India

India is a culturally complex country composed of a diverse array of languages, beliefs and social structures. It is the 7th largest country by geographical area, the second largest by population, and boasts 23 official languages, divided into two major linguistic families. Nearly 70% of the population of India lives in economically depressed rural areas, with the major urban centers being more westernized in social structure and cultural beliefs.

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History

India’s cultural history is complicated by a series conquering invaders, bringing with them an influx of different religious and cultural beliefs. Some of the major religious influences on East Indian culture have been Hinduism, Hellenism, Buddhism, and Islam. One of the most influential occupying cultures was that of the British, who entered as a trade organization (The British East India Company) in 1608, took over rule of the country in 1858 and remained in power through 1947. During British rule, religious tension arose between Muslim and Hindu members of Indian culture. This clash of ideals led to the eventual establishment of Pakistan and India as separate nations, with the majority of Muslims moving to Pakistan. This conflict continues today as a political struggle regarding land boundaries.

US Immigration History:

Under British Rule, the Alienation of Land Act prohibited members of certain non-farming castes from owning agricultural land, triggering the immigration of roughly 3000 people to the US West Coast in 1908. In 1946, legislation was passed to allow Asian Indians the right to apply for citizenship and begin to bring relatives to the US as well. The 1965 Immigration Act granted visas to individuals in certain high-tech fields or professions requiring higher education, as well as allowing family members to join already admitted citizens, resulting in a large influx of peoples of East Indian descent which continue to this day.

Even though a large number of highly educated professionals are immigrating, one of the most difficult issues facing Asian Indian immigrants is discrimination in employment. Some individuals may be unable to find work which reflects their professional qualifications or experience in fields such as engineering, medicine or law, as educational programs in India are not directly acceptable in the US without additional training.

Demographics

Asian Indian Americans (also referred to as East Indians, Indo Americans, or Indians) are the 3rd largest Asian American group in the United States numbering over 1.8 million individuals who identify themselves as first and second generation immigrants or those whose ancestors migrated from the Indian subcontinent. According to 2000 US census data, they account for .66% of the US population and 16.2% of those who identify themselves as Asian American. Between 1980 and 1990, the population of Asian Indians living in the US increased by 125%, and the number of Asian Indian elders who followed their offspring to this country has also risen due to family reunification laws.

The largest proportion of Asian Indians live in the northeast (35%), primarily in New York, New Jersey, and Washington DC. Communities tend to be close knit regardless of geographic location. While clinicians should always be aware of confidentiality breaches, additional care should be taken to ensure the anonymity of any client cases they discuss with others, particularly when enlisting the aid of a cultural broker, interpreter, or asking for outside help with cultural considerations for the family.

Culture

Family Roles and Structure

Traditional family roles and practices may be influenced by the caste system, which is rooted in Hinduism. This traditional system is often practiced in rural areas and villages; however many practices have changed significantly with population shifts to urban Indian areas and immigration to the US. A full discussion of history and implications of the caste system is beyond the scope of this work, but interested persons are encouraged to read the Wikipedia entry entitled, ”Indian Caste System”

In traditional Indian society, extended family members, including grandparents, parents, children and possibly extended families which include parental uncles, may live together as a single family unit. In many urban areas and Indian individuals in the west, family structure may reflect more closely that of a nuclear family comprised of parents and children only. However, extended families are still culturally relevant. It is not uncommon for the husband’s parents to move in with the family following their retirement or if their help is needed following the birth of a child or an illness. Grandparents are particularly revered in traditional Indian culture as they are seen as the link to traditional heritage, culture, and religion. Sibling relationships tend to be especially close as well.

Family roles in treatment are of particular importance for individuals of East Indian descent. The extended family often provides support. Individual care might be best approached by emphasizing the needs of the family above those of the individual.

Gender Roles

It is difficult to make an overarching statement regarding gender roles in India, due to the cultural diversity of the landmass. According to Norma Downes in “Ethnic Americans for the Health Professional” (1994) families in the north and west of India are likely to be male-dominated, with female-dominated family structures found more in the south and northeast. Therefore one should be cautious when making assumptions as to the power structure of the family unit that they are currently treating.

According to Charles Kemp's article “Indian Health Care Beliefs and Practices”, in traditional Indian society gender roles are distinct and separate. Women are typically viewed as more passive and men being more authoritative. Women are traditionally in charge of the home by managing finances, family issues and social issues, where men are seen as supplying the family’s primary income and acting as the family spokesperson for individuals within the community, including health care professionals. These roles are changing in urban centers and western countries, particularly among educated Indians located in comparatively permissive societies.

Other sources state that it may be the mother-in law, grandmother or eldest son who is the family decision maker.

It is important to note that East Indian families in the United States tend to be more egalitarian, sharing responsibilities and decision-making

Social Considerations

Again it is difficult to generalize a diverse population into social constructs regarding proprieties and customs. There are, however, a few considerations which may be important to the health professional. Many native Indians will avoid negative responses, rendering many “yes” responses unreliable10). This is not only an important consideration when taking a health history, but may also be an implication for certain types of treatment – particularly Aphasia or cognition treatment which focuses on answering yes/no questions. The clinician might also experience trouble obtaining answers to personal questions due to modesty issues. Research suggests that prior to asking for personal medical information regarding disorder or family history, the clinician might consider beginning conversations with superficial topics as a way to lead into sensitive subjects.

Broad Cultural Considerations

Other cultural considerations a clinician might want to be aware of when working with peoples of Indian descent are:

• Modesty is highly valued among Indians and patients are decidedly more comfortable and secure with same-sex care providers.

• Sustained eye contact may be considered rude to some individuals

Language

Many well-educated Asian Indians are fluent in Hindi, English, as well as a regional language or dialect, and many individuals speak excellent English, however as more extended family members immigrate to the US, one may not assume that their client will be fluent. Be prepared to use an interpreter with unknown clients.

Speech

Speech Sound Disorders

Incidence statistics collected in the 1975 found that defective articulation, one of many Indian terms used for speech sound disorders, ranged from 10.25% to 21.6%. One study (Kalran, Sukhiany, Misra & Dayal, 1975) conducted in the community and schools of Agra City found a 216% incidence rate, with the highest incidence being in the 6 to 12 age group . Another study (Kalra, Lumba, Lal & Dayal, 1975) conducted with 1,200 children between the ages of 5 to 12 in the schools of Agra City found a 10.25% incidence rate. This study found that the most common type of defect was substitution at 72.3%. Next, were distortion and omission, which were found to be 18.1% and 9.6% respectively. They also noted that velar sounds were most commonly affected in the children that participated in their study.

Range of Acceptable Intelligibility

Speech sound disorders, more commonly referred to as “misarticulation” or “speech defect” are diagnostic entities in India, but they are not given a high priority. Stammering (stuttering) is the speech disorder given the most attention with voice disorders also being given high priority. The lack of clinical attention given to speech sound disorders seems to indicate that there is a wide range of acceptable intelligibility. This wide range of acceptable intelligibility may also be due to the large number of languages and dialects in India.

Treatment

Treatment of speech sound disorders in India is provided by speech therapists. The first speech therapists in India registered with the newly founded Indian Speech and Hearing Association in 1967. There are now over 1,500 registered audiologists and speech therapists. Admission requirements for academic programs are the same as medical school and a bachelor degree is the entry level clinical educational requirement, while individuals with masters degrees frequently teach in a university setting along with those who receive Ph.D.s.

Treatment of speech sound disorders in India can involve a wide range of methodologies. Some clinics use modeling and practice of the target sound while others endorse frenulum-clipping surgery. Phonetic drills have also been listed as a common practice for some therapists. Some therapists also have strong feelings regarding parental correction of a child’s misarticulated speech. These therapists believe that parents who correct their child’s speech will effectively cure their child’s articulation disorder. They also say that parents who do not correct their children’s articulation encourage habitual misarticulation. Other therapists believe that children with articulation difficulties should be referred to a child psychiatrist. There also seems to be a predominant view that articulation treatment should at least begin with a wait and see approachIndia parenting: pronounciation problems.

Healthcare beliefs and practices:

As a whole, Asian Indians accept and practice westernized medicine, as well as highly complex health and illness systems rooted in spiritual and religious belief. While it is impossible to categorize the belief systems of such a diverse population, traditionally, Asian Indian individuals believe that health is influenced by the body’s ability to heal itself and that illness may be caused by both internal and external forces. Some may believe that internal forces or emotions such as anger, fright or jealousy make one susceptible to disease and disability, and that external forces such as spiritual retribution for misdeeds in this or past lifetimes influence the health of the individual as well.

Due to the integrated spiritual nature of healthcare beliefs and practices, more specific information may be found by investigating the specific religions of your clients if they are known.

Primary religions among Indians are:

• Hindu (80% of the population of India)

• Islam (13.4% of the Population of India)

• Christianity

• Sikhism (30-40% of the Indian population in California)

Healthcare Culture

Information specific to healthcare that may be of use to clinicians when working with this unique population include ensuring that diagnostic or prognostic information be given to the head of the family. Some research may be required on the part of the clinician to ensure that one is addressing the proper member of the family. In the case of adult onset disorders, this may in fact be the afflicted individual. A clinician should take care to address the head of the household rather than the unimpaired family members present to maintain the appropriate level of respect.

Because of the value placed on independence and privacy in Indian culture and the desire to save face, family issues - including healthcare decisions - are frequently discussed within the immediate family before seeking outside help. Because of the close-knit family structure, a family can expect many visitors when a family member is in the hospital. Likewise, home, hospital and hospice are all accepted forms of care, with the order of preference being home, hospice, hospital.

Relatives and extended family may be expected to provide food and care throughout the duration of a hospital stay. Clinicians in an acute or post acute care setting may find that immediate family refuse to leave the facility to the point of purchasing a bed for the spouse for the duration of the stay. Additionally, family members may insist on involvement with intervention strategies, and finding a way to co-treat the afflicted individual may aid in easing any conflicts between clinician and family.

Many Asian Indians accept western medicine, however if they disagree with treatment options they may not object out of deference for the caregiver’s opinion. Instead they may choose not to return to the same caregiver.

Finally, clinicians should attempt to provide authoritative advice or instruction to families rather than multiple choices. The medical professional is looked upon with a great deal of respect, and signs that the clinician is unsure of him or herself may be interpreted as a sign of incompetence.

Implications for the SLP

As of this writing there is little information to be found that is specific to children of East Indian immigrants and the difficulties that they may experience in the US school system.

• In general, the clinician should follow the same guidelines for assessment and treatment that they would for other bilingual or multilingual children in the absence of a native The clinician should be aware of the amount of exposure the child receives to his or her native language as well as English exposure, and decide how to best support language learning in both languages, as much as possible.

• The clinician should be able to discern whether language learning delays are global or if they are effecting only the L2. In the case of the latter, the child should be supported in an ELL program rather than traditional speech therapy. If it is determined that the child is experiencing a global language learning problem, then the clinician may want to consider administering therapy in both languages, perhaps enlisting the aid of a parent, sibling, or friend.

• While there are in existence Hindi language assessments, these woud have to be administered by a native Hindi speaker to be considered valid, and may also be very hard to come by from within the United States. Additionally, these tests would likely be normed on a specific regional population and may not be applicable to the given child's language background.

• Finally, the clinician should be aware of the phonetic differences between Hindi and English, including a lack of /v/ or /ʒ/ sounds, as well as a larger phonetic inventory of consonants, including place and manner differences.

History of Speech Language Pathology in India

India has a long and rich history of support and research in the speech and hearing fields, and in Speech Language Pathology in particular.