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Effective communication is the currency to accessing a wide range of public services and underpins a person's ability to engage in society and the opportunities in life. However, for many people with a communication difficulty, either through neurological damage such as a stroke or issues related to cultural and linguistic diversity, communication problems can often be the cause of social exclusion. Aphasia is a neurological language disorder which can result in difficulty with speaking, understanding, reading and writing, usually without affecting other cognitive processes. There is a growing body of literature investigating communication access for people with aphasia (T Howe, Worrall, & Hickson, 2007; T Howe, Worrall, & Hickson, 2008; Pound, Duchan, Penman, Hewitt, & Parr, 2007; Rose, Worrall, & McKenna, 2003; Simmons-Mackie et al., 2007) and the link with social inclusion (Parr, 2004, 2007; Simmons-Mackie & Damico, 2007). While aphasia can create many barriers to participation, it has been proposed that social inclusion can be facilitated through increased public service awareness of strategies that improve communication access (Byng, Pound, & Parr, 2000; Kagan, 1998; Kagan, Black, Duchan, Simmons-Mackie, & Square, 2001; Lyon et al., 1997).
There have been suggestions that communication access principles in aphasia may also assist people with the communication difficulties associated with English as a Second Language (ESL) (T Howe, et al., 2008; Worrall, Rose, Howe, McKenna, & Hickson, 2007) and that future research should include people from culturally and linguistically diverse backgrounds (T Howe, et al., 2008). Although the cognitive processes underlying the linguistic impairment in aphasia are distinct from those involved in acquiring a second language, the potential similarities between the communication experiences of these heterogeneous groups has not yet been explored. In a review of the "communication support needs" literature, (Law, van der Gaag, et al., 2007)recognise the need to look at the experiences of the full range of people with communication difficulties to improve public attitudes and to develop an accessible communication environment across all community settings. Although the focus of this change has been highlighted in a Scottish context, it could be argued that Australia needs to look at a similar, coordinated approach to facilitate legislative change that recognises this need at a systemic and policy level.
In Western Australia (WA), the communication needs of people who use ESL are considered within the WA Language Services Policy (Office of Multicultural Interest, 2008). However, this policy tends to focus on the use of translating and interpreting services with a gap in the understanding of the collaborative communication strategies which people with ESL and public service providers naturally use to succeed in their interactions. Australia has one of the best translation and interpreting services in the world to support its expanding multicultural constitution and it is not within the remit of this study to investigate this aspect of language policy. Instead, this study will explore whether there is the potential for the disciplines of clinical aphasiology and those involved in language policy and access and social inclusion policies in WA, to combine their expert knowledge, skill and resources to improve communication access and inclusion in the broadest sense. This study will explore whether there is any overlap with the issues of communication access and social inclusion between ESL users and people with aphasia. The findings will be discussed within the context of Western Australian Language policy and Government Access and Social Inclusion policies.
Communication is essentially a social process involving the collaborative construction and negotiation of the sending and receiving of a message between two people or more. Through communication we defining who we are to others through what we say and how we say it, we develop and maintain our personal relationships and social contacts, we take part in activities and the interests we enjoy, we express our values, beliefs and our personal knowledge and experiences.. We use spoken language for a range of functions; to express how we are feeling, to share information or exchange ideas, to tell a story or a joke, or state a viewpoint in a dispute or an argument, to talk on the telephone or to perform a range of speech acts such as requesting, ordering, apologising and warning - everyday things that many of us take for granted. (Pauwel, (1995 provides a clear overview of the fundamental concepts of language, communication and culture and how they are interrelated. Verbal and non-verbal communication are two key components of how people interact and cooperate with each other to produce a meaningful dialogue. Verbal communication refers to the linguistic aspects of phonology (sounds), semantics (words), syntax (grammar) and how we link our utterances to produce coherent spoken discourse. This 'linguistic competence' is only part of successful communication and participants are also required to demonstrate 'communication competence' which takes into account how to use language in different contexts and also considers the broad principles of non-verbal communication such as the prosodic features of speech: intonation, rhythm, stress, pitch, tone and resonance as well as body language: facial expression, gestures, posture and eye contact and the rules of conversational management
Schriffin (1998) describes conversation as a "basic form of communication" which is integral to participating in a wide range of interactions and forms the basis for "establishing and advertising our social identities" Lippi-Green's (1997, p.5). Within a conversation, each participant is required to demonstrate an understanding of the principles of turn-taking (Schegloff, 2000), construction of conversational sequences (Schegloff, 1990), the repair of trouble spots (Perkins, 1999; Schegloff et al., 1977), topics and the opening and closing of a conversation (Button & Casey, 1984), the role of linguistic resources ((Couper-Kuhlen & Selting, 1996) and the relationship between verbal and non-verbal activities (Schegloff, 1984). Importantly, communication has to be considered as a collaborative process whereby both participants need to work together to negotiate the content and the meaning within the interaction. When one member of the interaction has difficulty communicating, it often falls to the other member(s) to provide the necessary communication scaffolding to support the development of the exchange (Booth & Perkins, 1999; Dooley, 2009; Kagan, 1998; Lyon, et al., 1997). This can enhance the appearance of social and communication competence, help the person with a communication difficulty feel more socially included (Kagan, 1995; Parr, 2007; Simmons-Mackie, 1998; Simmons-Mackie & Damico, 1995) and can be of enormous psychological benefit (Lyon 1989, Kagan& Gailey 1993). The repair of trouble spots in conversation is socially sensitive as there is a potential 'threat to face' for the person who has produced the trouble source and requires both participants to work together to avoid an unsatisfactory outcome (Sacks, 1984). Repair sequences are more complex and happen more frequently if one person has a communication difficulty. Clark and Schaefer (1987, 1989) describe a model of repair organisation in conversation whereby participants use the principle of least collaborative effort to resolve a misunderstanding as quickly and efficiently as possible to help 'save face' and minimise the potential issue of non-competency.
Linguistic and communication competence are intricately linked and influenced by a person's cultural background. The concept of 'culture' is not easy to define and there are many diverse interpretations and descriptions which continue to be debated across the disciplines of anthropology, sociology, psychology and communication. Dorjee (2002) in a review of cross-discipline definitions of culture, found that five recurring themes of patterns, beliefs, symbols, meanings and values occur in all definitions of how groups of people behave. Language, as a system of symbols used for communicating, can differ substantially across cultures at all levels with phonological, semantic, grammatical, conversational management and non-verbal features of language production all being influenced by our cultural background. Although we are taught some of the rules governing culture and communication explicitly, most are learned unconsciously by being immersed in the culture. People who migrate to new countries will not only have to learn the new language, but also the cultural aspects of how the language is used in the new setting. One of the difficulties defining culture is that it is dynamic and constantly changing, especially in multicultural societies where different cultures interact and influence each other. It is important that we don't assume that people from a similar racial or ethnic background share the same cultural values as variations associated with gender, age, social and economic status and educational level will all influence how people behave. However, having an appreciation of the broad cultural issues that may affect language and communication is an important feature for the non ESL communication partner to be aware of in their interactions with people who use English as a Second Language.
Often we don't think about communication, it's just something that we do and it's not until something goes wrong as a result of a specific communication disability such as aphasia or it becomes more difficult due to cultural and linguistic diversity, that we realise just how important it is to our personal and interpersonal well being and our ability to engage with society and the community in which we live. Communication difficulties can have a significant impact on a person's life and can lead to poor self image and lack of confidence, anxiety, depression, unemployment, problems with relationships and difficulty accessing social support networks all of which are intricately linked with the key drivers of social exclusion in Australia (ref).
Aphasia is an acquired language disorder resulting from neurological damage. Although stroke is the most common cause with approximately 30% of people experiencing a first ischaemic stroke presenting with aphasia (Engelter et al., 2006), it can also be caused by a head injury or brain tumour. There is no specific data on the incidence and prevalence of aphasia in Australia. However, it is estimated that of the 48,000 Australians experiencing a stroke each year (Thrift, Dewey, Macdonell, McNeil, & Donnan, 2000), 14,400 will present with aphasia.
Aphasia affects a person's linguistic and communication competence across all language modalities and for many, it is a long term, chronic condition that impacts significantly on their ability to integrate and engage in life as they knew it. The influence on a personal level can be immense, with people reporting feelings of personal exclusion such as isolation, boredom, depression, low self esteem, frustration and anger (Parr, 2004; Parr, Byng, Gilpin, & Ireland, 1997). At the interpersonal level, aphasia can affect the whole network of social relationships within the persons environment, making it difficult to engage with family, friends, neighbours, work colleagues, previously enjoyed activities and groups and a whole range of public, health, voluntary and educational services. Access to a wide range of services is a major issue for people with aphasia due to the lack of understanding of the nature of aphasia and the issues people with it face, contributing to people feeling excluded from the communities in which they live. (Law, Pringle, et al., 2007; Parr, 2007).
Communication access in aphasia
The construct of communication access has emerged over time and although there is no universal definition, with individual researchers and therapists using different word variations and interpretations to describe the concept, the key components can be considered in terms of the barriers faced by people with aphasia and what needs to be done to support them to fully engage with their community and the people in it. In the seminal work by Parr et al, 1997, 50 people with aphasia took part in in-depth interviews to explore the impact of aphasia on their every day life. The barriers they encountered were grouped into four categories; attitudinal, structural, informational and environmental. Attitudinal barriers related to the negative responses of other people, while structural barriers concerned the lack of legislation and policies as well as the lack of adequately designed systems, services and resources which facilitate the inclusion of people with aphasia. Information barriers reflect the difficulty people have either finding the information they need or understanding it when they do. Providing accessible written information is a legislative requirement of State and Commonwealth Governments (ref) and there are comprehensive guidelines available on how to provide written information in formats that meet the needs of people with communication difficulties (WA State Government Access Guidelines for Information Services and Facilities, 2009). However, although information access is widely acknowledged as being fundamental to empowering people to take an active role in decision making and community participation, there is evidence that people with aphasia continue to have difficulty accessing written information in the printed form (Rose, et al., 2003; Worrall et al., 2005; Worrall, et al., 2007) and on the internet (Ghidella, Murray, Smart, McKenna, & Worrall, 2005) even thought there is research which shows what can be done to improve information access in aphasia (Rose et al 2003, Worrall et al 2005, Brennan, 2005).
Environmental factors included the wide range of physical and language barriers such as other people speaking too quickly or not giving the person with aphasia enough time or there being too much background noise with no opportunity offered to move to a quieter area to speak. There is a growing body of evidence about the environmental factors that influence how accessible a particular situation is for someone with aphasia (Brown et al., 2006; Howe, et al., 2007; O'Halloran, Hickson, & Worrall, 2008; (T Howe, et al., 2008). O'Halloran et al reviewed the literature on the environmental factors that impact on adults with a range of communication difficulties when interacting with healthcare professionals in acute hospital settings and found similar themes emerging across the different groups which were consistent with the findings in the Parr et al study. Howe et al (2007) conducted in-depth, semi structured interviews with 25 people with aphasia to explore their perspectives on the broad spectrum of barriers and facilitators that impacted on their community participation. The findings were analysed using the World Health Organisation's (WHO) International Classification of Functioning, Disability and Health (ICF) (WHO, 2001), with results categorised into the effects of other people, the physical environment and society. In terms of the impact of other people, barriers included; overcorrection of linguistic errors, lack of eye contact, poor listening skills and negative attitudes, while helpful strategies included; more time and patience, clear information, offering suggestions, speaking slowly, help with form filling, displaying some knowledge about the communication difficulty and exhibiting good communication skills. A further companion study (Howe et al, 2008) which used participant observation to evaluate the negative and positive environmental factors, supported the findings of the original study. However, as with Parr 1997, Howe et al (2007, 2008) explored a wide range of environmental factors and did not set out to specifically investigate the impact of other peoples' communication behaviours and how this affects the social participation and inclusion of people with aphasia. As discussed earlier, the skill of the communication partner is an essential part of the communication access construct and has long been acknowledged as an important part of engaging the person with aphasia in services.
The following table offers a description of some of the techniques that communication partners can use to support people with aphasia in communication interactions, based on the reports from people with aphasia ((T Howe, et al., 2007; Parr, 2004; Parr, et al., 1997), the evidence from aphasia research (Kagan, 1998; Simmons-Mackie & Kagan, 1999) and recognised best practise recommendations.
Helpful strategies communicative partners can use to facilitate communication access in face to face interactions
Be patient and give the person time to communicate
Be attentive and respectful
Use a natural tone of voice. Don't shout or be patronising
Talk directly to the person - not to others who may be with them
Treat the person as a competent adult
Speak slowly, using plain English
Avoid complex instructions and information
Avoid using difficult words
Draw or write the key ideas to help the person to understand
Use natural gesture to aid understanding
Check regularly that the person is following what is being said
Repeat if necessary, emphasising key words and using alternative words
Encourage the person to get their message across in other ways e.g. write, draw, use props in the environment
Work together to help minimise the effects of any linguistic difficulty
If you can't work it out together, suggest you come back to it later if you can
Don't correct linguistic errors if you know what the person was trying to say
Be aware of cultural differences
Use an interpreter if necessary
Write down the key points of the discussion for the person to use for future reference
However, there have been no studies which have specifically examined the person with aphasia's perspective on barriers and facilitators to successful face to face interactions with service providers and how this impacts on the concept of social inclusion.
The Commonwealth Disability Discrimination Act (1992) makes it unlawful to discriminate for example, in the areas of employment, access to premises, the activities of clubs and associations, sport and the provision of goods and services. The WA Equal Opportunity Act 1984 (amended 1998), recognises that people with disabilities are entitled to the same level of service that is available to other members of the community. The 2004 amendment to the Disability Services Act (1993) states that all public authorities are required to develop and implement Disability Access and Inclusion Plans (DAIPs) to facilitate the independence, opportunities and inclusion of people with a wide range of disabilities. The six desired outcomes of the DAIP include; all people to receive the same level of quality service and to have the opportunities to access services, buildings, information, public consultations and to make complaints. However, although there is some consideration given to the needs of people with hearing loss, visual impairments and intellectual or psychiatric illness within the (WA State Government Access Guidelines for Information Services and Facilities, 2009)), the DAIP Resource Manual for Local Government (2006) and the Resource Manual for State Government (2006), there is little evidence that policy makers recognise the communication access needs of people with aphasia. From the discussion so far, it is clear that this lack of a broad communication policy puts people with aphasia and other communication difficulties at risk of discrimination and unequal opportunities. Similar to the findings of the Law et al., (2007) study, further research to look at the diverse needs of the heterogeneous groups that experience communication barriers and to translate the findings into the key directions for future policy development would be beneficial to people in Australia who use non-conventional forms of the English language. This lack of legislative awareness of the broad issues affecting communication access, can be compared with the multifaceted and universal approach to reducing physical barriers through the use of strict 'physical access' legislation that supports people with physical disabilities to engage at all levels of society. A similar multidimensional approach to communication access needs to be considered by society which recognises the importance of communication and how to create environments, services, information and communication contexts which are more readily reached by people who have a wide range of difficulties.
English as a Second Language
Twenty-seven percent of the Western Australian population are migrants, making the state one of the most culturally and linguistically diverse in Australia. The WA Office of Multicultural affairs recognises that for some migrants, communicating in English can be a barrier to participating fully in Australian society.
Cultural beliefs and values implicitly underpin our personal and interpersonal communication, influencing the content and the structure of our interactions. The relationship between culture and communication has been extensively reported in the multicultural sociolinguistic and anthropological literature (see Samovar and Porter, ?year )for a comprehensive overview). As Gallois and Callan (1997) point out, we are largely unaware of the impact of our culture on our communication and it's not until something changes, for instance, when moving to a new country, learning a new language and having to interact in different personal and interpersonal situations, that we become more acutely aware of its powerful influence. As well as the ubiquitous cultural, linguistic variations between languages, a person's cultural framework will also impact on non verbal features of communication. There are countless non-verbal behaviours attributed to different language and cultures. Samovar and Porter (p.15) provide an overview of the cultural variations of: bodily behaviour; e.g the different meanings assigned to various hand gestures, facial expressions, gaze or eye contact or touch, the concept of time; e.g. some cultures are timebound, while others are driven by a slower pace or behaviours that are determined by how busy you are and the use of space; e.g the distance or positioning of people when speaking to each other.
Cultural education is an important part of informing service providers of how to improve their interactions with ESL migrants and is recognised in some Western Australian policies on access and inclusion of culturally and linguistically diverse groups. However communication is still viewed as one of the most significant barriers to meeting the diverse needs of minority groups (refs). WA Language policy focuses almost solely on interpreting and translation services, which although of commendable quality, does not offer the range of communication access solutions that may be required in different situations. Dooley (2009) highlights the lack of attention to the influence of the non ESL communication partner's skills to contributing to successful conversational interactions. She discusses the need for a socially inclusive model of intercultural communication in the classroom setting, whereby all students (ESL and non-ESL) learn the basic principles of how to manage conversational contributions in a positive and collaborative manner. Although some ESL speakers may have learned conversational management skills as part of the ESL acquisition process (Thornby and Slade, 2006), the dominant language user learns these rules implicitly and therefore may not have adequate knowledge of how to use or develop these skills to circumvent disruptions in talk due to linguistic or cultural misunderstandings. By readjusting the balance and recognising the collaborative nature of conversations, the non-ESL partner's support can help reduce similar issues of 'threat-to-face', stigma and incompetence that are apparent in the experiences of people with aphasia.
Although Dooley (2009) draws attention to the need for more research on what can be done to facilitate the native speakers involvement in successful interactions to promote a more inclusive approach, there is a rich body of evidence concerning the understanding of the strategies used by the dominant language participant to allow the conversation to flow with least collaborative effort, allowing the competence of the less proficient speaker to be revealed (see chapters 6 and 7, Bremner et al.). Some of the strategies described are similar to those used by the conversational partners of people with aphasia (see table 1). Normally, the burden of establishing understanding in a conversation falls to the listener. However, in ESL/non-ESL discourse, the situation is reversed with the ESL speaker often the one who has to support the understanding, even if they are not the listener (Lippi-Green, 1997). This reflects the notion of 'linguistic power', which in many instances, equates to 'racial power' with non ESL communication partners viewing the misunderstanding as the problem of the ESL speaker because they don't speak English well enough, reinforcing the ESL speaker's negative feelings of shame, embarrassment, loss of face, reduced self image and confidence (Yoon, 2007; Lippi-Green, 1997). Similar to people with aphasia, participation and engagement in community services is likely to increase if people from CALD backgrounds feel supported in their communicative attempts and the risk of 'face-threatening' repair work is sensitively managed in conversations.
The WA Language Services Policy (2008) outlines the procedures and processes involved for State Government agencies to improve service delivery through better communication between staff and service users. However, as previously mentioned there is no recognition of the potential benefits of improving the communication skills of the government service providers to facilitate communication access and service inclusion to some ESL users. This is not only common to WA, but is also reflected internationally. A literature review on translation, interpreting and communication support services in Scotland (ref) found that there was a significant gap in the knowledge of how service providers and those from non conventional English language backgrounds actually communicate with each other. Although the focus of the review was Scotland, they drew heavily from the international literature, particularly Australia because of the recognised high quality language support services. McPake et al. acknowledge that in some contexts, translation and interpreting services are not always practical or necessary and the ESL user and service provider will routinely have to depend on their communication skills to help circumvent the potential problems that restricted linguistic ability may present. They argue that although the increase in the professionalism of translation and interpreting services is laudable, there needs to be a multidimensional approach to communication within non conventional English language use which takes into account a continuum of support strategies based on the contextual risks (p.56). However, they suggest in some 'low stake' contexts, improving intercultural communication could mean that service providers "know enough of a language to facilitate service encounter"'. It could be argued that this still implies a reliance on 'language' and misses the opportunity to explore whether language policy could include the wider concept of communication access, similar to the theories discussed in the aphasia literature. The report recognises that there needs to be a significant paradigm shift from one of service provision model, where auxiliary services are provided to assist with communication (e.g. translation and interpreting services), to one of social inclusion where the emphasis is on everyone taking a role in facilitating access and inclusion for all.