Published on June 21st, 20190
A Critical Review of Aphasia in Indigenous Seniors
By Kelsi Breton
What do we know about aphasia in Indigenous communities?
Stroke is the third leading cause of death of Canadians (Statistics Canada, 2019). Canada’s Indigenous people are particularly susceptible to experiencing a stroke. The effects of colonization, the residential school system and the creation of reserves have caused risk factors such as fatty diets, obesity and diabetes to be more prevalent within Indigenous communities (Kakekagumick, 2013). Indigenous communities are often remote, posing huge barriers in accessing healthy foods. The time and distance required to travel to some communities also impacts the freshness and quality of foods coming in while inflating their costs (Kakekagumick, 2013). Diets have thus become high in saturated, trans-fats and refined carbohydrates causing rates of obesity and diabetes to rise. The result: Indigenous people have twice the risk of stroke and have a higher likelihood of developing stroke at a younger age than the rest of the population (Hill et al, 2017).
Roughly 35% of stroke patients will develop aphasia (Dickey et al, 2010). However, rates of aphasia among Canadian Indigenous people are unreported. Language and oral storytelling are important aspects of life in Indigenous communities. Elders, the gatekeepers of tradition and culture, communicate most of their teachings orally. Very little traditional knowledge is written. Thus, barriers to communication and loss of access to language pose serious implications to the transmission of tradition and knowledge.
Virtually no literature exists regarding aphasia or its impact in Indigenous communities in Canada. However, studies have been done investigating aphasia in Australian and South African Indigenous peoples. Although these populations live on opposite ends of the world, they share common colonial pasts, histories of discrimination and lack of services and meet the World Health Organization’s (WHO) definition of Indigenous Peoples (Penn & Armstrong, 2017). I decided to draw parallels from this research to help guide speech-language pathologists (S-LPs) in modifying aphasia assessment and treatment approaches with Indigenous clients.
As no aphasia batteries have been standardized on Indigenous populations, linguistic and cultural differences between patient and clinician can complicate assessment. S-LPs must interpret results with caution as there is an increased potential for mislabeling or misdiagnosing (Javier, 2007). Aphasia batteries are neither culturally relevant or appropriate for Indigenous peoples and this may mask competencies. For example, the picture description task in the Western Aphasia Battery (WAB) may be more difficult for Indigenous clients as words like ‘sailboat’ may not be a commonly used word in an Indigenous context. Traditional ideologies of health and illness differ largely from Western ideologies and this may affect communication around illness (Vukic et al, 2011). Additionally, older Indigenous clients may have knowledge of their traditional native language. S-LPs who are unfamiliar with the language risk misinterpreting phonetic, morphological and syntactic differences between English and Indigenous language. There also exist differences in communication styles and pragmatic rules between Indigenous and non-Indigenous populations8. 76% of Australian S-LPs who work with Australian Indigenous clients with acquired communication disorders reported that their biggest hurdle in providing therapy was a lack of culturally appropriate assessments and treatment (Cochrane et al, 2016).
Researchers studying intercultural aphasia in Australian and South African Indigenous populations listed six suggestions to assist clinicians when gathering assessment info (Penn & Armstrong, 2017):
- Gain access to the community – This involves the building of trust (discussed further below). Commitment and long-term engagements are needed by clinicians to understand the impact of aphasia on the client and their family. This can also reveal the patient’s and the community’s understanding and views of aphasia.
- Observation/ethnographic methods – Help to develop a sense of group norms, functional communication contexts and the quality and quantity of interactions with others.
- Action research – Keep assessments “on-going” as opposed to a one-time event. This helps to see the patient in multiple contexts with different communicative partners.
- Interviews and narratives – Use open-ended questions or invite patients to “tell a story.” This puts patient in control, allowing the most important aspects to arise while giving the S-LP insight to language and cognitive impairments.
- The group and community model – Collecting data in an aphasia group helps to promote a greater sense of safety amongst patients. Australian S-LPs also suggested involving family members to fill in gaps and capture a more complete picture of the client (Hersh et al, 2015).
- Partnerships with cultural brokers (or liaisons) – Cultural liaisons are ‘cultural experts’ that can help deepen S-LPs’ cultural knowledge and facilitate links within the community.
The approaches suggested below are from my own experiences providing services in both Anishinaabe and Mi’kmaq communities as well as the research mentioned above.
- Building trust – Trust in the medical community has been destroyed due to negative experiences of discrimination and racism encountered in health care facilities, as well as a lack of continuity of care caused by poor retention of S-LPs. Clinicians must be cognizant of historical injustices and focus on relationship building and collaboration with community members. Research suggests that clinicians should be prepared to spend more time building rapport, gaining background information and providing informal therapy and conversation before jumping into ‘traditional therapy methods’ (Cochrane et al, 2016).
- Learning phonetic and language differences – By speaking to community members, cultural liaisons and using various resources (I have listed some below!), S-LPs can gain a better understanding of dialect differences influenced by Indigenous languages.
- Involve family and community members – This is a great way to educate others while promoting carry-over. This collaboration helps enhance social communication for the patient while facilitating clinicians’ connections in the community (Cochrane et al, 2016) (Penn & Armstrong, 2017). These relationships can also help S-LPs develop more culturally relevant therapy materials (Cochrane et al, 2016) (Penn & Armstrong, 2017). Community members can help run informal, community-based conversation groups or inform clinicians on group activities within the community (Penn & Armstrong, 2017).
- Aphasia education – S-LPs can hold workshops for community members that focus on increasing aphasia awareness, supported conversation techniques, etc. to facilitate conversation with family and friends who may have aphasia.
- Advocate for sessions provided within the community – Some organizations still require Indigenous clients to travel long distances for therapy. Travel challenges are further compounded by other challenges in patients’ lives. Thus, therapy may not be a top priority (Penn & Armstrong, 2017). By going to the patient, we can alleviate stress and increase therapy participation while promoting a more natural environment (McLellan et al, 2014).
Facebook: Anishinaabemowin with Roy Tom
Facebook: Learning Mi’kmaq – One picture at a time
App store: L’nui’suti
- Cochrane, F. C., Brown, L., Siyambalapitiya, S., & Plant, C. (2016). “… Trial and error…”: Speech-language pathologists’ perspectives of working with Indigenous Australian adults with acquired communication disorders. International journal of speech-language pathology, 18(5), 420-431.
- Dickey, L., Kagan, A., Lindsay, M. P., Fang, J., Rowland, A., & Black, S. (2010). Incidence and profile of inpatient stroke-induced aphasia in Ontario, Canada. Archives of physical medicine and rehabilitation, 91(2), 196-202.
- Hersh, D., Armstrong, E., Panak, V., & Coombes, J. (2015). Speech-language pathology practices with Indigenous Australians with acquired communication disorders. International journal of speech-language pathology, 17(1), 74-85.
- Hill, M. E., Bodnar, P., Fenton, R., Mason, B., & Bandoh, G. (2017). Peer Reviewed: Teach Our Children: Stroke Education for Indigenous Children, First Nations, Ontario, Canada, 2009–2012. Preventing chronic disease, 14.
- Javier, R. A. (2007). The bilingual mind: Thinking, feeling and speaking in two languages. Springer Science & Business Media.
- Kakekagumick, K.E., Naqshbandi Hayward, M., Harris S.B., Saksvig, B., Gittelsohn, J., Manokeesic, G., Goodman, S., & Hanley, A. J. (2013) Sandy Lake Health and Diabetes Project: A Community-Based Intervention Targeting Type 2 Diabetes and Its Risk Factors in a First Nations Community. Frontiers in Endocrinology. 2013;4:170.
- McLellan, K. M., McCann, C. M., Worrall, L. E., & Harwood, M. L. (2014). Māori experiences of aphasia therapy:“But I’m from Hauiti and we’ve got shags”. International journal of speech-language pathology, 16(5), 529-540.
- Penn, C., & Armstrong, E. (2017). or. Aphasiology, 31(5), 563-594.
- Statistics Canada. (2019). Leading causes of death, total population, by age group. Retrieved from https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1310039401
- Vukic, A., Gregory, D., Martin-Misener, R., & Etowa, J. (2011). Aboriginal and Western conceptions of mental health and illness. Pimatisiwin: A Journal of Aboriginal and Indigenous Community Health, 9(1), 65-86.
Kelsi Breton is a graduate student of Mi’kmaq ancestry and is in her final year of the speech-language pathology program at Western University. Prior to her studies at Western, Kelsi was an English as a Second Language (ESL) teacher in Thailand and online for South Korean students. During her time at Western, she has completed placements in both Anishinaabe (Whitedog and Grassy Narrows) and Mi’kmaq (Elsipogtog) communities.