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an unequal
power
M
odern Britain is culturally diverse and most recent figures suggest that the minority ethnic population includes 4.6 million people, or 7.9 per cent of the population (ONS, 2002) (see table 1). It is widely acknowledged that speech and language therapists (and all other health professionals) should be sensitive to the cul tural needs of various minority ethnic groups. However, Holland & Hogg (2001) have rightly identified that, whilst health professionals are encouraged to do this, there is a definite lack of leadership within the health care services on such cultural issues.
Table 1: The UK Popul at io n by ethn ic grou p, April 2001

and cui r.

refers to a common ancestry, a particular geo graphical territory, and those who share a lan guage, religion and social customs (Fenton, 1999). Other indicators of ethnicity might include diet, name and nationality.

Heterogeneity
It is important to recognise that minority ethnic groups are not homogenous, and that there is a great deal of heterogeneity, including differences of socio-economic status, gender and age, amongst others. More recently, sociologists have highlighted how the term 'ethnic' usually refers to those in minority ethnic groups, rather than the 'White' majority. However, Pfeffer (1998) argues that the term 'White' is unhelpful as it can include people of Irish origin and Jews, amongst others, reflecting a rather diverse range of needs and experiences. Defining ethnicity is complex and there is no universally agreed classification. However, the most recently recommended classifica tion for ethnic identification can be seen in figure 1.
Figure 1 Classification of Ethnic Groups in Britain

Percentages Percentage of total population White Mixed Asian or Asian British

Indian Pakistani Bangladeshi Other Asian Black Black Black Black or Black British
Caribbean African Other Percentage of minority ethnic population nfa

92.2

0.8 1.7 1.3 0.5 0.4 1.0

o.g

11 .0 21.7
16.7
6.1
5.7
13.6
12.0
1.5

4.2

White British Irish Other White Mixed White and Black Caribbean White and Black African White and As ian Other Mixed Asian or Asian British Indian Pakistani Bangladeshi Other Asian Black or Black British Black Caribbean Black African Other Black Chinese or Other ethnic group Chinese Other ethnic group
Source: ONS (2002)

0.1 0.3 0.6 0.2 7.6 100

Chinese Other Not stated

7.4

nfa

All minority ethnic population

All population
Source: ONS (2002)

100.0

nfa

It is useful to begin by defining what we mean by the terms 'race' and 'ethnicity'. The term 'race' is commonly used and usually refers to genetic or physical variations between groups of people skin colour is a good example of this. However, sociologists prefer to use the term 'ethnicity' as this recognises the socially constructed nature of 'dif ference'. Sociologists usually agree that ethnicity

In spite of the difficulty of defining ethnicity and measuring differences between ethn ic groups, research studies time and again demon strate wide-ranging inequalities . Surveys have consistently shown that the health of most minority ethnic groups is significantly

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co v er story : inequality series ( 4 )

However, it is important to be research with Black and White stu worse than that of the general population. The It should be cautious when considering cul dents in the United States, they most recent Health Survey for England (DoH, 1999) recognised that the tural differences. Ahmad (1994) reveals that Pakistani and Bangladeshi men are argue that White people are more therapist is always argues that minority ethnic cultures likely to perceive Black people's three to four times more likely to describe their speech negatively: as loud, ostenta are often demonised as 'wrong' own health as 'bad' or 'very bad'; Black Caribbean in a position of tious, aggressive, active and argu or 'bad' in comparison to those women are almost twice as likely. The same survey power relative to mentative. This is relevant to thera of the so-called 'White' majority. reveals that Pakistani and Bangladeshi men and pists because, as they argue, speech Studies also demonstrate that, women, and Black Caribbean women, are most their client. within education, children from style stereotypes exist' not on Iy to likely to report suffering from cardiovascular dis minority ethnic groups feel devalued, and assump ease conditions (for example, heart attack, stroke, describe "what is" but to prescribe "what should be'" (Popp et ai, 2003: 317). Figure 2 lists points to tions are often incorrectly made by teachers, based angina) . Indeed, Bangladeshi men report rates of on perceived cultural 'differences' (for example, see cardiovascular disease that are 70 per cent higher consider in relation to ethnicity and language. Brah & Minhas, 1983). than those of the general population. Rates of dia Figure 2 Ethnicity and languag e: points to co nsider Other theorists suggest that it is impossible to betes are also significant with Bangladeshi men why children from minority ethnic groups understand the experiences of minority ethnic and women being nearly six times more likely to may be either over or under-represented report this condition (DoH, 1999). groups without considering structural factors and within your case load; Given these figures, it is relevant to ask if speech that an analysis of culture alone is inappropriate (Smaje, 1996; Karlsen & Nazroo, 2002) . In general whether you expect English to be the and language therapy services for adults plan for dominant language; terms, people in minority ethnic groups are more the higher incidence of stroke in people from some likely to be socially excluded; that is, they are minority ethic groups. There is some evidence to whether you perpetuate racist speech more likely to be living in poverty, to be unem suggest that people from minority ethnic groups style stereotypes. receive an inferior service from the NHS compared ployed or in low-paid employment and are more to the service received by others. Torkington (1991), Understanding ethnic inequalities is complex likely to have a lower standard of living than the for example, argues that there is a lack of knowl and there are several perspectives. One explanation general population (ONS, 2002). Indeed, Nazroo (1997) argues that material deprivation probably suggests a genetic component. Traditionally, this edge amongst NHS staff of the conditions that accounts for most of the inequalities between most affect people from minority ethnic groups. explanation has been used to explain differences in ethnic groups and Karlsen & Nazroo (2002) argue levels of IQ, although this has been widely discredited. Many empirical studies also show evidence of racism and racist discrimination, leading to poorer More recently, theories of genetic variation have that experiences of racism and perceptions of quality care (for example, see Bowler, 1993). been used to explain differences in the prevalence racist discrimination are also strongly related to Power and privilege can be mediated and perpet of some health conditions, for example, diabetes, inequality. In other words, many sociologists suggest hypertension and sickle cell disease. However, Braun that it is not ethnic culture and identity per se uated through language (Crawford 2001). Indeed, Pugh & Jones (1999: 530) suggest that language has (2002) argues that our knowledge of the history of which leads to inequality, but the marginalisation populations and their identities and affiliations is of people in minority ethnic groups. a powerful role 'in constructing social realities, too vague and incomplete to make such an asser There is no single explanation that can account delivering discourses, and representing particular ideologies' which should neither be overlooked, nor tion, and furthermore that, for ethnic inequalities and it is likely that there 'the current emphasis on genetic explanations rei underestimated. It is not surprising, therefore, that are multiple factors. A recent study of language fies racial and ethnic classifications by reinforcing development in West African children (Law, children from minority ethnic groups are often over represented in referrals to speech and language the notion of biological difference rooted in 2000), for example, demonstrates that delays in genetics. This reification leads to stigmatization of speech and language may be related to stress, therapy (Law, 2000), although it is difficult to assess quite how widespread this is. There is also evidence racial and ethnic minorities and to research strate unemployment, financial worries, immigration to suggest that, in some areas, minority gies that divert attention from status, as well as the influence of cultural beliefs confronting the multidimensional ethnic groups may be under-represent and expectations, which place high expectations It is important ways in which racism, not race, ed in relation to the overall population on children . to recognise (Winter, 1999). influences patterns of disease.' Speech and language therapists clearly need to that minority (Braun, 2002: 160). be aware of cultural differences that may affect ethnic groups This implies that other factors practice. Clients from some minority ethnic back Although English is the language must contribute to the patterns of grounds may differ in relation to language, reli are not most commonly spoken in Britain, gious beliefs, and beliefs about health, illness and inequality that can be found with homogenous, minority language use is extensive in healthcare, education and elsedisability; these may all influence compliance and and that there is where. and probably underestimated. Pugh adherence to treatment. Similarly, the therapist & Jones (1999) argue that mistaken needs to be wary of stereotyping clients according a great deal of assumptions are often made about to so-called ethnic categories, recognising both heterogeneity minority languages and that minority Cultural variations between ethnic homogeneity across ethnic groups and hetero
groups are often thought to account for a wide language issues may be oversimplified in practice . geneity within groups.
variety of inequalities. Sociologists regard culture as An exampl~ of this was noted by the Royal It should be recognised that the therapist is
College of Nursing (cited in Holland & Hogg, a set of beliefs and values which are shared by all always in a position of power relative to their
2001) who identify some of the difficulties members of a cultural group. However, culture is client. Speech and language therapy is a predomi
encountered when using translators: believed to be dynamic and changing, rather than nantly 'White' profession whose 'expert' status is
inaccurate translation of important concepts static. Culture is thought to influence the interpre derived from a predominantly Western biomedical and ideas; tation of experiences and to guide behaviour. For model. It is, therefore, important for therapists to example, beliefs about food, diet and body image bias and distortion; reflect on whether they operate within an ethno are thought to contribute to higher rates of cardio centric framework which serves to marginalise lack of confidentiality. vascular disease and diabetes amongst some minor Popp et al (2003) also highlight the prevalence and exclude those with different cultural beliefs of racist speech style stereotypes. Drawing on ity ethnic groups (Holland & Hogg, 2001). and values, or whether they operate within a ~

Assumptions

Dynamic and changing

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co v er story: inequalit y series ( 4 )

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~ VI EVVS
CONVERSATIONAL PRACTICE

model of openness and informed sensitivity to cultural needs (figure 3). To con clude, as Henley and Schott (1999:76) suggest: 'The only person who can tell you what will or will not be right for them is the patient. If we really want to find out, we have to ask.'
Figu re 3 Action points for speech and language therapi sts

DOES HALF OF WHAT IT SAYS

The Sourcebook of Practical Communication (A programme for conversational practice and functional communication therapy) Sue Addlestone
Speechmark
ISBN 0-86388-317-6 29.95

improve your inter-cultural communication skills; respond adequately to cultural and religious needs; portray positive attitudes to minority ethnic clients and their families; avoid stereotyping and listen to individual needs. Dr Sarah Earle is Senior Lecturer in Health Studies at University College Northampton. Address for correspondence: Centre for Healthcare Education, Boughton Green Road, Northampton NN2 7AL, tel. 01604 735500, e-mail sarah.earle@northampton.ac.uk.

References
Ahmad, W. (1994) Consanguinity and related demons: science and racism in
the debate on consanguinity and birth outcome. In: C. Samson & N. South
(Eds.) Conflict and Consensus in Social Policy. Basingstoke: Macmillan.
Brah, A. & Minhas, R. (1983) Structural racism or cultural difference: school
ing for Asian girls. In: G. Weiner (Ed.) Just a Bunch of Girls . Buckinghamshire:
Open University Press.
Braun, L. (2002) Race, Ethnicity, and Health: can genetics explain disparities?
Perspectives in Biology and Medicine, 45 (2), (Spring): 159 - 74.
Bowler, I. (1993) 'They're not the same as us': midwives' stereotypes of South Asian
maternity patients. Sociology of Health & Illness, 15 (2): 157 - 178.
Crawford, M. (2001) Gender and language. In: R. Unger (Ed.) Handbook of
the Psychology of Women and Gender. New York: Wiley, 228 - 244.
DoH (1999) The Health of Minority Ethnic Groups, Health Survey for England
1999. London: DoH.
Fenton, S. (1999) Ethnicity: Racism, Class and Culture. London, Macmillan.
Henley, A. & Schott, J. (1999) Culture, Religion and Patient Care in a Multi
Ethnic Society. London, Age Concern.
Holland, K. & Hogg, c. (2001) Cultural Awareness in Nursing and Health Care.
London : Arnold .
Karlsen, S. & Nazroo, J.Y. (2002) Agency and structure: the impact of ethnic
identity and racism on the health of ethnic minority people. Sociology of
Health & '"ness, 24 (1): 1 - 20.
Law, J. (2000) Factors affecting language development in West African chil
dren: a pilot study using a qualitative methodology. Child: Care, Health and
Development. 26 (4): 289 - 308.
Nazroo, J.Y. (1997) Health and health services. In: T. Modood, R. Berthoud, J.
Lakey, P. Smith, S . Virdee & S. Beishon (eds.) Ethnic Minorities in Britain:
Diversity and Disadvantage. London: Policy Studies Institute, 224 - 258.
ONS (2002) Social Focus in Brief: Ethnicity. London: ONS. Pfeffer, N. (1998) Theories of race, ethnicity and culture. Do I ensure translators appreciate British Medical Journal, 317 (14 the need for accuracy, impartiality Nov): 1381 - 1384. and confidentiality? Popp, D., Donovan, R.A ., Do I recognise that heterogeneity Crawford, M., Marsh, K.L. & is a feature of all ethnic groups, Peele, M. (2003) Gender, Race including my own? and Speech Style Stereotypes. Do I seek (or provide) leadership Sex Roles, 48 (7/8): 317 - 325. Pugh, R. & Jones, E. (1999) on cultural issues? Language and Practice: Minority Language provision with the Guardian ad litem Service. British Journal of Social Work, 29: 529 - 545. Smaje, C. (1996) The ethnic patterning of health: New directions for theory and research. Sociology of Health & Illness, 18 (2): 139 - 171. Torkington, P. (1991) Black Health: A Political Issue. London: Catholic Association for Racial Justice. Winter, K. (1999) Speech and language therapy provision for bilingual chil dren: aspects of the current service. International Journal of Language & Communication Disorders, Jan-Mar, 34 (1): 85 - 98.

This photocopiable sourcebook will be useful for clients who wish to continue
working in a therapeutic way on their output. The 90 topics, with open questions,
are structured enough to be given directly to assistants or family members who
require ideas to continue with conversational practice.
Recording forms can be used to monitor which topics have been discussed,
success at conversation and amount of time spent on each topic.
It will not replace naturalistic interaction, the use of conversation ramps 0
truly functional communication. It does half of what it says on the cover and
is value for money if you need 'a programme for conversational practice'.
Ruth Williams is a specialist speech and language therapist with the Prima ry Care Rehabilitation Team, Sa ndweII, West Midlands.

PHONOLOGICAL AWARENESS

RECOMMENDED FOR CONTENT AND VALUE

Soundaround Andrew Burnett & Jackie Wylie David Fulton ISBN 184312001 1 14.00

Re

ections

I enjoyed using this photocopiable book of games to help children develop early phonological awareness skills. It is fun and interactive, and designed to be used either in a group or individual setting in mainstream classes for foun dation through to Key Stage I. It has a clearly understandable section on the developmental progression of phonological awareness starting with the development of concepts (often overlooked) right through to developing an understanding of letters/symbols. It includes very simple games which are often overlooked in other books. The layout is simple and easy to follow. The developmental framework and record keeping forms allow the therapist or teacher to plot programmes and chart progress easily. The photocopiable pictures and vocabulary lists are good time savers. Although many practitioners will be familiar with the games, Soundaround presents them in a new and fun way. Children enjoy the games especially those such as 'worm sandwiches' and 'sylla ble steps'. The games are easily adaptable to an individual child or group's need. I would recommend this little book both in terms of content and value for money. It is a very useful tool to develop collaborative working between teachers and therapists. Wendy Wellington is a senior specialist speech and language therapist for spe cific language impairment with Sheffield Speech & Language Therapy Agency.

SEMANTICS

QUICKLY EXHAUSTED
Semantic Workbooks Caroline Davidson, Kaye Beveridge & Carol Nelson Speechmark ISBN 0 86388 267 6 90.00
On first impressions this is a well-presented boxed set of basic training exer cises. Patients find the worksheets easy to access, as the pictures are clear and the text is a good size. It is useful for supplementing therapy, but the volume of exercises is quickly exhausted. As the pages are photocopiable they may be appropriate for take home packs but there are few explanations within the workbooks, therefore sometimes it is unclear what the therapist is expected to do. This promotes cre ativity with the resources but, as there is nothing new that goes beyond other well-established products, departments may find it of limited value. This resource is probably most useful for those starting out in semantic therapy who need some ideas and a guide to the breadth of basic exercises to try with their patients. Mary Bailey is a speech and language therapist with Surrey and Sussex Healthcare NHS Trust.

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SPEECH & LANGUAGE THERAPY IN PRACTICE AUTUMN 2003