Intersectionality in Aphasia Services for Ethnosocially Diverse Adult Populations

Post-stroke life reengagement has become an important driver of aphasia intervention (Chapey et al., 2000; Kagan et al., 2008; Simmons-Mackie & Azios, 2024). Complementary to impairment-focused treatment (Coppens & Patterson, 2018), life reengagement is a crucial intervention goal for each person with post-stroke aphasia (PWA). For stroke survivors with aphasia, the powerful psychosocial life changes accompanying the communication disorder underscore the critical need for aphasia therapies recognizing individual communication environments and other personal life factors (Hunting Pompon & Mach, 2022; Simmons-Mackie & Azios, 2024).

With steady growth in ethnosocial diversity in the U.S. population, aphasia caseloads progressively reflect the growing ethnoracial and social heterogeneity of the general population (Centeno & Harris, 2021). The caseloads of speech-language pathologists involved with helping PWAs include individuals of different personal ethnoracial backgrounds (i.e., White, Hispanic, Black or African American, American Indian or Alaska Native, Asian, and Native Hawaiian or Other Pacific Islander) and complex social profiles (e.g., gender, sexual orientation, socioeconomic circumstances, religious beliefs, educational histories; Centeno et al., 2023). As the population rapidly ages and becomes more ethnoracially diverse in the country (Vespa et al., 2020), increased age-related vulnerability to cardiovascular complications, including stroke, especially in underserved Black, Indigenous, and People of Color, is estimated to result in larger numbers of older adults with complex ethnosocial life histories in post-stroke aphasia care (Centeno et al., 2023; Centeno & Harris, 2021; Feigin et al., 2019; Uomoto & Loughlin, 2016).

Ethnosocial heterogeneity in aphasia caseloads calls for special attention to the individual life history of each PWA for person-centered culturally responsive aphasia intervention for life reengagement after a stroke (Centeno et al., 2023; Guerrero-Arias et al., 2020; Harris, 1997). Intersectionality, a central tenet in health equity and human rights (Bridges et al., 2017; Crenshaw, 1989), has been a valuable principle to focus healthcare policymakers, practitioners, and researchers on the multifactorial interactions that converge in individuals and social groups resulting in discrimination, marginalization, vulnerability to illness, and, in turn, inequities in health, care, and outcomes (Bridges et al., 2017; National Advisory Council on Minority Health and Health Disparities [NACMHD], 2023; United Nations Partnership on the Rights of Persons with Disabilities & United Nations Women [UN PRPD & UN Women], 2021).

An intersectional healthcare framework can meaningfully transform approaches in policymaking, care, and research to improve services and minimize health inequities in vulnerable populations (i.e., ethnic/racial minority groups, people from limited socioeconomic environments, underserved rural communities, sexual and gender minority groups, and individuals with disabilities; NACMHD, 2023; UN PRPD & UN Women, 2021). An intersectional approach to health care shifts the focus from narrow, unidimensional, and discrete perspectives to a more nuanced, broader lens that recognizes how an individual person's ethnoracial and social identities can intersect resulting in forms of privilege or marginalization with an impact on health, care, and outcomes (Hankivsky et al., 2017; NACMHD, 2023; UN PRPD & UN Women, 2021; Wilson et al., 2019). Applying an intersectional perspective to aphasia services in ethnosocially diverse environments contextualizes clinical care by focusing speech-language pathologists on the complex individual ethnosocial profiles shaping well-being and life trajectories of each PWA (e.g., race, ethnicity, gender, sexual orientation, sociocultural history, geographic residence, religion, ability). This focus facilitates the design of personalized, culturally attuned aphasia intervention (Asher BlackDeer, 2023; Guerrero-Arias et al., 2020; Harris, 1997; Laures-Gore et al., 2018).

Covering the transformative depth of an intersectional approach to clinical services is beyond the scope of a single journal issue (UN PRPD & UN Women, 2021). The articles in the current special issue provide an illustrative snapshot of the multiple factors and interactions in the intersectional profiles of PWAs that can inform the design, implementation, and outcome assessment of aphasia intervention. Because increasing ethnosocial diversity in aphasia services is a global phenomenon (Centeno et al., 2020; Centeno & Harris, 2021), the six articles in this issue, while highlighting service contexts in Australia and the United States as examples, discuss often overlooked, yet exceedingly important variables and intersectional connections relevant to ethnosocially diverse aphasia caseloads worldwide. The issue starts with three articles focused on different variables (i.e., emotions, religion/spirituality, and climate change) that intersect with personal, community, and systemic determinants of individual health, services, and outcomes in aphasia intervention, and concludes with three additional articles that describe applications of intersectionality to clinical contexts (i.e., Australian First Nations communities, Life Participation Approach to Aphasia [LPAA]) and experimental paradigms relevant to aphasia care (quantitative assessment of intersectionality). Specifically, Harmon (2024) starts the issue by using a cognitive–motivational–relational framework to highlight the intersecting possibilities of individual emotions with language processing and social participation in PWAs. Next, Laures-Gore and Griffey (2024) discuss how the intersectional connections between PWAs' religious and spiritual belief systems and their mental and physical health may impact aphasia intervention. Greenwald et al. (2024) follow with a focus on the climate change vulnerability of PWAs by describing the intersectionality of climate change and preexisting inequities in social determinants of health. In the last three articles, Armstrong et al. (2024) discuss the importance of a community-led intersectional intervention model that has been critical to minimize the impact of marginalization and discrimination on services for adults from Australian First Nations with neurogenic cognitive–communicative disorders. Next, Centeno (2024) describes intersectional LPAA-based strategies, grounded in personal storytelling, to collect the input that can inform culturally responsive intervention in ethnosocially diverse aphasia caseloads in the United States. Finally, Evans et al. (2024) propose a socioecological model to evaluate the impact of intersecting individual, environmental, and structural determinants of health on aphasia outcomes, especially in vulnerable populations.

The articles in this special issue provide a brief yet valuable glimpse into the possible breadth and depth of an intersectional approach to design and implement intervention and assess the outcomes in ethnosocially diverse aphasia contexts. While the application of an intersectional lens in healthcare policy, care, and research is in its preliminary stages and lacks systematicity (Ghasemi et al., 2021; Wilson et al., 2019), rapid growth in ethnosocial heterogeneity in aphasia caseloads in many world regions compels us to use, assess, and refine intersectional procedures to support person-centered, culturally responsive aphasia therapy (Centeno et al., 2020).

Publication History

Article published online:
17 January 2024

• References

• Armstrong, E., Colegate, K., Papertalk, L., Crowe, S., McCallister, M., Hersh, D., Ciccone, N., Godecke, E., Katzenellenbogen, J., & Coffin, J. (2024). Intersectionality and its relevance in the context of Aboriginal people with brain injury in Australia. Seminars in Speech and Language. (Advance online publication) doi: 10.1055/s-0043-1776755
• Asher BlackDeer, A. (2023). Culture as treatment: a pathway toward Indigenous health equity. Healthy Populations Journal, 3(1), 5–8
• Bridges, K. M., Keel, T., & Obasogie, O. K. (2017). Introduction: critical race theory and the health sciences. American Journal of Law and Medicine, 43(2–3), 179–182
• Centeno, J. G. (2024). A call for transformative intersectional LPAA intervention for equity and social justice in ethnosocially diverse post-stroke aphasia services. Seminars in Speech and Language. (Advance online publication) doi: 10.1055/s-0043-1777131
• Centeno, J. G., & Harris, J. L. (2021). Implications of United States service evidence for growing multiethnic adult neurorehabilitation caseloads worldwide. Canadian Journal of Speech-Language Pathology and Audiology, 45(2), 77–97
• Centeno, J. G., Kiran, S., & Armstrong, E. (2020). Editorial: aphasia management in growing multiethnic populations. Aphasiology, 34(11), 1314–1318
• Centeno, J. G., Obler, L. K., Collins, L., Wallace, G., Fleming, V. B., & Guendouzi, J. (2023). Focusing our attention on socially-responsive professional education to serve ethnogeriatric populations with neurogenic communication disorders in the United States. American Journal of Speech-Language Pathology, 32, 1782–1792
• Chapey, R., Duchan, J., Elman, R., Garcia, L., Kagan, A., Lyon, J., & Mackie-Simmons, N. (2000). Life participation approach to aphasia: a statement of values for the future. ASHA Leader, 5(3), 4–6
• Coppens, P., & Patterson, J. (eds.). (2018). Aphasia Rehabilitation: Clinical Challenges. Jones and Bartlett Learning
• Crenshaw, K. W. (1989). Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 138(1), 8
• Evans, E., Jacobs, M., & Ellis, C. (2024). The intersection of social determinants of health and post-stroke aphasia outcomes: A need for intersectional analysis. Seminars in Speech and Language. (Advance online publication). doi: 10.1055/s-0043-1774783
• Feigin, V. L., Nichols, E., Alam, T., Bannick, M. S., Beghi, E., Blake, N., . . . Vos, T., & the GBD 2016 Neurology Collaborators. (2019). Global, regional, and national burden of neurological disorders, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurology, 18, 459–480
• Ghasemi, E., Majdzadeh, R., Rajabi, F., Vedadhir, A., Negarandeh, R., Jamshidi, E., Takian, A., & Faraji, Z. (2021). Applying Intersectionality in designing and implementing health interventions: a scoping review. BMC Public Health, 21, 1407
• Greenwald, R., Laures-Gore, J. S., & Nogueira, L. (2024). The intersectionality of climate change and post-stroke aphasia. Seminars in Speech and Language.
• Guerrero-Arias, B. E., Agudelo-Orozco, A., & Pava-Ripoll, N. A. (2020). Intersectional identity chronotopes: expanding the disability experience. Disability & Society, 35, 1660–1681
• Hankivsky, O., Doyal, L., Einstein, G., Kelly, U., Shim, J., Weber, L., & Repta, R. (2017). The odd couple: using biomedical and intersectional approaches to address health inequities. Global Health Action, 10, 1326686
• Harmon, T. G. (2024). Understanding and addressing the individualized emotional impact of aphasia: A framework for speech-language pathologists. Seminars in Speech and Language. (Advance online publication) Doi: 10.1055/s-0043-1776418
• Harris, J. L. (1997). Reminiscence: a culturally and developmentally appropriate language intervention for older adults. American Journal of Speech-Language Pathology, 6(3), 19–26
• Hunting Pompon, R., & Mach, H. (2022). Characterizations of resilience in post-stroke aphasia: a scoping review and considerations for treatment. Topics in Language Disorders, 42(3), 236–251
• Kagan, A., Simmons-Mackie, N. N., Rowland, A., Huijbregts, M. P., Shumway, E., McEwen, S. E., Threats, T., & Sharp, S. (2008). Counting what counts: a framework for capturing real-life outcomes of aphasia intervention. Aphasiology, 22, 258–280
• Laures-Gore, J. S., & Griffey, H. (2024). Religiosity, spirituality, healthcare, and aphasia rehabilitation. Seminars in Speech and Language. (Advance online publication) Doi: 10.1055/s-0043-1776308
• Laures-Gore, J. S., Lambert, P. L., Kruger, A. C., Love, J., & Davis, D. E., Jr. (2018). Spirituality and post-stroke aphasia recovery. Journal of Religion and Health, 57, 1876–1888
• National Advisory Council on Minority Health and Health Disparities (NACMHD) Working Group on Persons Living with Disabilities. (2023, September 20). Final progress report. Accessed December 13, 2023 at: https://nimhd.nih.gov/docs/advisory-council/nacmhd_workGrpOnHealthDisparitiesAndPeopleWithDisabilities_report_2023sept.pdf
• Simmons-Mackie, N., & Azios, J. H. (2024). The State of Aphasia: A Global Perspective. Aphasia Access
• United Nations Partnership on the Rights of Persons with Disabilities & United Nations Women. (2021). Intersectionality resource guide and toolkit: An intersectional approach to leave no one behind. Accessed December 13, 2023 at: https://www.unwomen.org/en/digital-library/publications/2022/01/intersectionality-resource-guide-and-toolkit
• Uomoto, J. M., & Loughlin, J. (2016). Neuroepidemiology and racial disparities in neurorehabilitation care. In: J. M. Uomoto (ed.), Multicultural Rehabilitation: Clinical Principles for Rehabilitation Professionals (pp. 3–24). Springer
• Vespa, J., Medina, L., & Armstrong, D. M. (2020). Demographic turning points for the United States: Population projections for 2020 to 2060. Current Population Reports. Series P-28, Special Censuses, 25–1144. Accessed December 13, 2023 at: https://www.census.gov/library/publications/2020/demo/p25-1144.html
• Wilson, Y., White, A., Jefferson, A., & Danis, M. (2019). Intersectionality in clinical practice: the need for a conceptual framework. The American Journal of Bioethics, 19, 8–19