Share this article on:

Using Culture to Improve Hearing Healthcare on a Remote Reserve

Scott, Jack M. PhD

doi: 10.1097/01.HJ.0000441079.44601.7f

Dr. Scott is assistant professor in the School of Communication Sciences and Disorders at Western University in London, ON.



There is a Cree proverb that says, “Love one another and help one another.” In the field of audiology, charitable outreach work can take many forms, including diagnostic services; coordination with an ear, nose, and throat physician; education; and the provision and troubleshooting of amplification.



These services are, on their own, commendable and outstanding contributions. However, the provision of outreach services becomes a richer, more successful experience when audiologists hold paramount the culture of the receiving community and the sustainability of the services provided.

This article describes how these variables affected the establishment of a First Nations audiology outreach program in northern Canada.

Back to Top | Article Outline


As a complement to an outreach initiative already in place for preschool speech and language assessment and intervention, the School of Communication Sciences and Disorders at Western University in London, ON, decided to extend the existing services to include preschool hearing screenings. The location of the outreach was Attawapiskat, ON.

Attawapiskat is a First Nation reserve located near the western edge of James Bay. It is accessible only by boat, plane, or, during the winter months, by a frozen river that functions as an ice road.

There are about 1,900 residents living on the reserve, which is affiliated with the Mushkegowuk Tribal Council (First Nation Detail; Aboriginal Affairs and Northern Development Canada

The remote location and harsh living conditions in Attawapiskat required special consideration—not only from the perspective of how this isolation from other communities and support services created the Cree culture, but also in terms of the challenges it presented for developing a sustainable program.

To ensure sustainability of the program, we developed a five-year plan for integrating services within the existing community resources and cultural framework. An integral part of the Cree culture is the concept of the Medicine Wheel.

The Cree Medicine Wheel is represented as a circle divided into four quadrants. It has been modified to represent several different philosophical concepts, such as the aging process, the interaction of all living things, and human emotions (Native Soc Work J 2010;7:139-161). In one construct, the center of the circle represents the self, balance, beauty, and harmony.

An outreach “Medicine Wheel” was modeled after the traditional Medicine Wheel as a guide for the development and continued growth of the initiative (see image on the next page).

The center of the outreach Medicine Wheel describes the end goal of the initiative: improving the overall hearing health of the community and empowering members of the reserve to be their own advocates for hearing healthcare. While this is a goal that will evolve over time based on input and events from previous visits, the central core of better hearing health remains constant.

As the right quadrant of the traditional Medicine Wheel represents the spiritual aspect, the outreach quadrant represents integration of the initiative within the community. Integration includes determining need, identifying roadblocks, and expanding the program based on input from community workers and elders.

The left quadrant of the traditional and outreach Medicine Wheel represents the physical aspect. The physical aspects of the initiative range from determining the environment in which testing will be performed to procuring the necessary equipment and identifying situations when the outreach should occur outside of a traditional audiological setting, such as a classroom, home, or hospital examination room.



The top quadrant of the traditional Medicine Wheel represents wisdom; the outreach quadrant represents education of faculty, students, audiologists-at-large, and community members about the hearing healthcare needs on First Nation reserves.

Finally, the bottom quadrant of the traditional Medicine Wheel represents trust, which corresponds to sustainability in the outreach framework. This quadrant encompasses building sustainable funding sources, educating students and other audiologists so they may become involved, and getting buy-in from the community and its members to facilitate the initiative as it continues.

Back to Top | Article Outline


A plausible concern with many outreach initiatives is their lack of sustainability. Some programs can be described as “airdrop outreach.”

While these programs have honorable intentions of service provision, they deliver supplies without appropriate follow-up support or conduct one or two visits to a community and then terminate the outreach program due to lack of funding or interest.

Such approaches can lead to distrust among members of the local community and create challenges in establishing rapport.

Further, programs without appropriate follow-up can lead to wasted or misused resources, and those with limited or inconsistent opportunities for community interaction do not allow the outreach services to be fully integrated into existing community resources.

A critical step when developing an outreach program must be to create a long-term plan for the sustainability of services, including equipment needs, as well as financial and personnel support, both within the community and as a part of the outreach team.

Audiologists establishing outreach programs should consider beginning with a minimum five-year plan and re-evaluating it annually. Program duration of less than five years may not allow for the integration of services into the community at a pace that ensures their acceptance and sustainability.

Careful, considerate, and well-paced implementation of new services into existing communities may be a wiser approach than overwhelming a community too quickly or beyond its capacity for incorporating the services offered.

Regular and consistent visits to a place not only allow for maintaining the primary service goals but also for the acquisition of information that may facilitate the creation of additional goals for the outreach program.

Understandably, in some situations, it is not possible to visit a community once a month or even once a year. However, consistency of commitment may be more important than frequency of visits.

One well-established solution is to involve a local community member or healthcare professional in the initiative who can provide reinforcement. This act in and of itself demonstrates a clear commitment to the community.

Back to Top | Article Outline


The Western University Attawapiskat Outreach Initiative is currently in its fifth year. Over that time, the initiative has changed from a predominately preschool screening program to a mandate for improvement of the community's overall hearing healthcare.

The program has expanded to include adult assessments at the local school and hospital. It also has educated students about the dangers of noise exposure, as well as provided FM systems to several of the classrooms at the elementary school and personal amplifiers to be used in the hospital and by the community health center.

The acquisition of outside funding through the Hear the World Foundation has permitted the addition of two trips to Attawapiskat, allowing four more Western University students to have the experience of providing outreach services.

The outreach Medicine Wheel is revisited before, during, and after each trip to the North. It is used as a guide to ensure the initiative adheres to the overall mandate of the outreach program and provides a framework for improvement and growth through the feedback of audiologists, elders, and community members.

The valuable information gleaned through regular interactions with local community members provides insight into many variables, such as who are the best contacts in the community for specific services, whether the contacts in the community have changed, when are the best times of year to arrange visits, and what is the community's overall perception of outsiders during changing economic or political climates.

By establishing relationships and an ongoing dialogue with the community both at the onset of program development and as the initiative evolves, many of the possible roadblocks experienced during implementation and maintenance of services can be substantially reduced.

Back to Top | Article Outline

Audiology Without Borders

Our Audiology Without Borders column, featured each month in the HJ eNewsletter, highlights humanitarian hearing healthcare programs.

The column is edited by active humanitarians Jackie Clark, PhD, and King Chung, PhD. Dr. Clark is a clinical associate professor at the University of Texas at Dallas and a research scholar at University of the Witwatersrand in Johannesburg; and Dr. Chung is an associate professor of audiology at Northern Illinois University in DeKalb.

Let us know about your humanitarian program! Send the details to—manuscripts should be about 1,000 words, and photographs are also welcome (300 dpi in jpg, tif, or gif format).

Read past Audiology Without Borders columns in a special collection at

HJ Return to

Back to Top | Article Outline


The author thanks Casey Enright, the Western University Faculty of Health Sciences and School of Communication Sciences and Disorders, Hear the World Foundation, Starkey Canada, and Bernafon Canada for their contributions to this outreach work.

© 2013 by Lippincott Williams & Wilkins, Inc.