How to Help—Not Harm—Underserved Populations Abroad Providing services internationally can be fulfilling for audiologists, speech-language pathologists and the people you’re trying to help—if you do it right. The Leader listened in to a recent ASHA Web chat as two experts talked about ethics, the traps of “voluntourism” and how to truly (and appropriately) make a difference abroad. Overheard
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Overheard  |   May 01, 2015
How to Help—Not Harm—Underserved Populations Abroad
Author Notes
  • Brooke Hallowell, PhD, CCC-SLP, is a professor and director of Ohio University’s Neurolinguistics Laboratory. Specializing in neurogenic language disorders, she assists in developing academic programs in CSD in underserved regions, primarily in India, China and Malaysia. She serves on the ASHA International Issues Board and is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; 10, Issues in Higher Education; and 17, Global Issues in Communication Sciences and Related Disorders. hallowel@ohio.edu
    Brooke Hallowell, PhD, CCC-SLP, is a professor and director of Ohio University’s Neurolinguistics Laboratory. Specializing in neurogenic language disorders, she assists in developing academic programs in CSD in underserved regions, primarily in India, China and Malaysia. She serves on the ASHA International Issues Board and is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; 10, Issues in Higher Education; and 17, Global Issues in Communication Sciences and Related Disorders. hallowel@ohio.edu×
  • Ellen Hickey, PhD, CCC-SLP, is an associate professor of speech-language pathology at Dalhousie University in Halifax, Nova Scotia, Canada. She has spent time in Malawi, Tanzania, Kenya and Belize training local educators and health care workers to work with people with communication disorders, particularly those with neurogenic communication disorders. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; and 17, Global Issues in Communication Sciences and Related Disorders. ehickey@dal.ca
    Ellen Hickey, PhD, CCC-SLP, is an associate professor of speech-language pathology at Dalhousie University in Halifax, Nova Scotia, Canada. She has spent time in Malawi, Tanzania, Kenya and Belize training local educators and health care workers to work with people with communication disorders, particularly those with neurogenic communication disorders. She is an affiliate of ASHA Special Interest Groups 2, Neurophysiology and Neurogenic Speech and Language Disorders; and 17, Global Issues in Communication Sciences and Related Disorders. ehickey@dal.ca×
Article Information
Professional Issues & Training / ASHA News & Member Stories / Overheard
Overheard   |   May 01, 2015
How to Help—Not Harm—Underserved Populations Abroad
The ASHA Leader, May 2015, Vol. 20, 24-25. doi:10.1044/leader.OV1.20052015.24
The ASHA Leader, May 2015, Vol. 20, 24-25. doi:10.1044/leader.OV1.20052015.24
Participant: What are the ethical and legal issues of students providing clinical services abroad?
Brooke Hallowell: There are many! One example: We and our students—even if they don’t have any clinical training—may be perceived as knowledgeable or expert or competent because we are in a clinical role, or even just because we come from the Western world. Students working in other countries are sometimes permitted to do things they would never be allowed to in their own country.
Ellen Hickey: Yes, I agree with Brooke. We need to be very cautious about people assuming that our students are more competent than they are simply because they are being educated in Western universities.
Hallowell: A lot of what applies to students applies to faculty members and experienced clinicians, too. For example, we may use resources in a way that is burdensome. We may require escorts, interpreters, food, housing, etcetera. In doing so, we may cause decreased productivity and use of precious resources on the part of people and agencies we are visiting.
Hickey: People often make assumptions that taking students to “help” will indeed be helpful. In some cases, it is helpful. But in many cases, the students are the ones getting the most out of the experience, and we must be careful about how we are using limited resources. We also need to recognize that for ourselves and our students, we are still obligated to follow the ASHA Code of Ethics, or the code of ethics of whatever professional association you are certified by. That means that we must provide adequate supervision, stay within our scope of practice and follow the standards accordingly.
Participant: So how do we develop more sustainable, collaborative practices in countries with limited resources, without over-burdening [them]?
Hallowell: It is absolutely critical that we prepare extremely well in advance of going anywhere. And that includes a lot of pre-service work with students.
Hickey: I think it’s important to have strong communication with the locals with whom we are partnering. We must find out from them what they see as their needs and what sorts of solutions they have tried—what works and doesn’t work.
Participant: Regarding the issue of using resources, is it possible to fundraise or crowdfund in our countries so that we can pay for things ourselves?
Hickey: Yes, that is possible. When I was in Malawi, students at the Arizona State University raised money for me to buy supplies locally. I encourage people to buy materials locally in order to benefit the local economies, rather than bringing many donations. There have been many examples of donations from other fields or projects that a) are not helpful and b) do more harm than good. Donations are often not very culturally relevant as well.
Hallowell: Yes, many people do [fundraise or crowdfund]. And that, too, has important ethical implications. It’s important that we challenge our own conceptions of what the money is needed for. I think it helps to look at what we can do in terms of pre-departure training and preparation, best practices while abroad, and maximizing impact and sustainability after returning home.
Participant: Students from New Mexico State who went to Peru did fundraising and then left literally suitcases of materials for the children.
Hickey: That can be helpful as long as the materials are culturally relevant.
Hallowell: So true, Ellen. I have heard from colleagues in several countries about “junk” being left behind by our CSD colleagues. Others are highly appreciative of much-needed materials. The difference has to do with the depth of appreciation of what is needed.
Hickey: That gets back to the point about having good communication with our local colleagues. We should communicate with them about the materials they have, what they would like us to bring, and what we can purchase locally. When I went to Tanzania, a Dutch SLP asked me to bring tests. But she was unable to explain to me how tests from the United States would be culturally relevant and useful to her, or which tests she wanted. When I spoke with local colleagues, they asked for toys, like animal puppets and other manipulable toys that they had a hard time finding locally. But it is important that materials not be battery-operated or easily breakable with nobody to repair them. In conversations with local SLTs in Kenya, some recommended that toys not be brought in at all, as local families in the villages have no access to such things. Mothers may feel that they cannot provide adequate help to their children if they do not have the same kinds of materials at home. They recommended using the types of toys that children tend to make on their own—enlist the siblings or children in the community to make these toys for the children with disabilities.
Participant: Dr. Hallowell, I am curious to know what ethical stumbling blocks you have come across in your work.
Hallowell: In Cambodia, there are many basic unmet needs related to virtually every aspect of life—especially health care and any type of human service. So when we talk about communication disorders programming to some Cambodians, it seems like a luxury—beyond other sorts of services they already know they need and want. Also, the universities and hospitals are really still just getting going after massive genocide, [the] killing of most medical and health care workers, faculty members, destroying of libraries. When we speak of building new academic and clinical programs, sometimes it doesn’t match with what Cambodians see as their most important foundational steps. Another key issue in Cambodia is a (common, especially at administrative levels) lack of recognition of certain psychological and educational needs—and thus for services that entail counseling or behavioral methods.
Participant: Yes, in other words, how much will they find speech and language therapy relevant … Many doctors I know now are 25 to 30 years old. There are a few in their fifties, but that is all.
Hallowell: Great point. Those of us going to Cambodia to work with older people can just be baffled by the lack of older people in general. In Vietnam, the issues are quite different. There are well-established universities and hospitals. Some challenges include cultural perspectives on what disabilities are and related stigma. Others have to do with the lack of expertise in CSD. When the primary expertise is from outside the host country, then it’s hard for insiders to build the profession. Right now in Vietnam, much of the expertise comes from outside of Vietnam.
Participant: How do you handle unsafe situations involving medical personnel such as RNs (e.g., minimal hand-washing, no gloves when performing procedures, etc.)? Do you keep silent, is it a teaching moment…?
Hickey: I have not encountered that. At the rehab hospital in Malawi, there was only one RN on shift in the day (and none at night), so I had very little interaction with them. The rehabilitation staff were very diligent about universal precautions. The other settings I have worked in have not been that medical.
Hallowell: I think there’s an important point underlying your question. In fact, the “ethical” issues we are talking about are not all issues we can just avoid by simply “doing the right thing.” Often it’s not always clear just what the “right thing” is. And very often we have to make tough choices. There are some choices I’ve made that I would say do not exhibit exemplary practice!
Hickey: That’s a great point, Brooke. Doing “the right thing” can be very muddy.
Participant: I have encountered these unsafe behaviors and I have found it indeed muddy. I do not want to be the foreigner coming in telling people what they should do.
Hallowell: I think being thoughtful and tuning into what is best takes practice—and lots of reflection and re-evaluation, in context. I find it really helpful, too, to be challenged by others in how I think about things. Like the hand-washing issue. It’s good to think of it from all sides before deciding what our role is. My approach on issues like that is to seek a way to get a cultural insider to suggest a change, not to suggest it overtly myself—and not in a way that embarrasses.
Hickey: In Malawi, I frequently had local staff and the ex-pats who had been there longer tell me, “You have to stop thinking like home. It’s nothing like home.” I learned how to ask questions in a nonjudgmental way so that they can see you are open to learning and understanding their way of doing things. Then within that conversation, there might be an opportunity to teach our own way of understanding.
Participant: What are some of the ways an SLP can collaborate with a professional working in a country other than the one in which the SLP lives, [when] this professional living in the other country uses a method of service delivery that is considered to have little evidence that it is effective?
Hickey: I think that’s a tough question at home or abroad! Again, I think having open conversations where each person can explain their understanding of a problem and possible solutions is the best way to start. Getting at why people do what they do and trying to understand from the local perspective. Then brainstorming ideas together, rather than just telling someone how to do their job differently.
Hallowell: True! I think this is one reason it is so important to build lasting relationships—to build them over years. We built trust. We learn from one another. We get increasingly comfortable with adapting our ways of sharing knowledge—in mutual ways. There are many who love to travel and go for adventure. And that motivates their transnational work, rather than the notion of building something sustainable and truly helpful. “Voluntourism”—something Ellen has written about.
Participant: There was also a great NPR segment on voluntourism.
Hickey: In my experience, people seem to be almost too open to being told what to do by foreigners because they are so used to it, and because of the damage that colonialism has done—too much of a mindset of the “Western way” being the “right way.” I am extremely cautious about practicing in neo-colonialist ways.
Participant: What do you mean exactly, Ellen, by “practicing in neo-colonial ways”?
Hallowell: We say neo-colonial, referring to repeated patterns of old ways of whites colonizing non-white people/cultures. It’s important to look out for the phenomenon or stereotype of “whites in shining armor”—the notion that we know what we’re doing and command respect just because of where we come from.
Hickey: By neo-colonialist ways, I mean ways that are very driven by our own agendas and our own ideas of what we think people need. Ways that do not empower people but rather make them feel that we have all the answers. It’s rare that people are not aware of their problems or that they don’t have any ideas for solutions. We must listen, work collaboratively and work in ways that empower the locals.
Participant: You all have talked about learning from each other while providing services abroad. Have you ever seen a practice performed in another country that you would like to implement back in the States?
Hallowell: Absolutely! For example, my work with people doing community-based care in Malaysia has completely transformed my thinking about work with older people with disabilities in the U.S.!
Hickey: Yes! I really enjoy seeing the ways that “disabled persons organizations” (DPOs) work in other countries— much more driven by persons with disabilities than a lot of what I see in the U.S. and Canada. The ways that family and community can be enlisted in some places—less of an approach toward “fixing” people and more toward building a supportive network for them.
Hallowell: I’ve also learned a lot about doing things without a lot of resources. When you walk into your office and it literally only has a desk and chair, you learn how to be creative very quickly!
Hickey: Yes, that’s a great point, too, Brooke.
Participant: How many students do you generally supervise on your trips abroad?
Hickey: I have only taken a student once, and it was one student. My other trips have been on my own. When planning to take students, it is essential that you can adequately supervise them. Cate Crowley has written about this.
Hallowell: [Ellen and I] don’t do many student trips to provide clinical services. I have one (service-learning) in preparation for the summer and it is a LOT of preparation to do it well. I more commonly take students to engage in research elsewhere.
Participant: Would love to have the links for these resources!
Hickey: I highly recommend this website for thinking through some of the issues in taking students on service learning trips: blogs.ubc.ca/ethicsofisl. Another good website: bit.ly/slp-students-global.
Hallowell: When considering the number (of students), it matters so much what we’re doing and with whom. There are so many logistics to consider. Also, many universities have strict rules about that. And if they don’t, they should!
Hallowell: In 2012, we had the Global Summit on Higher Education in CSD. It was sponsored by CAPCSD. We had representation from 28 countries. You can find lots of related materials in the proceedings from that summit. I wrote a summary here: bit.ly/capcsd-summary.
Hickey: These are not necessarily specific to CSD, but important issues to consider in terms of cultural safety, issues of voluntourism in general, etc.: bit.ly/poverty-tourism-info, bit.ly/death-of-voluntourism, bit.ly/help-or-hurt
Participant: How do you address sustainability when providing services abroad?
Hallowell: One critical element of sustainability is to be sure you hold to any promises you make. It’s easy to go have a great time, have adventures, make friends, feel good about the work you do. But that’s not what sustainability is about. It’s important to find ways to stay in touch. It’s also important to keep going back. And to help and empower cultural insiders to take ownership of the work—not wait for you to return to keep building. I see a real problem with sustainability coming from so much work in our field being done through non-profits/NGOs [nongovernmental organizations] that are not driven by people who are truly representative of the people being served.
Hickey: Much of what we have already talked about ties into sustainability—building good communication with local partners so that you may prepare appropriately for trips and then keep up the communication afterward. Being sure to work on problems that locals identify as problems in ways that are culturally relevant is essential. In many cultures, they will not tell us “no” when we suggest solutions, but they may have no intention of implementing our ideas. We must work together to figure out what works for the context—the culture and available resources.
Participant: Could you please talk about the pre-service work that you do with students?
Hickey: Some important topics to cover in pre-departure training with students include language, cultural contexts, circumstances of work, models of care (e.g., CBR [community-based rehabilitation]), possible client scenarios, use of interpreters, expectations for the experience, taking photos/sharing information, and living conditions. Some students do not have much background in studying cultures, and some do not even have much of an awareness of their own cultural values. In my teaching, I have expanded the work that I do with all students around developing a critical diversity perspective that requires them to consider how they are situated culturally, the assumptions that they make, etc. I hypothesize that the more we can get students (and clinicians) thinking critically about culture, the less risk there is of practicing in ways that are paternalistic or neo-colonialist.
Hallowell: I am requiring students to take a course that includes ethics, ethical case studies, cultural and historical aspects of the place we’ll be working, safety and health precautions, basic language skills, politeness, etc. I think it’s important to get a sense of the students’ starting points, too. We’re all so different in our awareness, readiness, flexibility, adaptability and cultural competence according to any number of criteria. That is such an important part of what we should consider here. It’s not just the ethics of the people we serve. We should also be mindful of our responsibilities to our students, and consider thoroughly what consequences there could be for them. We need to think before we go about how to handle culture shock, distress, homesickness, sickness—and to have plans in place to deal with those things.
Hickey: An issue that is important to cover in pre-departure training is that of taking photos/posting photos. Students/clinicians need to be mindful of the photos that they take, especially of strangers. As I have stated earlier, they are obligated under the ASHA Code of Ethics and it is a clear violation to post photos of clients/patients on social media. However, this is something that I have seen happen. There have been a couple cases of medical students being expelled for this.
Participant: Are you familiar with the concept of community-based rehabs (CBR) that was initiated by the WHO [World Health Organization]? If so, have you tried this approach to bringing culturally relevant speech-pathology services to under-served areas abroad (e.g., East Africa)?
Hickey: Yes, I am familiar with CBR and have worked with organizations that practice CBR in Tanzania, Kenya and Malawi.
Hallowell: Yes, CBR models are also being implemented in the U.S. I live in the poorest county of Ohio, in the Appalachian region. There is a tremendous need for us to use what has been learned in other countries for implementation with underserved people in North America. CBR is a promising way to empower people with disabilities and the people who care about them—and at the same time, to raise awareness and reduce stigma associated with differences/disorders.
Participant: What are your experiences with conducting research across borders? What ethical concerns should be considered?
Hallowell: Many countries do not have IRB [Institutional Review Board]/Ethics review panels that function as ours do in the United States and Canada. This means we have to go way out of our way sometimes to help cultural insiders set up such processes there. I do a lot of research in various countries. Paramount is not thinking from the start that you will just go over, collect data and simply publish your work. There is always a lot of ground work to do. An important point to keep in mind is that most research studies won’t benefit the people who participate in them. So we have to be clear and honest about that. The principles of research ethics from the Universal Declaration of Human Rights, the Belmont Report, principles of the Declaration of Helsinki. Those are not intellectual documents for passing your IRB training. Those are really real, vital documents that should inform our work.
Hickey: I have not done research yet, but am preparing to do so next year. One of the most significant concerns for me is how to truly obtain informed consent. Sally Hartley has done a lot of interesting work in Uganda and Kenya and has used qualitative processes to get a better understanding of the needs of persons with communication disabilities and the types of services that would be culturally relevant. Her work carefully uses local informants and interpreters.
Hallowell: Informed consent is an especially serious issue if participants are low-income, if they have low education, low literacy, communication disorders, and/or if they do not have access to care. Basic values of transnational research include also the social value of the work we are doing, its scientific validity, relevance, fair selection of participants and respect for all who participate.
Hickey: Brooke’s last point is important. I have had conversations with people who are very skeptical about research being conducted when it is not considered relevant to the locals—there is an awareness that people come in to do research to serve their own needs and that it will not likely “help” them or there will be no change due to the results. There are some negative feelings around feeling “used” by Westerners for research purposes. That is why I brought up Sally Hartley’s work, which is quite a different approach.
Participant: What means of communication have you found to be effective in terms of keeping in touch with your contacts abroad to enhance that sustainability of services?
Hickey: E-mail and Facebook. WhatsApp can also be a good way to keep a connection, and then use e-mail to discuss the details of work.
Hallowell: The communication so depends upon the culture and country. Hardly anyone uses e-mail the way Westerners do, for example.
Hickey: Yes, it’s essential that we not expect immediate replies.
Participant: What has your experience of using interpreters been like when delivering services in other countries to compensate for the language barrier?
Hickey: Using interpreters is challenging. In Malawi, I found it difficult to get people to interpret everything that was being said. But in Tanzania and Kenya, the staff that I worked with were either SLTs or more used to working with SLTs, and it was easier. It’s important to train the interpreters so that they understand the goals of our sessions, what we are doing and why.
Hallowell: I agree with Ellen. I prefer working with the cultural insider, coaching, modeling, sharing … and then observing rather than trying to carry out direct intervention if possible.
Participant: Have the interpreters been helpful in serving as cultural brokers in your experience?
Hallowell: Yes! I’ve had amazing interpreters and guides. I would rather have an SLP or student who is passionate about the content than a professional interpreter whose English is stronger. I also love when interpreters help us sharpen our language skills in the hosts’ language.
Hickey: It varies, but mostly yes. I have not worked with anyone who was strictly an interpreter—always a health care staff member, usually an OT or PT. Many have worked with other volunteers so they have some understanding of our culture already, and some who have studied or worked in the U.K., Canada or U.S.—they tend to be excellent cultural brokers.
Participant: One of the things that faculty who take students abroad are engaged in is research. What are some of the benefits and challenges to conducting research with colleagues abroad? Also, what are some of the more important research questions to address regarding sustainable and culturally responsive global engagement?
Hallowell: Those are two big questions! In terms of benefits, some of us have research that depends on work across cultures and languages. So there’s no other way to do it. Other benefits are that it is stimulating, challenging and productive. And we have the hope of maybe making a difference by doing something truly translational. The issue of what are the important questions has transformed the kinds of research I am doing in Asia. I started by doing experimental work there, and in building an experimental track related to aphasia across languages. What I realized, though, was that few people would access the products of that work. So I got much more into issues of access to care—fundamental questions about what would make people with neurological disorders even seek any kind of rehab services in the first place.
Participant: How do you collect your data and how do you use assessments? Especially for those children who don’t speak English?
Hickey: I have not used any standardized assessments in my work in Malawi, Kenya or Tanzania because they wouldn’t make sense. The organizations that I have worked with have developed some informal assessment tools—mostly developmental checklists and questionnaires. For treatment, I generally have used or taught locals to use the same sorts of data collection procedures that I would use at home to track behaviors and progress.
Hallowell: I don’t collect data from people whose language I don’t speak. I work with insiders. Also, I recruit fantastic PhD students who are native speakers and they collaborate with me, as well as with our non-U.S. partners.
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May 2015
Volume 20, Issue 5