Addressing health inequalities: the role of speech and language therapy

Health inequalities, under-served groups and the equality, diversity and inclusion (EDI) agenda

Those experiencing health inequality are often from particular under-served groups. The equality, diversity and inclusion agenda should strive to serve such groups to mitigate health inequality.

Increasingly, research is evidencing the differential outcomes experienced by under-served groups:

• Black and ethnic minority patients experience differential (often poorer) outcomes in healthcare, and people from ethnic minority groups are more likely to report being in poorer health than white counterparts (The King’s Fund, 2021).
• People who are LGBTQ+ are more likely to experience health inequalities, caused by societal norms that prioritise heterosexuality as well as outright discrimination and stigma (Zeeman et al, 2018).
• Those who are homeless are vulnerable to health inequalities, arising from intertwined adverse social and economic conditions (Stafford and Wood, 2017).
• People with learning disabilities face health inequalities and are at particular risk of premature death (LeDeR, 2020).
• Those living in socio-economically disadvantaged areas may be more likely than those living in affluent areas to experience multiple health problems in adulthood (multi-morbidity) though the causal factors require examination (Olutende, Mse, Wanzala and Wamukoya, 2021).
• Looked after children, who predominantly interact with social workers, may have their health needs overlooked, contributing to health inequalities (Bywaters, 2009).
• There are inequalities in the health of people who belong to traveller communities, more so than almost any other group in the UK (van Cleemput, 2010).

What leads to health inequalities?

As outlined in the previous sections, the associated variables, causes and pathways to health inequalities are varied and complex. Members are encouraged to use the references and resources list to explore these further.

Here, we outline some key factors related to discrimination that can contribute to health inequalities.

Institutional biases

Different types of institutional biases exist, for example systemic racism, homophobia, transphobia, classism or ableism.

Typically, these biases arise from the design of our healthcare systems and the paradigms in which they operate under, which may foster and perpetuate discriminatory beliefs and values (Hui, Latif, Hinsliff-Smith Chen, 2020). Thus, a system and workforce develop which are unable to deliver equitable care (Bailey et al, 2017).

‘Systemic’ or ‘institutional’ racism refers to “how ideas of white superiority are captured in everyday thinking at a systems level: taking in the big picture of how society operates, rather than looking at one-on-one interactions.” (O’Dowd, 2020).

In healthcare systems, institutional racism may contribute to health inequality for Black and minority ethnic populations – this is inextricably linked with the anti-racism agenda.

Examples of system-wide issues that may perpetuate health inequalities are:

• Our health care systems being underpinned predominantly by one model of illness and disability (i.e. ‘western’ medicine, medical models of disability) which render service users operating outside of this vulnerable to disempowerment and leads to inequitable care.
  • See examples of religious beliefs relevant to understanding and experiencing health and healthcare in Swihard, Yarrarapu and Martin (2021).
  • See specific perspectives from under-served groups on approaches to speech and language therapy in Roulstone et al (2015, p 143-145).
• Historically poor representation of people from ethnic minority backgrounds, women, who are LGBTQ+ or with disabilities in clinical research, potentially leading to recommendations that are not appropriate for different populations, which can result in inadequate clinical guidance (see eg Smart and Harrison, 2017).
• Biased educational materials and curricula meaning clinicians are not taught how to deliver appropriate care to those from marginalised groups (see example of speech and language from Pillay and Kathard, 2015), or the development of assessment materials lacking sensitivity and representation of marginalised groups therefore creating barriers to engagement.
• Failure to adequately fund a workforce and services required to meet the needs of diverse populations such as overcoming language and cultural barriers, for example not allocating funding for interpreters or development of diverse resources (Piacentini, O’Donnell, Phipps, Jackson and Stack, 2018).
• Ethnicity and gender disparities in position, prestige and pay among healthcare staff have been described in research, affecting, for example, hiring practices and career progression of ethnic minority staff (Milner, Baker, Jeraj and Butt, 2020).

Implicit bias

A clinician’s implicit bias may also contribute to health inequalities. Implicit bias is the making of “associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender.” (FitzGerald and Hurst, 2017).

Research has shown that healthcare professionals may possess implicit biases which can influence health outcomes. A systematic review concluded that healthcare professionals exhibit implicit bias at the same degree to the mainstream population. These biases may influence clinical decision making, and the level of care offered to service users (FitzGerald and Hurst, 2017).

Studies have documented examples of healthcare professionals with biases toward under-served groups such as:

• Traveller communities (Frances, 2013).
• People of colour (Hall et al, 2015).
• LGBTQ+ people (Sabin, Riskind and Nosek, 2015).
• Disabled people (VanPuymbrouck, Friedman and Feldner, 2020).

As an SLT, are you cautious about making direct assumptions or judgements of service users who both share or do not share your own culture, race, ethnicity or religion?

Going unresolved, a clinician’s implicit bias may therefore create inequality in healthcare. Changing this is unreservedly imperative and is an element of becoming anti-racist, anti-homo/transphobic or anti-ableist, and an ally to those from other under-served groups.

What is the SLT role in health inequalities?

Interventions to tackle health inequalities need to reflect the complexity of how health inequalities are created and perpetuated, otherwise they could be ineffective or even counterproductive.

This guidance looks firstly at the broader role of speech and language therapists and then more specifically at the typical factors that impact on a service users’ experience, and how an SLT might contribute to reducing or mitigating any health inequalities that arise. There are also some interesting observations on the impact of allied health professionals (including SLTs) on health inequalities in a recent rapid review (Ford et al, 2021).

The NHS Constitution requires all staff to contribute towards providing fair and equitable services for all and help to reduce inequalities.

The COVID-19 pandemic has highlighted existing health inequalities (see, for example, Katikireddi et al, 2021). As we move through the pandemic, we are noting an increasing focus on population health and health prevention. This is an opportunity to highlight the role of speech and language therapy in contributing to better population health and reducing health inequalities.

See this King’s Fund article for a definition and discussion of population health.

Members can log in to see our public health guidance for further information on the SLT role.

Broader role of SLTs

A crucial part of the speech and language therapist’s role is understanding not just the ‘norms’ of development and communication breakdown in English, but also the norms of development and communication breakdown in other languages – as well as thorough understanding of the implications of food modification for those with dysphagia.

An SLT must be able to provide personalised and equitable care to all service users who require it, thus understanding each individual’s preferred language, culture, religion, family setup, attitudes toward their health status, beliefs on approaches to play, language or rehabilitation is imperative. Having well-planned, accessible, equitable, and appropriate care pathways, resources, assessment materials and workforce are all essential to mitigating health inequalities.

Therefore, SLTs must develop ‘cultural sensitivity’ and ‘cultural inquisitiveness’ and commit to working reflexively across their careers. SLTs will need to constantly adapt their practices to best meet the communities that they work with.

Specific roles of SLTs

Access to services

• SLTs should consider the impact of services being accessible and especially to potentially under-served groups, for example, do they have the confidence and skills to navigate their local healthcare system; can they travel to them or are there language barriers?
• SLTs are able to help a service user with health literacy, overcoming language barriers and using interpreters where necessary (see RCSLT’s Inclusive Communication guidance and information on Communication Access UK) This can support services to meet the requirements of the Accessible Communication Standard and supporting reasonable adjustments for people with communication impairments.
• SLTs need to assess whether digital poverty is impacting on access to services delivered via telehealth (see RCSLT’s telehealth guidance section on digital inclusion).

Health status

• SLTs can understand any co-occurring health needs and be aware of health needs of particular under-served groups in planning appropriate care.
• SLTs can take account of the prevalence and incidence of clinical conditions in the population in general, and if there is any known research about specific under-served groups.

Quality and experience of care, for example, levels of service user satisfaction

• SLTs can ensure they understand the service user’s experience and social factors that affect them. This can form a part of your initial assessment (see RCSLT guidance on assessment) and could include seeking views from service users in the planning of services, see RCSLT guidance on children’s services for example).
• SLTs can personalise care for individuals from different cultures, ethnicities, family setup, languages and socio-economic situations and intellectual ability from their own.
• SLTs can consider the cross-cultural differences in which families access speech and language therapy services and attend regular appointments, ie, older siblings or elder family members attending with children.
• SLTs recognise that adherence to expert dietary guidelines will vary due to food beliefs and practices which will impact on dysphagia management.
  • At a personal level the service users’ preference, taste, psychological state is considered.
  • At an interpersonal level, the patterns of the household, food preparation and habits of significant others are investigated.
  • At a community level the food availability and prices which could influence the accessibility of modified food and food choices are also taken into account.

Behavioural risks to health

• SLTs can support service users to understand health risks and choices through Reasonable Adjustments to their communication needs.
• SLTs support early years development in their awareness of diverse cultural and social communication environments.
• SLTs can support general health promotion campaigns eg referral to a smoking cessation service for a parent who smokes when discussing their child’s glue ear, through the rapport they develop with service users and their carers eg Make Every Contact Count.

Wider determinants of health

• SLTs can take account of impacts of deprivation and socio-economic inequalities in managing their caseload eg arranging appointments in the community, where the majority of their funding is targeted.
• SLTs can signpost to appropriate services, both in healthcare and non-healthcare eg debt advice.
• SLTs can understand co-occurring intellectual disabilities and the structural barriers people with learning disabilities face in accessing health services, including diagnostic overshadowing and institutional ableism.
• SLTs can consider appropriate ‘did not attend’ policies to take account of ability to attend or language barriers or in planning interventions appropriately taking account of potential service user factors, eg homelessness.
• SLTs can facilitate success in education/employment as protective factors for health by assessing and treating communication disorders.

SLT and service role in collecting and analysing data

• An additional role of the SLT is evaluating and monitoring your caseload to ensure you are aware of the needs of everyone you are serving through your practice. The key to this is collecting data about your service users robustly and routinely.
  • This should include basic information about the service users, eg demographic information such as age, gender, ethnicity and diagnoses (see Equality Act 2010) and outcome measures.
• Data can then be analysed in conjunction with information you have about the local population, and prevalence/incidence of clinical conditions to see if ‘theory’ matches ‘reality’. Collecting data is valuable, but using data is what is powerful.
• The government’s ‘Early Years Health Development Review Report: The Best Start for Life, A vision for the 1001 Critical Days (2021)’ cites that “good quality datasets are essential to identifying and eliminating the greatest inequalities. Reviewing what data is collected and ensuring it is collected in a way that is both efficient and punctual and that it is correctly recorded will make a substantial difference.” (p 101). Read the full government report.
• SLTs can engage with learning from premature deaths and specific current data gathering approaches eg, reporting any death of a child (4 years plus) or person with a learning disability for a review through the Learning Disabilities Mortality Review (LeDeR) programme (LeDeR, 2021) (see the LeDer website)
• Collecting data can sometimes be a sensitive factor for some patients, especially with regard to ethnicity, gender and sexual orientation. The NHS has developed a Sexual Orientation Monitoring Information Standard which you may wish to refer to.

Members can log in to view related RCSLT guidance on:

• Outcome measurement
• Assessing the needs of your local population

Services can also participate in our pilot to explore how gathering additional data might help members meet the needs of the diverse populations they work with.

Summary of the SLT role

Inclusive speech and language therapy

As highlighted earlier in this guidance, whilst the reasons for health inequalities are vast and complex, evidence has shown that discrimination is an important underlying factor that can contribute to health inequalities.

Institutional and implicit bias can result in a lack of equitable and appropriate speech and language therapy thus we have a clear role in mitigating this. SLTs should be providing fair, culturally and linguistically appropriate and inclusive services to all.

To support the profession to do so, the RCSLT and members have produced:

• A self-audit tool to support you and your service to ensure you are meeting the needs of your diverse populations.
• A series of case studies illustrating good practice in delivering quality care to service users’ who may be particularly vulnerable to health inequalities (ie those from typically under-served groups).
• A programme of learning for our profession wide event Anti-racism in speech and language therapy, including:
  • Naomi Ignatius’s video series: Anti-racism in speech and language therapy: What is it like on the ground?
  • Sunita Shah and Dr Sean Pert’s video on bilingualism and cultural diversity.
  • Jo Fillingham’s video on examining the NHS context.
  • Towards cultural competency in dysphagia practice.