University of Southern California Mrs. T.H. Chan Division of Occupational Science and Occupational Therapy
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Cultural Barriers

America has long been called "The Melting Pot," a nation built of people from diverse cultures around the world who come together to make one country. Each group that comes to the United States bring with them the rich traditions of their home, including traditions of language, clothing, food, family life and work methods. Life in this "melting pot" has more "flavor" because of its many "ingredients" from around the world. We are also aware that, unfortunately, that sometimes differences in cultures and traditions cause conflict or misunderstandings among people. This is also true for people with spinal cord injuries, especially when those who are used to the way things are done in another country become patients in an American hospital or health care facility.

Because of the many medical needs that are created by a spinal cord injury, particularly in the days and months first following the injury, the person who is dealing with this kind of life-changing condition must establish a close working relationship with a number of medical professionals. In almost every case, there is also a long hospital stay immediately after the injury. While in the hospital, the patient might discover that a hospital has its own "culture," with a certain way of doing things, a schedule that is followed, and a "pecking order" (that is, ranking of who gives the orders and who takes them) that might range from strict to informal. Typically, a physician is in charge of the medical team, and expects a certain level of respect to go with his or her position.

Sometimes, the result of this is that a patient might feel intimidated by the doctor, or too afraid to speak up to the doctor if they have any questions, complaints or needs related to their treatment. On the other hand, some patients react to their situation, and to the authority of the doctor, with dissatisfaction, negative comments and rebellion. Causes for either of these reactions might be that the person who is injured or ill is overwhelmed by the pain and confusion they are feeling about their condition; respect (or disrespect) for the doctor's knowledge about medical matters; traditions from their own cultural background about obeying orders given by an authority; depression; or worry about appearing foolish or ignorant in front of someone with a great deal of education, such as a doctor. Sadly, a patient who comes from a country where people with disabilities are treated poorly or looked down upon as "weak" or "damaged" might not want to ask a doctor or medical staff for special attention because they might feel they are not worthy of attaining an improved quality of life 1. This is one way that "culture" can block someone from getting the most out of their health care: when the patient doesn't fit into the medical "culture," or doesn't do a good job of working in partnership with health care providers.

Very often, the medical system fails to fit into the culture of the patient or client. For example, a great number of people who need medical care do not speak English well, or at all. Some hospitals have staff who are bilingual, or even have translators available, but be aware that these translators are not always available. Without good communication between patient and medical care providers, the patient may not be able to learn important health care instructions and may not be able to give accurate information about their condition to their caregivers. The results could be disastrous for a person who is not able to let their doctors, nurses and other care providers know that they are experiencing new symptoms. Two of our study participants, Charlie and Steve, did not speak English and so had difficulties because their primary health care providers only spoke English. Some patients solve this problem by inviting friends or family members to translate for them. Others hire a bilingual care attendant. It might be useful to have a bilingual dictionary (bilingual dictionaries that specialize in medical terms are often expensive, but if you want one, they are usually available online or in stores that offer educational tools for nurses), or a list of common terms translated. If you have online access, there are websites with medical terms and with translations, such as the website maintained by the Heymans Institute of Pharmacology at the University of Gent in Belgium, which has glossaries, or vocabulary lists, of medical terms in nine European languages.

There are other "culture clashes" that occur in medical treatment situations. Often, people receiving medical treatments need to disrobe, that is, remove some or all of their clothes, but in some cultures, it might be considered improper to be nude in front of a person of the opposite sex. If you have concerns about disrobing, tell your health care provider; there might be someone in the same facility or medical practice who is the same gender as you who can perform the needed procedure. You might be able to get advice from an elder, clergy member, or authority from your own culture about proper procedure in medical situations. Another alternative is seeking a health care practitioner in your own community, from your own culture, who would understand your beliefs. There might be other creative answers; for example, a hospital in Portland, Maine, created special examination gowns for patients that are longer and more "covered up" for patients with concerns about being exposed 2.

In this day and age, we hope that people are not intentionally discriminated against on the basis of race, beliefs, culture or national heritage. However, it is also true that people sometimes feel awkward or unsure how to behave with people from a foreign culture they do not understand. If you sense that your health care providers are not "relating to you," you might choose to reduce the tension by offering to tell them about your culture and traditions (especially in the area of health care), or asking them about theirs. Just mentioning that you are aware there is a cultural difference, without trying to say that one culture is "better" than the other, might make it easier for you and your caregiver to overcome any gap between you.

Be aware that if you believe that you are intentionally being discriminated against based on your race, creed, color, national origin, sexual preference, economic status, immigration status or ability/disability status, you have the right to report any evidence you have of this discrimination. If you are in a hospital or medical facility, there is probably an official on the staff (sometimes with the job title ombudsman) whom you can report your concerns to; if you are living at home, your social worker or a community advocate might be able to help you, or you can contact the employer (boss) of the person who is being discriminatory. (If you are being discriminated against in an employment situation, you are protected by the federal Americans with Disabilities Act or by the U.S. Equal Employment Opportunity Commission, and the ADA also gives you protections in housing and other areas; their websites have links to information in a number of languages.) Other alternatives include confronting the person who is acting in discriminatory way, or changing health care providers.

Other websites that might be of interest on this topic include Proyecto Visión, a bilingual website by and for people of Latino heritage who have disabilities; a Spanish-language version of the National Institutes of Health's Medline Plus page of links to websites about spinal cord injuries; Mobilewomen.org, an online magazine for women with disabilities, maintained by Rutgers University, and "Portraits of Harlem", an article on the New Mobility magazine online, with interviews of African-Americans living with disabilities. New Mobility also features Bring It On, an interview with Minna Hong, who received a spinal cord injury at T12-L1 in a car accident, and who talks frankly about attitudes about disabilities she experiences as an Asian-American woman.

Diversity makes living in the United States a wonderful, enriching experience, but sometimes misunderstandings arise. If cultural differences are creating a barrier keeping you from the highest quality health care, keep in mind that you can - and should - do something about it. Even if the other person still doesn't "get" your culture, at least you can improve the medical treatment you are receiving from them.

1 Fishman, B. (2004, September 4). A prize novel full of truths that stretch believability. The New York Times. Retrieved September 4, 2004 http://www.nytimes.com/2004/09/04/books/04gall.html

2 Zezima, K. (2004, September 1). The Muslim patient will see you now, doctor. The New York Times. Retrieved September 2, 2004 http://www.nytimes.com/2004/09/01/national/01muslim.html