A Case Study: Prosthetics and the Hispanic Culture
DEBAECKE, M., BS., OTR/L AND ERB, J. S., MS., OTR/L
A 12 year old girl from Puerto Rico came to the Alfred I. DuPont Institute with prosthetic needs secondary to a congenital bilateral mid-humeral amputation. The occupational therapy treatment focus initially was directed toward the successful operation of the prosthesis with a later shift toward functional independence. It was during this shift of treatment that a disparity in cultural values began to be evident.
The cultural difference affecting values (such as establishing trust, encouraging self disclosure, independence with personal skills and communication with family members) lead to frustrations with treatment. It further prompted us to investigate the Hispanic culture and its possible impact on the treatment outcomes. The goals of this paper are these: 1. distinguish between the Hispanic patient's and the therapist's values and beliefs, 2. identify possible conflict areas that may hinder effective treatment and 3. reflect on our experience and determine solutions.
The population of the United States continues to change rapidly. A 1990 U.S. Census showed that growth of racial and ethnic minorities has occurred faster in the 1980s than at any other time in the twentieth century. Since 1980 there has been a 53 percent increase in the Hispanic population occurring mainly in the large metropolitan cities and Western states.3 With an influx of clients belonging to ethnic minority groups in the health care system, the need to learn as much as possible about the culture, their health beliefs, and their values is critical for effective treatment. To help bridge the gap between therapists and families who come from cultures other than our own, we must become cross-culturally competent. In order to accomplish this there is a need to have a self-awareness of our own culture, a cultural-specific awareness, and an understanding of cultural influences on communication.2
Particularly relevant to this case study is the Spanish American culture's views on several key areas. One of these areas is that this culture does not typically value insight or self disclosure.4 "Don't think so much" is a statement that may appropriately sum up this attitude. Revealing intimate revelations is considered unacceptable due to the impact which they may have on the family. Hispanics do not view themselves as individuals but as a family unit which also typically includes an extended family.
Verbal as well as non-verbal communication styles need to be recognized. Hispanics frequently speak softly, avoid eye contact with high status persons, and speak in an indirect manner. The cultural style of the United States and Canadian populations is the exact opposite: to speak loud and fast, with greater eye contact, and in a task-oriented manner.4 The different style of Hispanic communication frequently leads to misinterpretations of disrespect and rudeness within other cultural groups.
Not only are communication styles frequently a hindrance to effective interactions with clients but also unrecognized language barriers contribute to this problem. For example, speaking with those of bilingual background in English, and not in their native language, often leads to misunderstanding due to the overestimation of the bilingual persons language capabilities.4 While speaking English, brief or poorly phrased responses by the bilingual person often causes others to assume inaccurate motives. In addition, those who speak Spanish may not know how to read or write Spanish and this is frequently a source of embarrassment that needs to be handled with sensitivity.
Other cultural barriers that may hinder effective therapy arise from social class values.4 One whose immediate needs are uncertain may see little value in long range planning. The Hispanic view of illness may be perceived differently than expected by those of other cultural experience. Illnesses or problems that occur to a family member may be seen as a result of the presence of evil. This view of causation may effect the way in which the family assists the child with his/her disability.
As a result of our experience with the Hispanic culture, we suggest the following that may prevent client and therapist frustrations:
- Our first conflict arose with our goal of prosthetic independence in personal skills (i.e., feeding and toileting). Treatment sessions demonstrated the client's ability to successfully meet goals of independence, however, carry over to home and school was absent. As literature supports2 and as we experienced the issue of independence may be the greatest area for cultural conflicts. A solution to this barrier may be to adapt treatment goals to match the family and client's priorities as to whether dependence or independence for the client is expected in these skill areas. We need to respect these values.
- Our second conflict occurred during our attempt to communicate with the family through writing and telephoning. Telephone calls were consistently answered by a member of the extended family despite provision of professional interpreters. This hindered communication and involvement of the client's mother. Letters and transportation arrangements were also not responded to by the client's mother. A solution to this cultural barrier is friendly, informal, and leisurely chatting that occurs in a familiar setting to the client and their family.2 This friendly communication can be aided by the use of translators with the appropriate Spanish heritage. Translators of a common heritage is often valued by Hispanics. This will foster greater familial cooperation and trust. Once a friendly relationship is established, it is important to arrange for family members and friends to be present within the hospital setting in order to feel secure and comfortable with the interventions.
In conclusion, each ethnic group has its own unique culture but individual variations will occur within each group. A maximally successful intervention can be attained through a better understanding of each culture with its respective beliefs, values, and communication.' A better understanding of each culture can also be obtained by using resources that are designed for or are part of that particular cultural community. A therapist with this cultural awareness will be better prepared to meet the challenge of the cross-cultural competence.
Alfred DuPont Institute, Box 269, Wilmington, DE 19899
- Hanft BE: Family-centered care: An early intervention resource manual. Maryland: American Occupational Therapy Association, 1989.
- Lynch EW, Hanson MJ: Developing cross-cultural competence: A guide for working with young children and their families. Maryland: Paul H. Brooks, 1992.
- Schreiner T: Minorities move to cities, west-Expert predicts polarization. In: Dillard M, Andonian L, Flores O, et al: Culturally competent occupational therapy in a diversely populated mental setting. American Journal of Occupational Therapy 46(8):721-726, 1992.
- Sue DW, Sue D: Counseling the culturally different: Theory and practice. New York: John Wiley & Sons, 1990.