CULTURALLY RESPONSIVE PRACTICE: 

PERCEPTIONS AND PRACTICES OF SPEECH AND LANGUAGE THERAPISTS 

IN GHANA 

 

 

 

 
BY: VIVIAN KAETOCHUKWU ASOMBA 

(10874176) 

 

 
THIS RESEARCH DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF 

GHANA, LEGON, IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR 

THE AWARD OF MASTER OF SCIENCE IN SPEECH AND LANGUAGE 

THERAPY 

 

 

 

JANUARY 2023 

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DECLARATION 

 
I, Vivian Kaetochukwu Asomba, do hereby declare that this dissertation which is being submitted 

in fulfillment of the requirements for the award of Master of Science degree in Speech and 

Language Therapy is the result of my own research performed under supervision, and that except 

where otherwise other sources are acknowledged and duly referenced, this work has not previously 

been accepted in substance for any degree and is not being concurrently submitted in candidature 

for any degree. 

I hereby give permission for the Department of Audiology, Speech and Language Therapy to 

seek dissemination/publication of the dissertation in any appropriate format. Authorship in core 

such circumstances to be jointly held between me as the first author and the research supervisors 

as subsequent authors. 

Signed:  Date: 24-Jan-2023  

Vivian Kaetochukwu Asomba  

Signed:   Date: 23-Jan-2023 

Primary Supervisor: Dr. Karen Wylie  

Signed:   Date: 23-Jan-2023  

Secondary Supervisor: Ms. Josephine O. Bampoe  

 

Signed:  Date: 2023 

Head of Department: Dr. Ewurama Ampudu Owusu  

 

 

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ABSTRACT 

 
The profession of speech-language therapy has been growing globally, with training programs 

developing in several majority world countries, including Ghana. However, speech-language 

therapy emanated from western tradition, including beliefs about disability and child-rearing. 

There has been limited investigation into how speech-language therapists from a non-western 

cultural tradition navigate the western foundations of the profession and the cultures within their 

own countries. This qualitative study explored perceptions of speech- language therapists in 

Ghana about the role culture plays in service provision and how they attempt to respond to this 

cultural divide. 

Aim: The aim of this study was to explore the understanding of locally trained speech and 

language therapists (SLTs) about culture; why they think being culturally responsive is 

important; and to explore how they adapt western speech and language therapy practices to 

provide services tailored to the needs of their clients and families. 

Methods: Twelve locally trained Ghanian speech-language therapist were recruited through 

convenience sampling. Semi-structured interviews were conducted. Interviews explored beliefs 

about the importance of culture in speech-language therapy, and the ways in which participants 

incorporated consideration of culture into delivery of services. Data were analyzed using 

Thematic Network Analysis. 

Result: Three interconnected global themes represented the ways participants reported 

understanding and navigating culture to provide culturally responsive services: the centrality of 

culture in constructing a shared understanding of, and response to communication disability; the 

perception of culture as integral to creating a shared understanding; and the constant cultural 

translation/adaption required to make interventions meaningful to families. 

Conclusion: Even though speech-language pathologists in Ghana are ‘local’, the origin of the 

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profession and diversity of clients they support means that consideration of culture is central 

within therapeutic interactions. Considering culture supports speech-language therapists to 

provide services that are meaningful and relevant to people with communication disability and 

their families. 

Learning Outcome: To enhance understanding of the complexity of cultural adaptations 

required by speech-language therapists in majority world contexts. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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DEDICATION 

 
This study is dedicated to God Almighty who is my strength and fortress and to my amazing 

family for their love, support and sacrifices throughout this academic pursuit. Also, to my parents 

late Barrister James Ikechukwu Ezenwata and late Mrs. Marian Njideka Ifeanyi-Ezenwata, for 

laying the foundation of faith, hard work, and tenacity in my life. 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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ACKNOWLEDGEMENT 

 
I thank my father in heaven for his supply of strength, health, protection, and provision 

throughout this academic pursuit. I am immensely grateful to my supervisors, Dr. Karen Wylie 

and Ms. Josephine O. Bampoe, for their intellectual contributions, mentorship, and constructive 

feedbacks throughout the thesis process. I am also thankful to the love of my life, Mr. George 

Asomba for his financial and unrelenting support. Also, to my bundles of joy, Elsy, Kayla, David, 

and Nelly, thank you for being part of this journey. To you my elder sister Ms. Genevieve 

Ezenwata, thank you for your emotional and financial support, I love you ‘big-big” also to my 

younger sister, Mrs. Chika Ezeh, my step-brother, Agoziem, and my nanny, Mama Peace, as well 

as all my amiable friends/acquaintances whom I could not name due to space constraint, thank 

you all for your care and prayers  

I say a very big thank to all the speech-language therapists in Ghana, particularly those who 

participated in this study, thank you for giving your time and contributing to this work, may God 

almighty bless you richly in Jesus’ name, Amen. I would also like to thank the entire faculty 

member of the department of Audiology, Speech and Language Therapy, School of Allied 

Health, especially the H.O.D Dr. Ewurama Owusu, Ms. Nana-Akua Owusu, Mr. Clement 

Amponsah, for their contributions and advice towards this research work. To the SLT team at 

Korle-Bu Teaching Hospital, I say thank you for all your support and mentorship throughout my 

placements and for allowing me to leverage your networks to gain the support needed for the 

completion of this masterpiece. More so, to my classmates, especially Stella Ayivor and 

Emmanuel Addo, thank you for sharing your perspectives and gearing me up to the finish line. 

Finally, to all my mentors, particularly Prof. B. M. Mbah, Dr. Maazi Ebekue Chukwuma Okeke 

of the Linguistics Department, University of Nigeria Nsukka, and Ms. Eniola Lahami – thank you 

for being an excellent role-model. 

 

.   

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TABLE OF CONTENT 

 

DECLARATION .............................................................................................................................................. i 

ABSTRACT ..................................................................................................................................................... ii 

DEDICATION ................................................................................................................................................ iv 

ACKNOWLEDGEMENT .............................................................................................................................. v 

TABLE OF CONTENT ................................................................................................................................. vi 

LIST OF FIGURES ...................................................................................................................................... viii 

LIST OF TABLES .......................................................................................................................................... ix 

LIST OF ABRIVIATIONS ............................................................................................................................. x 

CHAPTER ONE .............................................................................................................................................. 1 

INTRODUCTION ........................................................................................................................................... 1 

1.1 CULTURAL RESPONSITIVITY AND THE ROLE OF CULTURE IN SLT ............................... 1 

1.2 PROBLEM STATEMENT ................................................................................................................... 3 

1.3 SIGNIFICANCE OF STUDY .............................................................................................................. 3 

1.4 AIM/PURPOSE/GOAL OF THE STUDY .......................................................................................... 3 

1.5 SPECIFIC OBJECTIVES .................................................................................................................... 4 

1.6 RESEARCH QUESTIONS .................................................................................................................. 4 

CHAPTER TWO ............................................................................................................................................. 5 

LITERTURE REVIEW .................................................................................................................................. 5 

2.1 FOUNDATIONAL SLT PROFESSION PRACTICES ..................................................................... 5 

2.2 LANGUAGE DEVELOPMENT IN CHILDREN AND IMPLICATIONS OF SLT PRACTICES 

IN MULTILINGUAL CHILDREN ............................................................................................................... 7 

2.3 CULTURALLY RESPONSIVE PRACTICES .................................................................................. 9 

2.4 THEORETICAL FRAMEWORKS .................................................................................................. 10 

CHAPTER THREE ....................................................................................................................................... 12 

METHODOLOGY ........................................................................................................................................ 12 

3.1 INTRODUCTION ............................................................................................................................... 12 

3.2 STUDY SITES ..................................................................................................................................... 12 

3.3 STUDY DESIGN ................................................................................................................................. 12 

3.4 STUDY POPULATION ...................................................................................................................... 12 

3.5 SAMPLING SIZE AND TECHNIQUE ............................................................................................ 13 

3.6 INSTRUMENT FOR DATA COLLECTION .................................................................................. 15 

3.7 PROCEDURE FOR DATA COLLECTION .................................................................................... 15 

3.8 ETHICAL CONSIDERATION ......................................................................................................... 16 

3.9 DATA MANAGEMENT AND ANALYSIS ...................................................................................... 16 

3.10 TRUSTWORTHINESS ...................................................................................................................... 19 

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CHAPTER FOUR ......................................................................................................................................... 21 

RESULTS ....................................................................................................................................................... 21 

4.1 INTRODUCTION ............................................................................................................................... 21 

4.1.1 . Thematic Network: Global Theme 1. Culture is a way of life that influences what we know about 

the world and how we interact with it. ........................................................................................................ 22 

4.1.1.1 Organizing Theme 1.1. Knowing About the World .................................................................... 23 

4.1.1.2 Organising Theme 1.2. Doing: A Demonstration of Culture ..................................................... 24 

4.1.2 Thematic Network: Global Theme 2. Culture is Integral to Creating a Shared Understanding. 25 

4.1.2.1 Organizing Theme 2.1. Culture Influences How Clients and Families Respond to Speech and 

Language Therapy Services .......................................................................................................................... 26 

4.1.2.2 Organizing Theme 2.2. Cultural Understanding Supports Clinical Reasoning In SLT .......... 29 

4.1.3 Thematic Network: Global Theme 3. SLTs Attempt to Use Their Cultural Understanding of 

Clients and Families to Make Clinical Practices Culturally Responsive .................................................. 32 

4.1.3.1 Organizing theme 3.1. SLTs develop and use cultural understanding about families as part of 

their clinical reasoning and decisions. ......................................................................................................... 33 

4.1.3.2 Organizing theme 3.2. SLTs attempt to use tools and resources they see as relevant to the 

child and the family’s culture (resources) ................................................................................................... 38 

4.1.3.3 Organizing theme 3.3. SLTs Use Their Understanding of a Family’s Culture to Develop 

Therapeutic Relationships ............................................................................................................................ 42 

CHAPTER FIVE ........................................................................................................................................... 46 

DISCUSION ................................................................................................................................................... 46 

5.1 INTRODUCTION ............................................................................................................................... 46 

5.2 DEFINING CULTURE (KNOWLEDGE) ........................................................................................ 46 

5.3 PERCEPTIONS OF THE IMPORTANCE OF CULTURAL RESPONSIVITY (ATTITUDE). 47 

5.4 BEING CULTURALLY RESPONSIVE IN PRACTICE (BEHAVIOUR) ................................... 50 

CHAPTER SIX .............................................................................................................................................. 55 

CONCLUSION, LIMITATIONS AND RECOMMENDATION ............................................................. 55 

6.1 INTRODUCTION ............................................................................................................................... 55 

6.2 CONCLUSION .................................................................................................................................... 55 

6.3 LIMITATIONS ................................................................................................................................... 55 

6.4 RECOMMENDATION ...................................................................................................................... 56 

REFERENCE ................................................................................................................................................ 57 

APPENDICES................................................................................................................................................ 64 

APPENDIX I: RECRUITMENT FLIER .................................................................................................... 64 

APPENDIX II: INFORMATION SHEET .................................................................................................. 65 

APPENDIX III: INFORMED CONSENT FORM ..................................................................................... 68 

APPENDIX IV: INTERVIEW TOPIC GUIDE ......................................................................................... 69 

APPENDIX V: ETHICAL CLEARANCE .................................................................................................. 74 

APPENDIX VI: COREQ (CONSOLIDATED CRITERIA FOR REPORTING QUALITATIVE 

RESEARCH) CHECKLIST REPORT ....................................................................................................... 75 
 

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LIST OF FIGURES 

 
Figure 1 - Structure of a thematic network 

Figure 2 - Thematic network: Global Theme 1  

Figure 3 - Thematic network: Global Theme 2  

Figure 4 - Thematic network: Global Theme 3 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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LIST OF TABLES 

 

Table 1 - Demography of participants 

Table 2 - Thematic networks: Global, Organizing and Basic themes 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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LIST OF ABRIVIATIONS 

 
ASHA - American Speech Language and Hearing Association  

SLT - Speech and Language Therapy/Therapist 

CRP - Culturally Responsive Practice  

LMICs - Low-middle income countries 

AHPC - Allied Health Professions Council of Ghana 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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CHAPTER ONE 

INTRODUCTION 

This chapter provides an overview of western epistemological foundation of speech and language 

therapy profession, the role of culture in delivery of speech-language therapy and the need for 

culturally responsive practice. Additionally, it describes the Ghana context, the problem statement, 

significance of the study, aims and objectives of the study.  

1.1 CULTURAL RESPONSITIVITY AND THE ROLE OF CULTURE IN SLT   

Culturally responsive practice (CRP) is the ability of health providers and organizations to deliver 

health care services that meet the cultural, social, and religious needs of patients and their families, 

(Swihart, Yarrarapu, & Martin, 2022). CRP is an important consideration guiding practice within the 

speech-language pathology profession (ASHA, 2004) which allows speech-language therapists 

(SLTs) to provide services with an understanding, appreciation, and respect for the unique cultural 

and linguistic attributes of the individuals they serve (Leininger, 2002; Sue, 2001). Historically, most 

of the speech-language therapy profession throughout the English-speaking world is built upon a 

foundation of ‘White’ cultural perspectives (Hopf, Crowe, Verdon, Blake, & Mcleod, 2021). As such, 

the values, cultural expectations including childrearing practices, conception of disability (Pillay & 

Kathard, 2015; Wylie et al., 2017; 2020) and linguistic norms of the western world have become 

inherent in the practices of the speech-language therapy profession (Farrugia-Bernard, 2018).  SLT 

practices for example, in United States, Canada and Australia are premised on monolingual English 

Language Speakers (Staley, Hickey, Rochus, Musasizi, & Gibson, 2021), which results in mismatch 

between the “linguistic homogeneity of the profession and the linguistic diversity of its clientele” 

(Caesar & Kohler, 2007). Pillay and Kathard, (2015) suggested that culturally responsive practice is 

critical when implementing practices with families where beliefs and practices may differ to the 

western origins of the interventions.  

Ghana is an example of one such country where the profession of speech and language pathology, 

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has been introduced, but the families receiving services may have differing childrearing and disability 

beliefs to those upon which many treatments are grounded. Ghana is a multilingual society and has 

about eighty languages and around 75 ethnocultural/native (The Bureau of Ghana Languages- BGL, 

2013).  It is a tropical country situated along the Gulf of Guinea coast, (World Bank, 2021) with Accra 

as its capital. The population of Ghana is approximately 31 million people (World Bank, 2021) of 

which 1 in 15 may have a communication disability (Hudson et al., 2020).  

Recent establishment of local SLT training and licensure of SLTs by the Allied Health Professions 

Council (AHPC), are contributing to the growth of the profession in Ghana (Owusu, 2016) with about 

35 practicing SLTs across the country presently (Ghana Gazette, 16th July, 2021). Currently, the 

University of Ghana receives external support from SLTs in the UK, Australia, and USA, (Hudson et 

al., 2020). This may likely embed further proliferation of western knowledge and practices in the 

speech-language therapy profession in Ghana. Wylie et al. (2017, 2020) pointed that in Ghana, as in 

much of Sub-Sahara Africa, Eurocentric approaches to the management of disease and disability have 

been adopted. Therefore, cultural responsiveness is a vital practice necessary to mitigate these 

disparities faced by non-mainstream culturally and linguistically diverse communities with 

communication disorders.  

Adapting traditional speech pathology professional practices is also warranted in high-income 

western countries when providing services to multicultural and multilingual communities. In the 

United States, Maul (2015) investigated perceptions and practices of SLPs regarding modifications 

of usual practices when interacting with culturally and linguistically diverse clients. Findings show 

that languages spoken, and working with interpreters, are barriers, while respect for cultural 

differences, positive interaction with family members aided culturally responsive practice. In Ghana, 

it is unclear to what extent Western practices or other more culturally relevant practices are being 

used. Since locally trained SLPs have been licensed to practice across the country, this qualitative 

research investigates how western resources and approaches are adapted to suit the needs, beliefs, 

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and values of the local families they serve.  

1.2 PROBLEM STATEMENT 

Speech and language therapy profession is underpinned by western belief (Pillay & Kathard, 2015). 

SLT practices for example, in United States, Canada and Australia are premised on monolingual 

English language speakers and pediatric intervention in speech-language therapy profession are 

founded on western perspectives on child development or rearing (Staley et al., 2021). It is vital for 

the profession of SLT in majority world countries, to develop in culturally and contextually relevant 

way (Pillay & Kathard, 2015). Part of the cultural imperative is to ensure that SLTs working in 

Majority World contexts engage in culturally responsiveness to provide appropriate services rather 

than trained merely to provide technical skills in a predetermined way” (Wickenden, Hartley, 

Kariyakaranawa, & Kodikara, 2003). However, since the inception of the SLT profession in Ghana, 

there has been no investigation to know to what extent Western practices or other more culturally 

relevant practices are being used when interacting with persons with communication disability and 

their families in Ghana.  

1.3 SIGNIFICANCE OF STUDY  

This study provides information on (1) the understanding of SLTs about culture and the specific culture 

of the client and their family and (2) how Ghanian SLTs adapt western oriented practices to make 

them responsive to local cultures. This information will be used to shape education for SLTs in Ghana 

in the future. Ultimately, this may support the development of assessment and intervention 

techniques that are culturally relevant for individuals with communication disability in Ghana.  

1.4 AIM/PURPOSE/GOAL OF THE STUDY 

The aim of this study is threefold: 

 

• To explore what Ghanaian SLTs understand as culture 

 

• To explore the SLTs perceptions of culturally responsivity 

 

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• To explore how SLTs describe adapting western speech therapy practices to deliver culturally 

responsive services. 

1.5 SPECIFIC OBJECTIVES 

 

Specifically, the study will: 

 

• Investigate how currently practicing SLTs in Ghana define culture (knowledge). 

• Describe the perceptions of SLTs in Ghana about the importance of cultural responsivity 

(attitude). 

• Investigate how SLTs in Ghana report adapting western SLT practices when providing 

services to persons with communication disability and their families within the Ghanaian 

context (behavior). 

1.6 RESEARCH QUESTIONS 

 

• How do currently practicing SLTs in Ghana define culture (knowledge)? 

• What are the perceptions of SLTs in Ghana about the importance of cultural responsivity 

(attitude)? 

• How do SLTs in Ghana report adapting western speech therapy practices when providing 

services to persons with communication disability and their families within the Ghanaian 

context (behavior)? 

 

 

 

 

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CHAPTER TWO 

LITERTURE REVIEW 

 

2.1 FOUNDATIONAL SLT PROFESSION PRACTICES  

Cultural Foundations and Implication for SLT Practice 

The profession of speech and language therapy (SLT) is conceptualized on epistemologies and 

theories developed around white middle class experiences and understandings of the world (Hyter, 

2022; Pillay & Kathard, 2018). As a result, cultural expectations, and linguistic norms of the white, 

have become embedded in the practices of the profession across the globe (Hopf et al., 2021), which 

does not reflect the linguistic and cultural diversity of the population in Majority world countries 

(Pascoe & Norman, 2011). Culture consists of the ‘learned, shared, and transmitted values, beliefs, 

norms, and lifeways of a particular group that guides their thinking, decisions, and actions in patterned 

ways’ (Leininger, 1991). Culture involves both explicit variables such as food, clothing, language, 

and implicit variables, including ‘age and gender roles within families, child-rearing practices, 

religious and spiritual beliefs, educational values, fears, and attitudes’ (Battle, 2011). Several 

researchers (Mcleod et al., 2017; Semela, 2001; Wegner & Rhoda, 2015) have discussed the 

influences of culture on family’s values, religion, language preference, kin structure, child-rearing 

practices, roles and responsibilities of family members and perception of health and the perception of 

disability. Nonetheless, Eurocentric beliefs continue to underpin many speech-language 

interventions, such as western parenting approaches including parent-child style of play (Pillay & 

Kathard, 2015; Wylie et al., 2017). Programs that utilize Parent-Child Interaction (PCI), such as the 

Hanen program (Johnson, 2013; Klatte Harding, & Roulstone, 2019) are also based upon assumptions 

that parents are the child’s primary caregiver and that the family values the child being talkative. 

These beliefs are not necessarily shared or accepted by families from other countries (Kleeck, 1994). 

For example, In Ghana, children are expected to show respect for their elders and listen respectively 

(Nyarko, 2014). It is necessary that SLTs working with clients and families from culturally and 

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linguistically diverse community or country to understand that clients may possess culturally based 

world views which may differ from theirs (Eckermann et al., 2010) and/or from their professional 

recommendations (Kenny, Lincoln, & Balandin, 2010), to ensure appropriate holistic care and client-

centered practice (Mathisen et al., 2015). 

Linguistics Foundations and Implications for Practice 

Linguistic knowledge of communication and its disorders are also derived from Indo-European 

languages such as English, French, German (Pillay, 2003) and this knowledge underpins judgments 

of ‘normality’ by SLT professionals. Important questions to consider are whether each individual-

client has their performance compared with the norms of a population that is representative of them, 

and whether norms used are truly representative of overall abilities of the population (Pascoe & 

Norman, 2011)? For example, a study conducted by Stanczak, Stanczak, & Awadalla (2001) found 

that typical Sudanese adults attained scores on the Arabic version of the Expanded Trail Making Test 

that were like those attained by US adults with brain damage. Bedore, Lisa, Peña, & Elizabeth (2008) 

further noted, that lack of understanding of what can be expected of young dual language learners in 

children may lead specialists to interpret bilingual children language performance as symptomatic of 

delay or even impairment when, in fact, it is typical of dual language learning. In addition, issues of 

determining language difference and or disorders in assessment findings is also an example of 

challenges posed by linguistics homogeneity of speech therapy profession (Smith, Summers, Mueller, 

Carillo, & Villaneda 2018). This is evident that culture, and familiarity with the type of testing 

material (Carter et al., 2005) and language development environments (Bedore et al., 2008) can 

influence performance outcomes. 

The linguistic homogeneity of SLT profession also poses a challenge when the same ideas are 

addressed in another culture in speech therapy intervention strategies. Vocabulary, stereotypical 

concepts, high-frequency words, body language and gestures differ between cultures and languages 

(Pascoe & Norman, 2011). For instance, a well-recognized therapeutic strategy such as cuing words 

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using the initial consonant sound as for English (Greenwood, Grassly, Hickin, & Best 2010) may 

not work well with languages which typically begin with a vowel sound (Gxilishe, 2011).  

In addition, one-on-one individual therapy approaches that historically informed the work in speech 

therapy may result in services that are inaccessible, unaffordable, and unattainable in countries in Sub 

Sahara Africa such as Ghana (Abrahams, Kathard, Harty, & Pillay, 2019.; Wylie, Bampoe, 

Amponsah, & Owusu, 2016) due to socio-contextual factors. Given the multicultural and multilingual 

characteristics and peculiar social context of the Ghanaian society, these existing health and 

educational disparities faced by non-mainstream culturally and linguistically diverse communities 

with communication disorders are equally evident. 

2.2 LANGUAGE DEVELOPMENT IN CHILDREN AND IMPLICATIONS OF SLT 

PRACTICES IN MULTILINGUAL CHILDREN  

Language is a social phenomenon and is inextricably linked with cultural identity (Al-Harbi, 2019.; 

Paradis, Genesee & Crago 2011). Physical immersion in a particular linguistic environment and 

interaction has a significant role in language acquisition, (Al-Harbi, 2019.; Paradis, et al., 2011,) 

Children begin to acquire the language in their environment in the first three years of life, progressing 

through key stages of language development, (De Keyser & Larson-Hall, 2005).  

The first stage of language acquisition in children is their innate predisposition for vocalization. In 

this stage children babble and coo, primarily, to exercise the articulatory organs in an experimentally 

random and playful manner, typically occurs in the first 6-months of life (Tomasello & Bates, 2001). 

The language (s) that the caregiver(s) use is the primary linguistic environment from which children 

acquire their language. According to Lieven and Tomasello (2008), between the ages of six to nine 

months children begin to babble in a pattern that is like the patterns of adult speech. At first, what 

predominates are nasal /m/, /n/ and /ng/ as well as the voiced stops /b/, /d/ and /g/. Children then 

progress to the one-word stage around the age of 1 (Lieven & Tomasello, 2008). At this stage, children 

use only one word (including made-up words) to refer to random things and, at times, to substitute 

for a complete sentence. For example, toddlers in this stage may imply “I am hungry” by saying “eat”. 

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Also, vocabulary acquired at this stage tend to be concrete words (e.g., ‘car’ and ‘ball’). By the age 

of 1 year and 8 months, the two-word stage begins, during which children begin to represent an entity 

with two words, albeit without morphological and syntactic markers, but with a unique word order. 

For example, the utterance “dada chair” could mean “dad is sitting on the chair,” “that’s my dad’s 

chair” or “Dad, could you put me on the chair?” The next stage of language development as stipulated 

by Lieven and Tomasello (2008) is the telegraphic stage which occurs between the ages of 2–2½ 

years. In this stage, children may only say about 50 words, and use rudimentary sentences, that is, 

word series without grammar. For example, a child may say to her mother “I good girl, but can 

understand many more complex sentences. This process of language development continues to 

puberty and is considered a critical period of language acquisition (Spada, & Lightbown, 2004)   

Bilingual children, particularly those who acquire two languages from birth (simultaneously) are 

found to acquire their target languages in correspondence, with their same-age monolingual children 

(Bedore, et al., 2008; Paradis et al., 2011). However, there is heterogeneity in language experiences 

or skills among young bilingual children which makes it possible for them to lag behind monolingual 

children of the same age, particularly in vocabulary and grammatical development when each 

language is measured separately (Hoff, & Core, 2013). This variability among young bilingual 

children further makes it virtually impossible to identify a single reference group for standardized 

testing of bilingual children (Thordardottir., Rothenberg., Rivard., & Naves, 2006). Yet, standardized 

tests are generally required for establishing language disability and to differentiate language disorders 

from language difference in young bilingual children. Further, it is well established that using 

monolingual norms to assess one of a bilingual child’s languages offers a limited view of language 

development, a practice, that results in an underestimate of bilingual children’s overall language 

knowledge, and over-identifies children at risk for language impairment (Thordardottir, et al., 2006). 

It is generally recommended that bilingual children be assessed in both of their languages. However, 

specific procedures for such bilingual assessment and for interpretation of the results are lacking 

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(Thordardottir, et al., 2006). Refining the notion of typical vs impaired language, as well as addressing 

the issues of determining language difference and or disorders in assessment findings (Smith et al., 

2018), requires that SLTs understand the cultural and appropriate language development expectations 

(Bedore et al, 2008), of the children they support. 

2.3 CULTURALLY RESPONSIVE PRACTICES 
 

Abrahams et al. (2019) assert that traditional SLT practices are a project of coloniality and argues the 

need to question, critique and rethink these professional practices. This requires the speech and 

language therapist to engage in reflexive, culturally responsive practice, in order to consider how to 

more effectively engage with individuals with communication difficulties and their families to achieve 

the best possible outcomes (ASHA, 2014). Verdon (2020) noted that therapeutic relationships and 

mutual understanding with families are an important part of engaging in culturally responsive 

practice. According to Melvin, Meyer, and Scarinci, (2020), engagement is enhanced when: “1) 

engagement is both a state and a process; 2) parents are supported to engage with intervention when 

they build trusting relationships with speech-language therapist; 3) parents are supported to engage 

with intervention when open, two-way communication is established; and 4) parents are supported to 

engage in intervention when speech-language therapists work together with them in sessions” 

(p.2665). Nyantakyi and Oetting, (2023), suggested that being responsive to the various culturally 

diverse needs of Ghanaians helps the SLT to efficiently partner with clients and their families. 

Nyantakyi and Oetting, (2023), described three culturally responsive strategies including empathy, 

affirmation, and additive or complementary expertise used regularly by SLT’s in serving the diverse 

multi- ethnic population of Ghana. Being culturally responsive is complex and requires a range of 

skills, attitudes, and processes. In 2015, Verdon, McLeod, & Wong developed six principles of 

culturally competent practice. These include: (1) identification of culturally appropriate and mutually 

motivating therapy goals, (2) knowledge of languages and culture, (3) use of culturally appropriate 

resources, (4) consideration of the cultural, social, and political context, (5) consultation with families 

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and communities, and (6) collaboration between professionals. While the term culturally competent 

has been largely replaced by the term culturally responsive, the principles continue to be relevant to 

everyday clinical practice. Zingelman, Pearce, & Saxton (2021) also, explored the perceptions of 

speech-language therapists with regards to culturally responsive service delivery and assessment 

practices, when working with Aboriginal and Torres Strait Islander children in Australia. They 

identified insufficient knowledge, training, and experience as a major barrier to the SLTs’ skills to 

cultural responsiveness. Other barriers included the impacts of colonization, accessibility, and policy. 

Critiquing the service provision model in western Kenya, Staley et al. (2021), investigated the 

successes and challenges of speech and language therapy delivery using Hyter’s (2014) framework 

for responsive cultural engagement, by examining three clinical case studies. Their study illustrated 

that services designed with local knowledge, away from the direct one-on-one model of care that is 

common in the minority world, may be a better way to deliver a more valid, relevant, and culturally 

acceptable practice, that is tailored specifically to the cultural context of the individual and the 

community. 

Insights from above empirical studies, particularly Staley et al. (2021) and Zingelman et al. (2021) show 

that indeed foundational practices in the SLT profession can frustrate delivery of services that are 

culturally responsive, valid, and relevant. Therefore, considering the unique multilingual and 

multicultural Ghanaian communities, few trained SLTs and limited structures to support the emerging 

speech and language profession in Ghana, it is timely and crucial to explore the perspectives and 

practices speech therapists in Ghana engage in meeting the needs of individuals with communication 

disability as informed by the specific dynamics of their client’ context. 

2.4 THEORETICAL FRAMEWORKS  

Valente, Paredes, and Poppe, (1998), noted that actions and activities of individuals are influenced 

by a complex mix of what they believe (their attitude), what they know (their knowledge) and how 

they enact this (their behavior). Thus, in exploring the perceptions and the practices of SLTs in Ghana 

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about culturally responsivity, we employed Schrader & Lawless’ (2004) framework of knowledge, 

attitudes, & behaviors, in framing the questions. The findings were also framed using the Verdon et 

al. (2015) six principles of culturally competent practice. The use of this framework enabled a clear 

interpretation of the ways that the overarching principles are enacted in Ghana, which represents a 

unique, social, cultural, and political context.  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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CHAPTER THREE 

METHODOLOGY 

 

3.1 INTRODUCTION 

This chapter discusses the method used in this study This includes the study setting and research 

design; participants and inclusion or exclusion criteria for participation; sampling methods; data 

collection procedures; the instrument used and data analysis and interpretation processes. 

3.2 STUDY SITES 

The study was conducted in Ghana, with participants located within Accra the capital and outside of 

Accra. These participants worked either at hospitals, inclusive mainstream schools or in non-

governmental organizations that cater for people with disability. Participants were able to be 

interviewed in places convenient for them, or opted for online or telephone interviews. Data was 

collected from participants in places that were convenient for them. Three (n=3) interviews were 

conducted at the participants place of work while nine (n=9) others were conducted via online Zoom 

meetings. 

3.3 STUDY DESIGN 

This study used a qualitative descriptive design to explore the knowledge, attitudes, and behaviors of 

SLTs about culturally responsive practice in speech and language therapy (Chafe, 2017; Sandelowski, 

2000, 2010). Qualitative description was considered relevant to the enquiry as it allows consideration 

of experiences and perceptions (Creswell, 2007; Sandelowski, 2000, 2010) enabling the researcher to 

gain a deeper understanding of the phenomenon under investigation (Doyle, McCabe, Keogh, Brady, 

& McCann, 2020). Descriptive research design is a highly relevant approach to explore clinical issues 

that can contribute to change and quality improvement in practice settings (Chafe, 2017). 

3.4 STUDY POPULATION 

The study population was Ghanaian trained speech and language therapists currently working with 

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children with communication disability in Ghana. 

Inclusion Criteria 

 

This study sought to understand the experiences and perspectives of the new workforce of 

Ghanaian speech and language therapists. To be eligible to participate in the study, participants 

were required to: 

• have received university qualification in speech and language therapy within Ghana. 

 

• be licensed as a speech and language therapist by the Allied Health Professions Council of 

Ghana at the time of the interview. 

 

• be working as a speech and language therapist in Ghana at the time of the interview. 

 

• be Ghanaian nationals. 

 

• have at least 1-year post-graduation work experience. 

 

Exclusion Criteria 

 

Participants were excluded from this research if: 

 
• they received university qualifications in speech and language therapy outside of Ghana 

 

• they did not meet the inclusion criteria. 

 

3.5 SAMPLING SIZE AND TECHNIQUE 

Twelve (12) speech and language therapists participated in this study. Sample size in qualitative 

research is often small, given the deep, detailed analysis that is central to its practice (Hennink & 

Kaiser, 2022).  Furthermore, speech and language therapy in Ghana is a very small profession with 35 

SLTs currently registered with the (AHPC) of Ghana (Ghana Gazette No. 66, 2022). The sample size 

represents just over one-third of the population of SLTs in Ghana. Small sample sizes in interview-

based research, reflective of numbers in this study have been shown to produce saturation (Hennink, 

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Kaiser, & Marconi, 2017). 

Participants were recruited using convenience sampling allowing the researcher to invite participants 

that are opportunistically available about access, location, time, and willingness (Lopez & Whitehead 

2013).  Recruitment Flyers (Appendix I) were distributed to speech and language therapists in Ghana, 

using the personal networks of the student researcher and supervisors to inform SLTs in Ghana about 

the study. Interested parties contacted the student researcher. The Participant Information Sheet 

(Appendix II) and consent forms (Appendix III) that described the study in detail, were provided. If 

consent forms were signed and returned, interview times were scheduled with each participant and 

conducted by the student researcher. Characteristics of these participants including information 

regarding age, language(s) they speak fluently, type of degree, the location where they work etc. are 

represented in the table below. All the participants are multilingual with English and Twi as mostly 

spoken languages. The participants were between the ages of 20-49 with 11 of the 12 participants 

working in greater Accra and with children living with speech and language disorder. 

Table 1. Demography of participants 
 
Participant Age Languages 

Spoken 

Year of 

Graduation 

University 

A;ended 

Degree 

Earned 

Work 

Location 

Work 

Organization 

Work Client Group 

P-001 20-29 English, Twi, 2020 UG MSc Outside 
Accra 

Hospital Speech Disorder, 
Language Disorder 
Multimodal 
Communication 
Voice, Stammering 

P-002 30-39 English, Twi 2017 UHAS BSc Accra School Speech Disorder, 
Language Disorder 
Multimodal 
Communication 
Voice, Stammering 

P-003 30-39 English, Twi 2018 UG MSc Accra Hospital, 
School 

Speech Disorder, 
Language Disorder 
Multimodal 
Communication 
Voice, Stammering 

P-004 30-39 English, Twi 2018 UG MSc Accra Hospital, 
School 

Speech Disorder, 
Language Disorder 
Stammering, Cleft 

P-005 20-29 English, Twi, 
Hausa 

2020 UG MSc Accra Hospital Speech Disorder, 
Language Disorder, 
Stammering, AAC 

P-006 20-29 English, Ewe 2019 UHAS BSc Accra Hospital, 
School 

Speech Disorder, 
Language Disorder, 
AAC 

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P-007 30-39 English, Twi, 
Ga, Ewe 

2018 UG MSc Accra Hospital Speech Disorder, 
Language Disorder, 
Voice, Head & Neck, 
Stammering 
Dysphagia 

P-008 20-29 English, Twi, 
Ga, Fanti, 
Dagbani 

2018 UHAS BSc Accra School Speech Disorder, 
Language Disorder, 
Stammering 
Dysphagia, AAC 

P-009 30-39 English, Twi, 
Ga, Ewe 

2018 UG MSc Accra Hospital Speech Disorder, 
Language Disorder, 
Dysphagia, AAC, Cleft 

P-010 30-39 English, Twi, 
Ga 

2020 UG MSc Accra School Speech Disorder, 
Language Disorder, 
Stammering, AAC 

P-011 40-49 English, Twi, 
Ewe 

2020 UG MSc Accra Hospital Speech Disorder, 
Language Disorder, 
Stammering, AAC, 
Cleft 

P-012 40-49 English, Twi, 
Fanti 

2018 UG MSc Accra Hospital, 
School 

Speech Disorder, 
Language Disorder, 
Stammering, AAC, 
Cleft 

 

3.6 INSTRUMENT FOR DATA COLLECTION 

Semi-structured interviews were used to collect data, giving participants the opportunity to represent 

their ideas using own words (Schutt, 2018). Semi-structured interviews are useful in exploring a 

person’s beliefs, experiences, and perspectives (Bachman & Schutt, 2020). A purpose-designed topic 

guide (Roberts, 2020; Tong et al., 2007), (Appendix IV) based on key concepts from previous 

literature and developed in collaboration with research supervisors, according to the principles 

developed by Roberts (2020), was used to guide questioning to enable consistency in interview 

processes. Basic demographic information, listed in the topic guide (Appendix IV) was collected as 

part of the interview questioning. The ability to describe the sample is important in qualitative 

research to ensure transparency, and promote rigor (Tong et al., 2007). 

3.7 PROCEDURE FOR DATA COLLECTION 

In-depth interviews were conducted from 5th October to 31st October 2022, with each of the twelve 

(12) participants. Participants selected dates and settings that were convenient for them. Each 

interview took between 30-45 minutes. All interviews were conducted in English language for 

consistency. Interviews were recorded, with consent, to enable accurate transcription and data 

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analysis. Responses were transcribed verbatim, and coding commenced concurrently with data 

collection. Concurrent data collection and coding is vital to review if data saturation is occurring 

(Tong et al., 2007). 

3.8 ETHICAL CONSIDERATION 

Permission to carry out the study was sought from Ethics and Protocol Review Committee (EPRC) 

of the School of Biomedical and Allied Health Sciences (SBAHS), to ensure all ethical protocols were 

addressed. Approval was granted on the fifteenth (15th) of September 2022 

(SBAHS/AA/ASLT/10874176/2021-2022). Thus, this study adhered to the ethical standards 

(APPENDIX V), provided by the EPRC of SBAHS of the University of Ghana. 

Prior to data collection, the researcher provided clear information about the study to the participants 

and sought voluntary informed consent for participation. Participants were informed that they could 

opt out at any point during the study without any reason and consequences. The researcher ensured 

anonymity of participants' identities and the confidentiality of their personal data. Interviews were 

held in a private location. Participant IDs rather than identifying information were used on all 

transcripts. Only the research team had access to the transcripts. All publications, including the 

thesis, did not contain identifying information. The researcher also ensured that participants were 

not exposed to any form of harm as a result of undertaking this study. Light refreshments such as 

water, soft drink and biscuits were provided to participants who opted for face-to-face interview after 

the interview session. A summary of findings of this research will be made available to all SLTs in 

Ghana, including participants. It is anticipated that this information may be beneficial to their clinical 

decision making when working with families or persons with communication disability from diverse 

backgrounds 

3.9 DATA MANAGEMENT AND ANALYSIS 

Audio recorded data were transferred to a computer immediately following data collection. All 

original audio and transcription files were password protected and backed up regularly. Hard copies 

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of documents, such as printed transcripts were stored in a locked cabinet. Thematic Network Analysis 

(TNA) (Attride-Stirling, 2001) was used to analyze the data and develop a map of key ideas or themes 

represented in the data. Thematic Network Analysis aims to “explore the understanding of an issue 

or the signification of an idea, rather than to reconcile conflicting definitions of a problem” (Attride-

Stirling, 2001, p.387). Thematic Network Analysis uses six analytic phases to enable consistency and 

transparency in theme development (Goldbart & Marshall, 2014; Hersh et al., 2021).  

The six steps of TNA (Attride-Stirling, 2001) used to develop themes and theme relationships were 

as follows: 

1. Coding the material: Data were imported and coded using NVivo software (QSR 

International, 2022). The text was broken up into manageable and meaningful segments. 

Inductive coding (Skjott, Linneberg & Korsgaard, 2019), with codes representing meaning 

embedded within the transcripts, was used to undertake preliminary coding of 33% of the 

sample (four interviews). Codes represented key ideas linked to the three research objectives – 

knowledge of culture, importance of culture to clinical practice and processes used by SLTs 

to respond to culture. A preliminary coding framework was developed and revised iteratively 

during coding of the remainder of the data. Each code had explicit boundaries (definitions), 

and codes were not interchangeable or overlapping. No new codes were developed in the last 

three interviews, indicating saturation was likely to be reached. 

2. Theme identification: Next, coded segments of text were repeatedly read, re-read, and 

reviewed to begin to extract key ideas, looking for underlying patterns. Preliminary themes 

were drafted and refined, gradually building key ideas into basic or key themes. This iterative 

process helped to reduce the data to a series of meaningful themes representing key ideas 

within the text, that related to the research objectives. 

3. Construction of the thematic networks: A thematic network is developed starting from the 

Basic Themes and working inwards toward a Global Theme. The basic themes identified 

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provide the fountainhead for the thematic networks. The following process was used. 

• Basic Themes: Codes were reviewed and grouped into preliminary Basic Themes, 

representing a central idea. Basic themes were reviewed and revised, reflecting content 

from the coded segments. Basic themes are the lowest-order theme derived. 

• Organizing Theme: Basic Themes were clustered into similar issues, drawing together 

key notions within the grouped Basic Themes. Names were generated and refined by 

the wider research team. Organizing themes are more abstract than basic themes and 

more revealing of what is going on in the texts. 

• Global Theme: Global Themes are super-ordinate themes that draw together the key 

ideas in the data. Organizing Themes reviewed and grouped considering their 

constituent Basic Themes, and brought together to illustrate a single conclusion about 

the research questions. Once the Global Themes were developed and reviewed by the 

team, the thematic networks (linking together basic, organizing, and global themes) 

were presented graphically. 

 

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Figure 1: Structure of a thematic network 

4. Describing the thematic network: Once the thematic networks were refined, the student 

researcher described the networks in text. This is presented in the results section of the thesis, 

supported by illustrative quotes from the original transcripts/data to support the analysis.  

5. Summarizing thematic networks:  A summary of the themes within each network, and links 

to relevant theory exploring key concepts are discussed.  

6. Interpreting patterns: Interpreting patterns is also discussion of the thesis. 

3.10 TRUSTWORTHINESS 

Trustworthiness can be described as procedures in which researchers engage to create confidence 

within their research (Norman & King 2020). Lincoln et al. (1985) highlighted four criteria promoting 

trustworthiness. These include credibility, transferability, dependability, and confirmability. 

• Credibility: In this research credibility was promoted using multiple investigators and 

theoretical triangulation. Multiple researchers were involved in the review of the analyses. 

Coding, of the data and the subsequent theme development were reviewed by research 

supervisors, experienced in qualitative research, promoting trustworthiness and rigor 

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(Tong et al., 2007). 

• Transferability: A second factor for trustworthiness offered by (Lincoln et al., 1985) is 

transferability. While qualitative research design, such as this, does not aim for 

replicability, we believe that the patterns and descriptions from this research may be 

applicable to another context. This is because thick descriptions such as contextual 

information about the field work site. Participants and the organizations where they work 

were well stipulated and described. 

• Dependability: In this study, there were regular communication events such as debriefings 

and collaborative review. This supported the dependability of findings, particularly during 

coding of data, construction of themes, analysis, and interpretation of data. 

• Confirmability: Confirmability means how close the research findings were to objective 

reality. The data was checked and rechecked throughout data collection and analysis. 

Clear coding schema was used to identify the patterns in analysis. Members of the research 

team were all familiar with the context, provided feedback on the coding and themes and 

discussed any possible bias, prior to data analysis. 

To support the quality of research design, conduct and reporting, the 32-item COREQ consolidated 

reporting criteria (Tong, Sainsbury, & Craig, 2007) provided a guide for the quality of the research 

project, particularly in conducting and reporting its findings. 

 

 

 

 

 

 

 

 

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CHAPTER FOUR 

RESULTS 

 

4.1 INTRODUCTION 

This investigation examined the perceptions and practices of Speech and Language Therapists (SLTs) 

in Ghana as regards to cultural responsivity in clinical practice. It sought to answer the following three 

(3) research questions (RQ): 

 

1. How do currently practicing SLTs in Ghana define culture (knowledge)? 

 

2. What are the perceptions of SLTs in Ghana about the importance of cultural responsivity 

(attitude)? 

3. How do SLTs in Ghana report adapting western SLT practices when providing services to 

persons with communication disability and their families within the Ghanaian context 

(behavior)? 

 

Thematic network analysis revealed three (3) Global Themes, with a single global theme linked to each 

research questions. These themes represented participants’ (SLTs) thoughts about how western 

practices are used, not used, and adapted in Ghana to suit the context and the needs of clients/family’s 

they work with during speech & language therapy, as well as their perceptions regarding the 

importance of cultural responsivity and their understanding of the nature of culture. The global themes 

with constituent organizing and basic themes for each network are outlined in Table 2 below. 

Table 2. Thematic networks: Global, Organizing and Basic themes 

Global Themes Organizing Themes Basic Themes 

1. Culture is a way of 

life that influences 

what we know 

about the world and 

how we interact 

with it 

 

1.1 Knowing about the world 1.1.1 Beliefs as culture 

1.1.2 Difference between the ways culture     think 

 

1.2 Doings: a demonstration of 

culture. 

 

1.2.1 Ways of dressing 

1.2.2 Food 

1.2.3 Languages used 

1.2.4 Ways of socialising and interacting 

1.2.5 Childrearing 

 

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2. Culture is integral 

to creating a 

shared 

understanding. 

 

2.1    Culture influences how 

clients     and families 

respond to speech and 

language therapy services 

 

2.1.1 Culture influences what families find acceptable 

2.1.2 Responding to culture can influence outcomes 

for clients 

 

2.2 Cultural understanding 

supports clinical reasoning 

in SLT 

 

2.2.1 Cultural understanding shapes SLT perceptions 

of what they should do 

2.2.2 Culture influences how SLTs understand the 

communication issue 

 

3. SLTs attempt to 

use their cultural 

understanding of 

clients and 

families to make 

clinical practices 

culturally 

responsive 

 

3.1   SLTs develop and use 

cultural understanding about 

families as part of their 

clinical reasoning and 

decisions 

3.1.1 Understanding family cultural background 

to help plan clinical activities 

3.1.2 Prioritizing every day and functional 

activities 

3.1.3 Explicitly considering language choices 

3.1.4 Deciding which SLT materials are relevant 

 

3.2    SLTs attempt to use tools 

and resources they see as 

relevant to the child and the 

family’s culture (resources)  

 

3.2.1 Using local materials 

3.2.2 Making resources 

3.2.3 From there to here – adapting western 

resources 

 

3.3     SLTs use their 

understanding of a family’s 

culture to develop 

therapeutic relationships  

 

3.3.1Using culture in creating connections with 

families 

3.3.2 Using cultural understanding to explain ideas to 

families. 

 

4.1.1 Thematic Network: Global Theme 1. Culture is a way of life that influences what we know 

about the world and how we interact with it. 

Research question one (1) investigated participants understanding of culture. Analysis of participant 

descriptions of culture resulted in the global theme 1, “Culture is a way of life that influences what 

we know about the world and how we interact with it”. All respondents discussed culture as a way of 

life, comprising a series of elements about how people view the world and live their lives. These were 

clustered into two organizing themes- “Knowing about the world” and “Doings: a demonstration of 

culture”. Each of these organizing themes are described below together with exploration of the  

constituent (basic) themes. Direct quotes have been used to illustrate the findings. 

 

 

 

 

 

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Figure 2: Thematic network: Global Theme 1 

 

4.1.1.1 Organizing Theme 1.1. Knowing About the World 

This organizing theme represented descriptions of internal ideas and processes that shape people’s 

way of life and worldview. These were described within two basic themes: beliefs as culture, and 

differences between the ways cultures think. 

• Basic Theme 1.1.1: Beliefs as culture. This basic theme represented notions about specific 

beliefs or beliefs systems held by individuals and communities, with a strong focus on 

spiritual and religious beliefs. 

The belief systems of people in a particular community (participant 1) 

Religion is part. People believe in religion, whether Muslim, Christian, whichever 

way there's (a) religion part. (Participant 10) 

• Basic theme 1.1.2: Differences between the ways cultures think. This basic theme 

represented more general references to thinking by cultural groups with a focus on 

               
                              

                             
                              

        

           
          

              
          

           
          

         
                

       

            
           
            

                  
              

            
     
            

            
             
                
          

            
           

                 
           

            
              

      

                 
                   

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contrasting one culture to another. 

Their worldview could be different from another culture (participant 12) 

 

4.1.1.2 Organising Theme 1.2. Doing: A Demonstration of Culture 

This organizing theme brought together ideas about behaviors that demonstrated culture and group 

belonging. It consisted of five basic themes. 

• Basic theme 1.2.1: Ways of dressing. This basic theme represented more general 

references to the ways groups dress as a demonstration of their culture. 

• Basic theme 1.2.2: Food. This basic theme represented general references to the type of 

foods people eat within their culture. 

• Basic theme 1.2.3: Languages used. This basic theme described language as a unifying 

or identifying aspect of culture and cultural belonging. 

Language defines the people. And so, in every community, we have language that 

defines them. So, for instance, I work in the Eastern region, if you go there its 

basically the Akupem Twi… then you get…very few people are with other 

languages, but it is basically the Akueem Twi, the pure Akupem people in that 

community. (Participant 1) 

• Basic theme 1.2.4: Ways of socializing and interacting. This basic theme went beyond the 

language used to discuss ways of communicating and interacting with others, including 

social norms. 

For example, if you’re talking to an elderly person, you put your hands behind your 

back. If you have a cap you take it off. That’s how they live, that’s how, that’s what 

their culture teaches them to do. (Participant 3) 

• Basic theme 1.2.5: Childrearing. This basic theme represented ideas central to raising 

children as culture. Given the topic of the research, numerous examples of elements of 

childrearing specific to Ghanaian culture overall were describing including relationships 

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between adults and children, the role of extended family in childrearing and gendering of 

roles, in terms of behavioral expectations of children and in parental responsibilities in 

rearing and decision-making about children. 

Growing up, you interact with adults more and you keep talking, then they will be 

like, a child shouldn’t be doing that. A child shouldn't be doing that. A child 

shouldn't be talking too much. A child shouldn't be playing with adults too much. 

As a child, you need to be(on) your lane when adults are talking, go away, let the 

adults talk. And sometimes when you're even talking to your mom or your dad, you 

don't have that kind of, mother son relationship because usually you see them as 

your superiors and don't have that liberty to freely play with them. (Participant 2, 

relationships between adults and children) 

 

4.1.2 Thematic Network: Global Theme 2. Culture is Integral to Creating a Shared 

Understanding 

Research question 2, explored the perceptions of SLTs in Ghana about the importance of cultural 

responsivity. All participants indicated that being culturally responsive was very important to their 

everyday practice. Participants described the reasons for this perceived importance, with reference to 

both how culture shaped their own thinking about practice with clients, and also describing how 

culture of their clients influenced whether and how families engaged with services. 

Overall, participants saw culture as integral to developing a shared understanding between families 

and SLTs of the communication issues, and how to best respond to it within the person's everyday 

context, represented by the global theme, "Culture is integral to creating a shared understanding". 

Participants recognized the diversity of cultures within Ghana and the importance of adapting and 

responding to this diversity in their everyday clinical practice. The global theme had two constituent 

organizing themes-. Culture influences how clients and families respond to speech and language 

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therapy services and Cultural understanding supports clinical reasoning in SLT. The thematic network 

is represented in figure three, with organizing and basic themes described below. 

Figure 3: Thematic network: Global Theme 2 

 

4.1.2.1 Organizing Theme 2.1. Culture Influences How Clients and Families Respond to Speech 

and Language Therapy Services 

All participants discussed the role of culture in shaping how families viewed communication issues 

with their children and how they engage with services. This organizing theme consisted of two basic 

themes. 

• Basic Theme 2.1.1 Culture Influences What Families Find Acceptable. 

 

Participants discussed the importance of culture in shaping what families find acceptable, 

in two key ways: the power of belief in influencing understanding and choice, and other 

ways that culture influences the way families engage with therapy services. Firstly, 

                           
                             

             

                                            
                                           

                         

                                             
                                  

                  
                  

         
               
             

     

            
               
              

           
              

                 
  

            
                 

               
         

             
       

                  
                  
                  

          

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participants recognized the strong spiritual belief held by many families, and the role that 

the spiritual beliefs play in navigating communication disability, including both the 

interpretation of the cause of the communication issue and the means to improve the 

situation. An example of the importance of belief in deciding what to do about the 

communication disability was expressed by participant 1, 

Even in the process of (SLTs) educating them to let them know that some condition 

we are seeing are not really spiritual, because, they have beliefs that may be that 

some conditions are spiritual … in some communities … they think that people who 

have cerebral palsy, are given by the river. And look when they come into the clinic 

and you are telling them therapy will work, they think therapy wouldn’t do anything. 

Taking them back to the river will solve the situation. It makes it makes it a little 

difficult to work with such families. 

Participants also discussed explicitly incorporating discussion of belief into their 

interactions with families to help them understand their options and to make choices about 

intervention. 

You have to also know how to present differing views. So, you your view differs from 

that of the family or their culture, you have to know how to address the differences. 

And then if there is a need, or if, if the family sees it as something that they would 

like to be corrected, then fine, but then you don't have to impose what you think and 

believe because of your culture. You don't impose it. (Participant 5). 

Secondly, participants also described how culture and cultural mismatch in SLT practice 

influence the ways in which families interact with services, for example relationships 

between therapists and parents: 

In the European countries, if a young person is talking to you the person's job is the 

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person’s job. So, professional professionally like speaking, but over here when you 

are young, and most of the time, we are working with people who have children, 

they ask you {akola- do you have a child?} So, they seem to see us as young girls 

who have not experienced life. We don't have the right to give them advice on the 

child. So, they won't take advice, which is also a cultural thing. Because the foreign 

people that we see, don't give us that idea, they take the recommendations. 

(Participant 6). 

A mismatch between western practices and local culture was commonly noted in early 

language intervention which focuses on play and language stimulation, resulting in 

parents struggling to engage in the therapy process, for example, 

(SLTs) telling them that when you go home, give more opportunities for the child, 

you play more with the child, and when you are speaking with the child you come to 

the eye level so the child is able to interact with you more; they sometime find it 

difficult…I see I it as a way that with our culture is not something that we do and 

it’s very difficult for us. And so, when you are a therapist and then you advise 

parents that when you go, may be do labelling of item, label the item before you 

give it to the child. Sometimes they find it difficult for them to do, and then they will 

end up telling you the therapist to come home and do it for them to see. (Participant 

2) 

• Basic Theme 2.1.2: Responding to Culture Can Influence Outcomes for Clients. 

 

Almost half of the participants described the importance of adapting practices to 

accommodate culture to achieve positive outcomes for clients. Participants highlighted 

that without responding to culture, SLTs may not be able to offer acceptable interventions, 

and the same progress in therapy would not be made. 

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Culture influences the way we do everything. So, the way we think the way we 

interact, everything is influenced by culture or the environment. And so, we when 

we when we adapt the materials, we are able to really meet the needs of an 

individual, we because a child, for example, a child acquiring language, the 

environment, plays and culture plays a key role. So, with that, if we’re able to adapt 

it and change, the needs of the clients that we serve, I think their needs (will) be well 

met, it should be able to meet their needs, and then get some progress with whatever 

we are doing with them. (Participant 2)  

Everything is influenced by our culture. If we don't adapt our practices…we 

wouldn't be able to make any impact that will be accepted by everybody in our 

setting. …So, that is why it is extremely important. (Participant 11) 

 

4.1.2.2 Organizing Theme 2.2. Cultural Understanding Supports Clinical Reasoning In SLT 

Participants talked about the ways in which they used their understanding of culture to understand 

and interpret the communication difficulties their clients were presenting with and to decide how best 

to intervene and support the clients and their family. The basic themes constituted around this 

Organizing Theme were: Cultural understanding shapes SLT perceptions of what they should do; 

Culture influences how SLTs understand the communication issue: 

• Basic theme 2.2.1: Cultural understanding shapes SLTs’ perceptions of what they should 

do. Participants talked about awareness of their own culture as well as awareness of the 

cultures of their clients as shaping their practice. In reflection, many participants talked 

about their own culture, and how they attempt to recognize but not let their own cultural 

background influence their therapeutic interactions in a negative way. 

Okay, so for example, maybe a family walks in, in, in my therapy room, and maybe 

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… they are like a more modern family, but I'm from a more culturally, let's say, a 

northern family. And in my culture, you don't you don't sit until offered a seat. So, if 

the child comes in, and then …walk(s) straight to the seat and sits down without me 

telling him, how do I how do I respond to that? Because knowing my culture, it is 

not permitted or it's not done. So, if if the child walks in and goes to sit down, would 

I promptly tell the child to get up and wait for me to tell him to sit down? Or how 

do I respond to such a situation. So be mindful of your own culture and being 

sure that it doesn't overstep the boundaries set. (Participant 4) 

Speaking the same or preferred language of the client was seen as a useful way to respond 

to the culture and language needs of the family. Therapists openly talked about handing 

over clients to other SLTs more fluent in that language, if possible, in their workplace. 

I'll I start to speak Ga with them, or I speak Eweh with them, then I'm like, oh, I am 

mainly Ewe, then they are nicer to me. So, it affects the rapport you have with the 

clients. Also, if another person comes in, who can explain better to the clients, the 

things you are trying to tell them. They would identify with that person better than 

you because it's easier for them. If you are having an assessment, and the child is 

of a different background. (Participant 9) 

Many participants described the importance of taking time to understand the cultural 

background of the client, and the contexts in which families live as this knowledge 

supported their decision-making about how to offer interventions, such as types of home 

activities, or who to coach to support the child at home. 

What I've come to realize that in Ghana, you cannot just be dishing out a set of 

activities. Even to a mother or to a father. The first question you have to ask, you 

know, as a speech therapist who spends more time with the child, okay? Yes, 

because it could be an auntie. And so, what you do is if it is an auntie, then you ask 

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that they bring auntie in the next session. So, you talk to, you are giving all the 

activities directly to auntie, whilst mum is there. The reason is that mom is not a 

professional. Okay? And so, they might not be able to, you know, sort of coach 

auntie as you would. (Participant 12) 

• Basic Theme 2.2.2 Culture Influences How SLTs Understand the Communication Issue. 

Culture was seen as an important mediator of knowledge, helping SLTs to interpret the 

nature of the communication issue that the child presented with. Participants referred to the 

lack of normative data relevant to Ghanaian communities and languages, and the overuse 

of western norms. We don't even know what our system is in terms of …our typical errors 

in terms of spoken (language), in terms of understanding what does it mean? What do I 

say that it (is) okay (when) a Ghanian child is not able to, say to understand the negatives? 

So, at what age are we saying that (is) okay, this Ghanian child is having this kind of error. 

(Participant 8) 

Many participants talked about the need to understand culture and language to help them 

to untangle language difference as opposed to disorders of language, made more complex 

by the lack of normative data above. 

Trying to find out the language disorder and the language difference. You know in 

our cultural settings the languages that we have, we have our various sounds in the 

various languages. For example, if I have, in my part, the part that I came from. 

We usually interchange our /l/and /r/, because some part like the Akupems, they use 

the /l/ and we use the /r/. So, when someone says bra/bla which means come; we 

see nothing wrong with it. So, if I have someone say /bla/ they may laugh at the 

person maybe he is having a disorder. I see that as differences in terms of culture. 

(Participant 2) 

Participants emphasized the need to make language assessments as culturally relevant as 

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possible, by considering the environment of the child and adapting assessment materials. 

This type of cultural adaptation was seen by participants as assisting them to 

understanding the true abilities of the child. One poignant example, from participant 4, 

described the following situation: 

I had a client, where I tried to test the receptive language of the client with one of 

the foreign tests, and this child wasn't performing well... But a teacher insisted that 

(they) know all these items you're presenting, the child is familiar with them. So, 

then I thought, okay, how about I change all these test materials to something that 

child, knows. So, I went in for their class books, their class text book, and I took 

pictures that were familiar to the test materials from those class books. And then I 

made them into some form of test. And when I presented this same item(s) to the 

child, the results showed that he performed, so he knew. He was familiar with the 

test materials, but then because of the, you know, unfamiliarity with the items of the 

western test kits. If I were to be a speech therapist that didn't take his culture into 

consideration, I would have scored him as someone that had a deficit in that area. 

But that wasn't the case. You see, so that's like, one example because speech 

therapist we need, so that we get valid assessments result. 

 

4.1.3 Thematic Network: Global Theme 3. SLTs Attempt to Use Their Cultural 

Understanding of Clients and Families to Make Clinical Practices Culturally Responsive 

The third research question for this study investigated what SLTs in Ghana report doing to respond 

to culture when providing services to persons with communication disability and their families in 

Ghana. All participants described how they use culture to frame the ways in which they adapt western 

approaches to SLT, to make them relevant to Ghanaian clients and their families. There was 

recognition by all participants about the need to tailor practices to clients and their families, given the 

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range of cultures within Ghana. The need to understand the culture of each client and their family was 

clear, leading to the global theme statement, SLTs attempt to use their cultural understanding of 

clients and families to make clinical practices culturally responsive". This global theme comprised 

three organizing themes, which related to clinical reasoning and decision making (Organizing theme 

3.1: SLTs develop and use cultural understanding about families as part of their clinical reasoning 

and decisions); the use of culturally relevant materials (Organizing theme 3.2: SLTs aspire to use 

tools and resources they see as relevant to the child and the family’s culture); and creating relationships 

with clients and their families (Organizing theme 3.3: SLTs use their understanding of a family’s 

culture to promote a shared understanding). Thematic network 3 is presented in figure 3 below and 

each of the organizing themes and constituent basic themes are then described 

Diagram 4: Thematic network: Global Theme 3 

 

4.1.3.1 Organizing theme 3.1. SLTs develop and use cultural understanding about families as 

part of their clinical reasoning and decisions. 

This subtheme represented the use of understanding of a client and their family's culture to reason 

about more appropriate ways to provide therapy services. This organizing theme, included the 

following four basic themes. 

• Basic theme 3.1.1: Understanding family cultural background to help plan clinical 

activities. This basic theme represented the examples of ways participants described their 

attempts to understand more about client culture and background to help them consider 

what types of activities may be useful. 

We (try) to get enough information about family background and culture…the 

people in their immediate surroundings and the area they are in, because it plays a 

big role. If I know the child is in Nima, for example, the way I would give the 

recommendations different from a child (in) …East Legon. I would go, can you at 

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least you know, try to talk to the moms in school to see if you can get friends (for the 

child to socialize with). But if I'm talking to somebody from Nima, I will be like "Ma, 

you know in Nima , there are lots of children there, does the child go outside? Do 

you mind letting the child go outside and play?" Because, again, they are two very 

different ideas of how they interact. (Participant 9) 

• Basic theme 3.1.2 Prioritizing every day and functional activities. It was clear that many 

participants used an understanding of families' everyday lives to plan interventions based 

on an individual's everyday experiences. 

It's all based on what they tell me during the assessment, and then … So, if they tell 

me that, okay, these are their routines, they maybe they have reading time, sleeping 

time, bath time, and then mealtime, those are their typical routines, things that 

they tend to do on an everyday lifestyle. So, I tell them, okay, so based on the 

routines they've given, then (I) advise accordingly. So, it has to do with how the 

family live, and what they do, their lifestyle and everything and then based on that, 

I'll be able to suggest based on the information they've given me. (Participant 5) 

This was seen to be important, rather than creating additional tasks for parents to do with 

their children, for example, 

I found that that's asking parents to carve out time to work with their child is almost 

like, you know, asking them to (fly to) the moon. And so, the best is to, you know, sort 

of get them to embed it in the daily routine. (Participant 12) 

To do this, participants described needing to understand details of the natural 

environments that the child and adult are in, to help them choose activities that they could 

use therapeutically within the person's everyday experiences. Participant 12 went on to 

eloquently describe the financial imperative, linked to poverty, of not placing additional 

time demands on parents: 

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So, remember that here in this part of the world. Poverty, okay, there's poverty. I've 

dealt with families in rural areas. And where I asked them, what do you do? And 

they said, we are farmers. And I say, okay, whilst, you're farming. Where do you 

put the child under the tree close by? Are you able to sing for the child to hear? Are 

you able to still talk to the child? And they say, yes, I said, okay, then you can do 

that. But if (you) don't ask all these questions and you're not ready to work with 

them and say, oh, you need to carve out time…where's the time? They still need to 

go to the farm, they still need to fend for their families, so I think I have become 

more and more culturally aware. 

Participants also discussed the importance of understanding and using daily routines, how 

they were conducted so they could use these routines to provide communication support. 

You still have to find things that they are comfortable with. …You don't pick 

anything out of their space, you try to use everything the family has, that can work 

for them. So, you don't impose other interventions that you know are not relevant 

to them. Otherwise, you might not see progress. Try to, you know, find interventions 

that they can get at home, it's accessible, it's easy to find it's easy to do. It …is in 

their daily practice, and then you are able to see much progress the next time they 

come. (Participant 7) 

• Basic theme 3.1.3: Explicitly considering language choices. Participants also talked about 

careful consideration of the language that assessment and intervention were delivered in. 

Participants discussed their own clinical reasoning about which language that they used 

with the client and their family. 

The language in which the assessment is being carried out, I've really taken a 

conscious look at that. Because one, when we see the clients, we ask the language 

the child speaks. You know, so many times parents will tell you, we speak English 

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and this, we speak English and Twi, or sometimes just English. I've had an instance 

where a mother continued to say that the child speaks English. But then when you 

when I did the assessment in English, he wasn't really getting it. Then later on, I 

asked "Mum, what other languages does he speak?" She said, "Ga". To my surprise, 

he answered all questions in Ga, you understand. So, we've really taken a very good 

look at the language, the language we are supposed to communicate, or interact or 

assess the child in first, that's the most important thing. (Participant 4)  

Okay so one is, a colleague sees a child, and then the child is not from his or they 

don't really know about the culture of that child, or maybe the language of that 

child, then they try to find a colleague, for example, if let's say I'm seeing a child, 

and then the language that they speak is Ga, and I don’t know that and then they 

tell me that this child is more exposed to Ga, I'll get a Ga colleague , to maybe go 

in do the assessment, because he 'll be able to speak the Ga with a child he will be 

able to get more from the child like when it comes to translating, items. I think we 

try to get someone to interpret the materials into the local languages to make sure 

that you're able to, to really get what we're trying to tell them. So, for example, if 

it's something that I know that maybe their Ga’s is something that it's easy to find 

in their community when a Ga person is there, he would be able to tell me oh, this 

thing, the child will not be able to know, so let's use this. So, we try to communicate 

with each other and then maybe find a better way, should I use better or try to find 

someone who is able to speak their language and can really relate well with their 

family. (Participant 2) 

Despite formal interpreting services being unavailable, several participants talked about 

translating materials as they conduct assessments, as in: 

Participant: Sometimes when the family comes in, you know that the English will 

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not work. So then in their presentation even though…I'm reading it in English I'm 

seeing it in English, when I'm talking … about it with a child or with a parent. I 

change the language. 

Interviewer: And in therapy too, do you always do therapy in English or other 

language. 

Participant: So, I mix it. I do some I do in English; some I do in Twi. (Participant 

3) 

• Basic theme 3.1.4: Deciding which SLT Materials are Relevant. Participants described 

their thinking about the use of a range of assessment materials for their clients. They 

indicated using a mix of formal tools and informal tasks, such as play based and functional 

tasks. Formal materials were predominantly in English, although the use of one Ghanaian 

resource in both Twi and English was widely mentioned by participants [Osei-Bagyina 

Twi Articulation Test (OB-TAT) and the Osei-Bagyina Test of English articulation (OB-

TEA)]. All participants recognized that the normative data linked to formal (western 

and /English) tools was not relevant to their clients, but many participants described 

deciding to use parts of these tools as a starting point for understanding the language 

issues of the client. For example, participant 3 stated  

"We picked some of the information from those standardized tools, and try to bring 

it to our, our, our context" and participant 2 "I can use It (a formal tool), but not 

try not compare with other kids, but try to look at that child in particular, the 

strength and weakness’ using it informally." 

Participants also described adapting how tests were administered. Rather than using the 

whole test, many participants described using only parts (either subtests or particular test 

items) within a formal test that were judged to be culturally relevant to a child and 

interpreting findings informally to describe the language of the child, for example, 

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When I realized that a Ghanaian child will not know this picture that I'm showing, 

I just skip it and go to the ones that I know that he should be able to, he should be 

able to say it or know it, I just sift through and stuff. And then at the end of the day, 

I won't say I did formal, I'll just write. … So, we use that we use that assessment, 

informally, so when you're writing a report, I’m supposed to state that I used the 

assessment tool informally for this child. (Participant 10) 

 

4.1.3.2 Organizing theme 3.2. SLTs attempt to use tools and resources they see as relevant to 

the child and the family’s culture (resources) 

This organizing theme represented the extensive consideration that participants reported engaging in 

about the cultural relevance of materials they use. Participants described attempting to ensure 

materials are relevant by doing three things, representing the basic themes. These included: Using 

local materials, making resources and adapting available western resources. 

• Basic theme 3.2.1 Using Local Materials. Participants described how they use locally 

available materials within assessment and intervention where possible. This included 

using real (locally sourced) objects that clients would be likely to be familiar with, with 

some element of judgement based on their cultural background. For example, 

So, using our Ghanian culture, like specific items in the environment, so if its Banku. 

If you're talking about food, I will not go and bring fried rice to the Ghanian child 

who is coming from a very typical zone unless the person is within the East Legon 

zones, then I can maybe use fried rice because it's, it's common there, but deep 

down, I will change, the object that I'm looking at in terms of food. In terms of 

clothing, I will look at different things that are more suitable. (Participant 8) 

Almost half of participants discussed the need to understand what resources families have 

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at home, to help them know which material to use 

So, I always ask, what do you have at home? what can we use at home, you know, 

I always will ask what they have, because some parents can’t afford buying all these 

luxurious resources, so I always dwell on what the person has got at home. 

(Participant 1) 

Linked to basic theme, 3.1.4, where participants described adapting how they used formal 

assessments, participants described what they do to make resources relevant, including 

selecting and using local, culturally relevant pictures within assessments and intervention. 

Also using culturally appropriate pictures. So … you use pictures such as pizza, 

and broccoli, to …assess a child that had never seen such things, and you scored 

them, for instance, that they could not identify such things. I think that that wouldn't 

… so it was good to use culturally appropriate pictures as well. Things that the child 

knew from their environment. (Participant 12) 

• Basic theme 3.2.2 Making resources. Participants also indicated that they made their own 

resources for both assessment and intervention with clients, using local materials or 

creating local pictures. 

We made some stories in different languages which fitted the sounds that had to be 

there. If the sound wasn't in the language that we know that it's not part of the 

assessment, and it's not needed. We did the same for developmental language 

delays… (participant 9) 

and 

 

There were times when we had to go around and take pictures, just so that we could 

be able to do the assessments, to be able to teach the child you know. (Participant 

12) 

Making or creating resources including pictures was seen as important to ensure that 

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children could be assessed in ways that could best represent their abilities, rather than 

being culturally biased. 

And then we've taken note of the resources, especially the picture-based resources, 

we've made sure that we have pictures that reflect more on the Ghanaian cultural 

things that the child can easily see, identify and understand. Imagine having a 

hippopotamus. The child has not seen a hippopotamus in Ghana before. But if you 

talk if you if you if you go "show me hippopotamus", the child will (not) be there, 

but then let's replace this hippopotamus with a let's say, cat, or even these hens, 

cow, goat, Sokoto, Goodale, you know, these animals that are readily seen around 

the child we immediately point to, because one, he's been seeing it every day. He's 

heard about it. (Participant 4) 

• Basic theme 3.2.3: From there to here – Adapting western resources. 

 

Participants talked about how they adapted western resources to make them more 

culturally appropriate. This often-included swapping pictures within the task, as in, 

We've changed the picture to somebody eating beans or sometimes somebody eating 

macaroni. We've changed the water to let's say, somebody's drinking water. It's not 

a glass, maybe sometimes, depending on the area the child comes from, again, 

because of cultural issues. Sometimes the water if you see them, the water some 

of the children, you see sachet water. Some of them you see glass, some of them 

you see Voltic. But it depends on the area. That's how we do it, we see the child 

were like, Oh, this child, where they're coming from how the mother is talking, if 

you give the child Voltic, the child will not see the Voltic bottle anywhere, it's sachet 

they have, so you use sachet. (Participant 9) 

Participants also discussed translating English language tools into other languages. 

And then sometimes I just like translate, whatever I want to do in the language. So, 

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for Ewe, for instance, we don't really have any test kits... So you just have to 

translate whatever questions in the language that they currently, they understand. 

So that's, those are some of the modifications that I do. (Participant 6) 

However, a few participants recognized that translating was not always easy, for example 

participant 2 stated  

"Since most of the things we practice are in English and from the western world, 

sometimes trying to translate it to our local languages becomes a bit difficult". 

Many participants described the need for flexibility in whether and how they adapted 

resources and tasks for participants, based on their culture due to the diversity of the 

clients that they see. 

So I think that for you to be culturally responsive, or to be able to culturally adapt, 

it's always to ask, ask, ask what works with the family. Don't assume that even your 

you think you have culturally done your cultural adaptation, that one size fits all, 

not one size doesn't fit all. Because remember that we live in a society, in Africa, in 

Ghana, that our culture is so different, even from unique people from Ashanti 

region, and then you meet various tribes. You know, in the Ashanti region, they are 

there. People come from here, people come from there, they do things so differently. 

Okay, even when you think that you have your culturally responsive material to work 

with, you still have to ask, you know, because they're telling you that, oh, in our 

culture, we don't do we don't have anything to do with snails, for instance, you 

know, here you are reading a snail story to the boy, you know? Uh huh. We always 

ask what works, what works? (Participant 12) 

Most participants clearly expressed those western resources needed adaptation to make 

them relevant and useful to the client and their family. 

More of contextualizing most of the assessments. So, making them relevant to our 

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culture, let me say yes, making them relevant to our system, our environment, how 

things work for us, not necessarily just picking that, the assessments and then 

imposing them on, on ours or on clients. But if there are a few changes, you have 

to make, you change a bit to suit the kind of patients we see. So I remember that 

was what we were told not necessarily just lift everything and then give to patients 

like they are in Europe or America or something. But so, contextualize it, make it 

make it make it Ghanaian, yes. More or less make it Ghanian, for them. (Participant 

7) 

For one participant, the importance of adapting re