 Acoustic reflex decay
 Otoacoustic emissions (OAEs)
 Pure-tone testing

Unmasked air and bone conduction
 Masked air and bone conduction

Translations – Standard
Audiological Tests
Play audiometry
 Visual reinforcement audiometry
(VRA)
 Behavioral observation audiometry
(BOA)
 Speech recognition threshold (SRT)

Verbal response (masked and
unmasked)
 Picture-pointing (masked and
unmasked)
 Body-part identification

Translations – Standard
Audiological Tests
Speech awareness threshold (SAT)
 Word recognition testing

Verbal response (masked and
unmasked)
 Picture-pointing (masked and
unmasked)


Auditory brainstem response (ABR)
Translations – Balance
Function Tests
Pre-test instructions
 Modified Clinical Test of Sensory
Interaction on Balance (MCTSIB)
 Romberg/Tandem Romberg
 Computerized Dynamic
Posturography (CDP)
 Vestibular evoked myogenic
potentials (VEMPs)

Translations – Balance
Function Tests
Dix Hallpike
 Positionals
 Tracking, saccades, and optokinetics
 Gaze
 Calorics
 Rotary chair
 Fukuda stepping test

Translations – Balance
Function Tests
CDVAT Set (Dynamic Visual Acuity
Test)
 Hyperventilation Nystagmus Test
 Headshake Nystagmus Test
 Orthostatic Hypotension Screening
 Miscellaneous comments and
questions

Test Descriptions and
Instructions

English version
Written by 2 audiologists and 2
audiology graduate students
 Reviewed by 2-3 audiologists at
TTUHSC
 Reflects wording typically used with
English-speaking patients


Spanish version

All materials translated into Spanish by a
bilingual audiology graduate student
Spanish Translations

Monolingual audiologist reviewers


Rated English test descriptions and instructions
for whether content was consistent with what
they would say to patients
Bilingual reviewers (non-audiologists and
audiologists)



Rated translated materials for ease of
understanding and appropriateness of dialect
Made corrections and comments
Audiologists – Also rated test descriptions and
instructions for whether content was consistent
with what they would say to patients
(http://www.gis.ttu.edu/center/cgstARCH/Access2HealthCare.php)
Spanish Translations

Bilingual reviewers



Bilingual audiologist reviewers



Goal = 6 or more
Obtained = 6
Monolingual audiologist reviewers



Goal = 60
Obtained = 55
Goal = 6 or more
Obtained = 5
Bilingual SLP professor/professional translator
Translations - Spanish

Diversity of Spanish dialects in Texas
Formal vs. informal
 Tex-Mex


Some words could not be directly
translated into Spanish.

Examples: Sound booth, insert
earphones, and cool
Feedback from Reviewers

Received feedback from 55 bilingual
reviewers

Grammar and punctuation

Differences in vocabulary
Medicamentos vs. medicinas
 Auriculares vs. audifonos
 Oído vs. oreja
 Oír vs. escuchar

Feedback from Reviewers

General differences in feedback
according to region
South Texas
 West Texas Border
 Central Texas
 West Texas

Feedback from Bilingual
Audiologists

Received feedback from 6 bilingual
audiologists


Tyler, Laredo, McAllen, San Antonio,
Midland, and Lubbock
ENT office, private practice,
educational and university settings
Feedback from Bilingual
Audiologists

Reviewers’ comments
Too “elaborate”
 Formal vs. informal
 Overall positive feedback

Feedback from Professional
Translator

Word choice

Syntax
Video Vignettes
Otoscopy – Translations



Test instructions – Child
To the parent: “Mr./Ms. __________,
I’m going to look in ____________’s
ears. I just need him/her to be as still
as possible.”

If needed and child needs to be
held: “Mr./Ms. X , can you please
hold ____________’s head and
arms like this (demonstrate) so
we can make sure he/she stays
still. He/she may not like it, but I
will go as quickly as possible.”
To the child: “Look, ___________! This
is my special flashlight. Watch…(shine
the light on the child’s hand). I’m
going to use my flashlight and look in
your ears. Do you think I’ll see any
butterflies (give other examples in
Spanish – dinosaurs, etc.) inside your
ear? I’ll tell you what I find!”

“Good job! There weren’t any
____________ in that ear! Let’s
look at the other ear!”



Test instructions – Child
To the parent: “Sr./Sra. ______, voy
a examinar los oídos de
_________, solamente necesito
que no se mueva.”

If needed and child needs to be
held: “Sr./Sra. ______, por
favor detenga la cabeza y las
manos de _____
(demonstrate) para
asegurarnos que no se vaya a
mover. Puede ser que no le
vaya a gustar, pero
administraré el examen lo más
pronto posible.”
To the child: “¡Mira ______! Esta es
mi luz especial. Mira… (shine the
light on the child’s hand). Voy a
usar mi luz especial para ver
dentro de tus oídos. ¿Crees que
voy a ver una mariposa
(dinosaurio, conejito, monito…)
dentro de tu oído? ¡Yo te digo lo
que encuentro!”

“¡Muy bien! ¡No hay _______
en este oído! ¡Vamos a ver en
el otro oído!”
Otoscopy - Video
OAEs - Translations



Test instructions – Adult
“For this test, I’m going to place
this plastic tip in your ear, and
you’re going to hear some tones
(“beeps” or “music”). The
computer is going to see how
your ear is working. All you need
to do is be still and quiet.”
If there are other people in the
room: “The equipment for this
test is very sensitive to any type
of noise, so we just need
everyone to be still and very
quiet while the test is running.”



Test instructions – Adult
“Para este examen, voy a
poner una puntita de plástico
en su oído, y va a escuchar
unos sonidos. La
computadora mide como está
funcionando su oído.
Solamente tiene que estar
bien quieto(a) sin hablar.”
If there are other people in the
room: “El equipo es muy
sensible a los ruidos. Es
importante que no hablen y
que estén bien quietos
durante el examen.”
OAEs - Video
VRA - Translations


Test instructions – Parent

You can sit here, and hold
_______________ (child’s name)
in your lap. Try to keep him/her
facing forward. We are going to
play some different sounds and
see how _______________
(child’s name) responds. You
may also hear the sounds, but
please be sure that you don’t give
______________ (child’s name)
any clues that the sound is on.
Test instructions – Child

“Listen.”

“Look up here.”

“Do you see my toy?”

“Keep listening!”


Test instructions – Parent

Se puede sentar aquí usted
con _______________ (child’s
name) sobre sus piernas.
Trate que siga viendo hacia al
frente. Vamos a presentar
diferentes sonidos y ver como
_______________ (child’s
name) responde. Es posible
que usted también pueda
escuchar los sonidos, pero por
favor no le de indicaciones a
_______________ (child’s
name) que el sonido está
presente.
Test instructions – Child

“Escucha.”

“Mira aquí.”

“¿Ves mi juguete?”

“¡Sigue escuchando!”
VRA - Video
Pure Tones: Unmasked Air
(Adults) - Translations
Test instructions – Adult
Unmasked (air)
Adult air: “Mr./Ms.
__________, now let’s go into
this booth for the rest of the
tests. Have a seat here. For the
first test, I will place these
inserts inside (or headphones
over) your ears. You will hear
tones (“beeps”) at different
pitches in each ear. I just need
you raise your hand (e.g., push
the button, say “yes”) each time
you hear the tone, even if it is
very soft. ”
Test instructions – Adult
Unmasked (air)
Adult air: “Sr./Sra./Srta.
__________, ahora vamos al
cuarto de examinación para
el resto de los exámenes.
Tome asiento aquí. Para el
primer examen, le pondré
estos audífonos de esponja
adentro de sus oídos (o
auriculares sobre sus oídos).
En cada oído escuchará tonos
diferentes. Necesito que
levante la mano (oprima el
botón, diga “sí”) cada vez
que escuche el tono, aunque
esté muy suave.
Pure Tones: Unmasked Air
(Adults) - Video
Dix-Hallpike - Instructions



Test Instructions
Before we start the test, do you have
any current neck or back injuries or
anything that limits movement?
For this test, I'm going to have you lie
down with your head hanging off the
table.

I will be supporting your head at
about a 45 degree angle so you
can just relax your neck.

You'll stay in that position for
about 45 seconds, and then, I'll
help you sit up.

We will do this twice, once with
your head turned to the right and
then with your head turned to the
left.

I need to be able to watch your
eyes during this test, so you need
to keep your eyes open wide the
entire time.



Test Instructions
¿Antes de comenzar el examen,
tiene lesiones recientes del cuello
o de la espalda o cualquier otra
cosa que impida los movimientos?
Para este examen, necesito que se
acueste con la cabeza colgando de
la mesa.

Yo apoyaré su cabeza en un
ángulo de 45 grados para que
pueda relajar su cuello.

Usted se quedará en esa
posición por 45 segundos, y
luego, le ayudaré a sentarse.

Vamos a hacer esto dos veces,
una vez con su cabeza
volteada hacia la derecha y
luego con su cabeza volteada
hacia la izquierda.

Necesito ver sus ojos durante
el examen, por eso necesito
que mantenga sus ojos
abiertos durante el examen.
Dix-Hallpike - Instructions

We're going to start on the right
side, so go ahead and turn your
head to the right. (Patient is in a
sitting position.)

On the count of 3, I want you
to fall back, keep your head
turned, and your eyes open.




Remember, I'm going to be
supporting your head, so you
can just relax your neck.

Vamos a comenzar en el lado
derecho, entonces voltee su
cabeza hacia la derecha. (Patient
is in a sitting position.)

Al contar a tres, quiero que
se deje caer hacia atrás,
mantenga su cabeza
volteada, y sus ojos abiertos.

Recuerde, yo apoyaré su
cabeza, para que pueda
relajar su cuello.
One, two, three... (Patient is in
the head hanging position for
45 seconds.)

Good, now I'm going to help
you sit up on the count of 3,
but keep your eyes open.

One, two, three...

Una, dos, tres…( Patient is in
the head hanging position for 45
seconds.).
Bien, ahora al contar tres le
voy a ayudar a sentarse,
pero mantenga los ojos
abiertos.
Una, dos, tres…
Dix-Hallpike - Video
Future of the Project
What’s Next for the Project?

Create final draft of module with
written translations and videos

Obtain feedback on cultural training
module from Texas audiologists
(bilingual and monolingual)


Revise as needed
Submit the project for publication
What’s Next for the Project?


Distribute project materials

TTUHSC audiologists and audiology
graduate students

Audiology programs in Texas

Attendees at TSHA 2012 presentation

Attendees at ASHA 2012 presentation

First 100 individuals who request the
information in response to the publication
Plan future research projects
Additional References


Center for Geospatial Technology,
Texas Tech University. (20052010). Public health regions in
Texas [Map]. Retrieved from
http://www.gis.ttu.edu/center/cgst
ARCH/Access2HealthCare.php
Morales, L. S., Cunningham, W. E.,
Brown, J. A., Liu, H., & Hays, R. D.
(1999). Are Latinos less satisfied
with communication by health care
providers? Journal of General
Internal Medicine, 14, 409-417.