Abstract
Culturally competent management of adults with swallowing disorders involves more than simply including ethnically appropriate foods in dysphagia therapy. It requires an understanding of the client's health beliefs, challenges, and unique cultural perspective regarding all aspects of food to ensure unbiased and culturally appropriate services are provided. This chapter begins with an overview of dysphagia management followed by a closer look at cultural beliefs regarding food and ethical conflicts that may arise. The strategies for shared decision-making presented help create a culturally sensitive dynamic between the clinician and the patient/family that positively influence therapy outcomes. The chapter concludes with a case study that highlights the importance of ethnographic interviewing needed to establish understanding and trust between the clinician and an elderly Mexican woman and her family. The strategies and techniques presented here can be applied across all cultures to achieve successful management of dysphagia.
TopIntroduction
The collective practices, rituals, and traditions surrounding food make it clear that eating is deeply rooted in culture. Eating food is much more than the physiologic process of breaking down a bolus that can be safely and efficiently swallowed so that nutrients can be consumed. It is an essential aspect of human social life. When swallowing is impaired, the health, psychosocial well-being, and quality of life (QOL) of an individual is threatened (Kenny, 2015). Approximately one in 25 adults are diagnosed with dysphagia each year (Bhattacharyya, 2014). Although the prevalence of dysphagia in adult populations is not fully known and often underestimated (ASHA, n.d.), even less is known about the prevalence of dysphagia across racial/ethnic groups. In one of the few studies, González-Fernández, Kuhlemeirer, and Palmer (2008) reported that the incidence of poststroke dysphagia was higher in minority groups, particularly Asians, as compared to Caucasians. Similarly, Brussel and González-Fernández (2011) found evidence of increased odds for dysphagia in racial/ethnic minority groups following stroke. Given the presence of racial disparities in general health care (Feldman, McDonald, Eimicke, & Teresi (2019), and the link between dysphagia and common stroke (Bhattacharyya, 2014), it is likely that dysphagia is impacted by such disparities as well.
Hispanics, particularly Mexican Americans, have a higher risk of stroke than non-Hispanics (Lisbeth et al., 2014). According to the U.S. Census Bureau (2016), the terms Hispanic or Latino refer to a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race. Hispanics represent that largest minority group in the U.S. Considering that all minority groups are rapidly growing in the U.S. (U.S. Census Bureau, 2016), SLPs can expect to see growing numbers of culturally-linguistically diverse patients (CLD) with dysphagia on their caseloads and the likelihood that they will be Hispanic is high.
The SLP treating patients with dysphagia from CLD groups must have a firm understanding of the role that culture plays in dysphagia management. This chapter presents an overview of food and culture. Next, strategies and suggestions to promote cultural competence are presented. This chapter focuses on the Hispanic culture and strategies to achieve culturally competent care. However, these strategies can be adapted for use with any patient, regardless of cultural background, and are the first steps toward cultural competence. It is important to realize though, that cultural competence is not limited to text-book knowledge of the customs, beliefs, language, and food preferences of culturally and linguistically diverse groups. Rather, cultural competence encompasses a much broader ability to evaluate one’s own culture, including one’s inherent biases and values, to better engage with persons from any culture, including one’s own (Riquelme & Rosa, 2013).
Key Terms in this Chapter
IDDSI: An international standardized framework for labeling texture-modified foods and thickened liquids. Level 1 = thin liquids; Level 2 = slightly thick liquids; Level 3 = mildly thick liquids; Level 4 = moderately thick liquids; Level 4 = extremely thick liquids/pureed; Level 5 = minced & moist foods; Level 6 = soft & bite-sized foods; Level 7 = regular foods.
Individualism: A societal view that places the needs of the individual as the priority. Decisions made are to benefit the individual.
Water Protocol: A protocol that allows patients who are NPO or on thickened liquids to receive regular water and ice chips following oral care between meals.
Nasogastric Tube: A feeding tube that runs from the nasal cavity to the stomach to deliver liquid nutrition.
Hispanic: Someone from a Spanish-speaking country. Hispanic is not a term that refers to a race of people but only refers to individuals with cultural ties to Spain. A person is any individual living inside the U.S. who Mexican, Puerto Rican, Guatemalan, Cuban, or Caribbean.
Tissue Plasminogen Activator (tPA): A drug used to dissolve blood clots causing strokes if given within 6 hours of the event.
Assimilation: A process whereby an individual changes following exposure to a different culture. In assimilation, individuals of differing heritages and cultures acquire the basic attitudes, habits, and way of life of the dominant culture.
Collectivism: A societal view that places the needs of the group before the individual. Decisions made are for the benefit of the group.
Latino: An umbrella term to refer to all people from a Latin American countries or a U.S. citizens of Latin American descent. Latinos (or Latina for females) are from Spanish-Speaking countries including Cuba, Puerto Rico, the Dominican Republic, Mexico, and Central and South America. All Mexicans are also Latinos. Not all Latinos are Mexicans.
Penetration Aspiration Scale (PAS): A scale to identify the level of penetration and aspiration in the airway. Level 1 = no penetration; Level 2 = material enters vestibule and is ejected with the swallow; Level 3 = material enters the vestibule and remains; Level 4 = material contacts the vocal folds and is ejected (coughed out); Level 5 = material contacts vocal folds and is not detected/coughed out; Level 6 = material crosses below the vocal folds and is cough out; Level 7 material crosses below the vocal folds, is detected but not cough out, despite effort; Level 8 = material passes below the vocal folds and is not detected (silent aspiration).