Attitudes towards disabilities in a multicultural society

0277-9536/93 $6.00 + 0.00 Copyright 0 1993 Pergamon Press Ltd

Sm. Sci. Med. Vol. 36, No. 5, pp. 615-623, 1993 Printed in Great Britain. All rights reserved

ATTITUDES TOWARDS DISABILITIES MULTICULTURAL SOCIETY MARY T. WESTBROOK,VAROE LEGGE

IN A

and MARK PENNAY

Department of Behavioural Sciences, Faculty of Health Sciences, University of Sydney, P.O. Box 170, Lidcombe, NSW 2141, Australia Abstract-Health practitioners (N = 665) from the Chinese, Italian, German, Greek, Arabic and Anglo Australian communities used social distance scales to rate the attitudes of people in their communities toward 20 disability groups. Significant differences were found in community attitudes toward people with 19 of these disabilities. Overall the German community expressed greatest acceptance of people with disabilities, followed by the Anglo, Italian, Chinese, Greek and Arabic groups. However the relative degree of stigma attached to the various disabilities by the communities was very similar. In all communities, people with asthma, diabetes, heart disease and arthritis were the most, and people with AIDS, mental retardation, psychiatric illness and cerebral palsy, the least accepted of the disability groups. These stigma hierarchies were remarkably similar to other hierarchies reported over the last 23 years. The findings have important implications for people with disabilities and health practitioners in multicultural societies. Key wordsdisability,

culture, stigma hierarchy, attitudes

The social science literature on disabilities has been described as suffering, “a curious omission in the relative lack of attention paid to a cross cultural or historic perspective” [ 1, p. 23; 21. The limited research that has been published suggests that both these factors are important in understanding social attitudes toward people with disabilities. For example, Jaques and other researchers [3,4] demonstrated significant differences in the attitudes held by American, Danish, Chinese and Greek samples toward people with disabilities, with Americans having the most favourable attitudes and Greeks the most negative. Compared to Americans, the Chinese have been reported to be particularly negative in their attitudes toward people with mental disorders [5]. Research in Israel has demonstrated more negative attitudes toward physical disability among Arabs and Jews from Arab countries than among Jews from western countries [6]. There is evidence that in developed countries attitudes toward people with disabilities are becoming less negative. The first major national survey of the experiences of Americans with disabilities which was conducted in 1986, found that 72% of respondents considered that life for people with disabilities had improved since 1975 [7]. There are also Australian data indicating that community attitudes have become more accepting [8] and that as a result of such changes people are more willing to identify themselves as having a disability [9]. However discrimination against people with disabilities remains relatively unchanged in many developing nations [lo, 111. Few theorists have attempted to link cultural variables with the status of people with disabilities in different cultures [12]. An exception is Hanks and

Hanks’ examination of the position of people with physical disabilities in a range of non-western societies which led them to hypothesise that social integration is greater in societies in which (1) the level of productivity is higher in proportion to the population and its distribution is more nearly equal (2) competitive factors in individual and group achievement are minimized (3) the criteria of achievement are less formally absolute as in hierarchical social structures and more weighed with concern for individual capacity, as in democratic social structures [13, p. 201. It has been argued that insufficient data are available to even allow for theoretical analyses of cultural or historical variations in attitudes toward disability [2, 141. Longmore speculated that a major shift in attitudes occurred in western societies during the eighteenth century with the emergence of a medical model which no longer viewed disability “as an immutable condition caused by supernatural agency” [2, p. 3551. However scientific advances were also associated with paternalism, custodialism, punitive medical care and discriminatory legislation often justified by the theory of Social Darwinism [2, 151. The widespread segregation of, and prejudice against, people with disabilities was not seriously challenged until the civil rights movements of the 1960s [2, 161. Mechanic has also linked a society’s acceptance of scientific medicine with a reduction in the stigma attached to being disabled [17]. Other writers consider that attitudes toward people with disabilities have deteriorated in modern society. Oliver argued that the social exclusion of people with disabilities resulted from the rise of capitalism with its emphasis upon individualism, achievement and independence [18]. The devaluation of people with disabilities in America has also been linked to individualism [15].

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MARY T. WFSTBROOKet al.

Sheer and Grace presented evidence suggesting that attributing higher status to disabled people in traditional societies represents a romanticised view [12]. The issue of cultural differences in attitudes toward disability has considerable practical implications for the many nations whose members come from a variety of cultural backgrounds. This is particularly so in countries which have received large groups of migrants. Frequently the attitudes of ethnic minorities regarding illness and disability differ from the values embodied in the health care system of the host society. This situation can lead to ineffective treatment and dissatisfaction both on the part of clients and health care providers. Recent reports have described such problems among Chinese Canadians [19], Chinese Americans [S], Canadian Bruits [20], Moroccan, Turkish and Italian migrants in Belgium [21], Black minorities in Britain [22] and Cambodian refugees in Australia [23]. The cultural background of health practitioners may also have important implications for patient care. For example, a survey of elderly Australians in nursing homes found, as predicted, that residents from non-English speaking backgrounds experienced problems with Anglo Australian staff due to factors such as poor English speaking skills and different illness behaviour. However Anglo Australian residents also experienced problems in their interactions with the many staff who came from ethnic communities [24]. Australia provides an ideal setting in which to study such issues. Since World War II the government has pursued an active immigration programme. As a result the population contains a higher percentage of people born overseas than any country in the world excluding Israel. Migrants have come from all over the world but particular nationalities have predominated at different times; displaced persons from northern and central Europe came immediately after the war, followed by peoples from the Mediterranean littoral, the Middle East and currently from Asian countries. Australian core culture is similar to that of Anglo countries such as England and the United States [25]. English is the official language, although the population consists of people speaking over 120 languages. The diversity of migrants’ origins makes it difficult to generalize but overall they, and even more so their children, have been economically successful and sociably mobile. For example migrants are now more likely to own their own homes and have higher incomes than native born Australians [26]. The philosophy of cultural assimilation that the government adopted until well in the 1960s has yielded to one of multiculturalism. The problems that people from non-English speaking backgrounds experience in the health care system have begun to receive increasing recognition with the appointment of health interpreters and ethnic community health workers [27-291. The evidence suggests that Anglo-Australians with disabilities are more likely to receive, and to fare

better in, rehabilitation than those from other cultural backgrounds. Injured Anglo-Australian workers were found to make a more complete recovery and in a shorter treatment time than samples of injured Greek, Yugoslav and Lebanese workers [27]. Children with disabilities from ethnic communities are sometimes kept away from welfare and rehabilitation services and indeed from any sort of social interaction [28,29]. The incidence of disabilities reported by some ethnic groups in population surveys is much less than would reasonably be expected [9]. The reasons underlying these phenomena are complex [28]. Case study evidence suggests that an important factor is attitude toward disability: the degree of stigma that some ethnic communities attach to being disabled or having a family member with a disability [29]. Despite this, there appears to have been no research investigating such attitudinal differences. This may be due to the fact that discussion of community differences in attitudes toward disability raises many sensitive and problematic issues. Comparing attitudes with those of the dominant cultural group may be criticised as ethnocentrism. Atkin has argued that there is no justification for considering any community’s beliefs regarding disability as inferior to those of other communities [22]. Discussion of cultural differences in illness behaviour has been condemned for leading to oppression of patients through stereotyping and failing to appreciate their individual needs [28]. Furthermore, the problem of defining cultural communities makes it difficult to generalize about them particularly as there is so much diversity within communities [28]. Morrissey wrote that “the category of handicapped migrant is not so much a relevant category of social analysis as an invitation to step into quicksand” [28, p. 271. To ignore community differences in attitudes has significant implications for people with disabilities and those involved in their care. If it is accepted that people with disabilities are entitled to equal opportunities and social integration, as propagated by the World Health Organization and Disabled Rights groups, it is apparent that some communities provide extent than do others these to a greater [ 10, 13,29, 301. Atkin’s view that no community’s attitudes toward people with disabilities are inferior to those of another would condone the ultimate form of exclusion of disabled people that was carried out during the time of Third Reich [3 11. While stereotyping patients in terms of their cultural backgrounds may lead to abuses, ignoring patients’ backgrounds also leads to problems. Several Australian studies found that many health practitioners had become so sensitized by their professional training to the dangers of cultural stereotyping that they tended to deny that patients from non-English speaking backgrounds have special needs or problems [32]. However these practitioners experienced considerably more tension when caring for such patients than

Culture and disability when caring for Anglo-Australian patients. This was particularly so when the accepted illness behaviours of the patient’s community differed markedly from Anglo-Australian mores. Thus less tension was experienced in caring for Chinese than for Greek patients. Many of these practitioners emphasized that their philosophy was to treat each patient as an individual. However, ignoring the patients’ cultural backgrounds often resulted in the meaning of their behaviour being misinterpreted. Turner [33] has argued that if health practitioners are to work effectively with culturally diverse patients they need to use a tripartite diagnostic paradigm which takes account of the person’s biology, their individuality and their cultural group membership. Negative social attitudes toward people with disabilities are most likely to be expressed in terms of exclusion from, or lack of access to, social roles, activities and facilities. Thus people with disabilities are less likely to be educated, to work, to marry or to be able to go to public places [30]. The social distance scales that Bogardus developed to measure the degree of exclusion or prejudice felt toward various racial groups [34] have frequently been utilized to compare the degree of acceptance of a range of disability groups [35-381. The term stigma hierarchy refers to the order of preference for some disability groups over others as revealed by the application of such scales. Typically researchers have found that less visible disabilities such as diabetes and asthma are those which are most accepted and that visible disabilities (e.g. cerebral palsy), disabilities involving mental functioning (e.g. psychiatric illness) or disabilities for which the person is seen as morally responsible (e.g. alcoholism) are those most stigmatized [35-381. Harasymiw et al. reported that the stigma hierarchy was relatively stable in a series of studies that they carried out in the United States between 1969 and 1977 [36]. The major aim of the present research was to investigate whether there were differences in the attitudes that members of six cultural communities in Australia held toward people with disabilities. These attitudes were investigated both in absolute terms (How negative were community attitudes toward particular disabilities?) and relative terms (Did the hierarchies of preference for particular disabilities differ between communities?). A secondary aim was to compare the stigma hierarchies generated by the subjects’ responses with those reported since 1969 [35-381 to determine whether changes in disability preferences were evident. METHOD

Questionnaire

A 12 page questionnaire was devised to measure attitudes toward disability and rehabilitation. The covering page of the questionnaire explained to respondents that the aim of the survey was to explore

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attitudes within Australian communities toward disability. They were instructed to: “Answer the questionnaire in terms of your knowledge and experience of the (name of the respondent’s) community. Of course there are a range of views about disability within any community. Answer the questions in terms of what you have found to be typical, usual or average attitudes. Remember you are being asked about the attitudes you have observed within the (respondent’s) community not your own personal attitudes.” The question which is the focus of the present paper measured attitudes toward 20 specific disabilities using five point social distance scales similar to those used in previous research [35-381. The questionnaire described the five degrees of social distance or community acceptance as follows: (1) No acceptance (people would prefer a person with this disability to be kept in an institution or out of sight); (2) Low acceptance (people would try and avoid a person with this disability); (3) Moderate acceptance (a person with this disability would be acceptable as a fellow worker); (4) High acceptance (a person with this disability would be acceptable as a friend) and (5) Full acceptance (people would accept a person with this disability marrying into their immediate family). Respondents were instructed: “Below is a list of 20 disabling conditions. Within the (respondent’s) community people with some of these disabilities may be more readily accepted than others. Please consider what level of acceptance is most usually found for each disability. Next to each disability circle the number that best describes the typical acceptance level.” The 20 disabling conditions are listed in Table 1. They appeared in a different order in the questionnaire. This list of conditions was derived from past research investigating stigma hierarchies with the addition of facial scars, multiple sclerosis and AIDS [35-381. Survey respondents The questionnaire was completed by 665 health practitioners from six Australian communities, viz. Anglo-Australian (177), Arabic speaking (75), Chinese (133), German (53), Greek (116) and Italian (111). To be included in one of the community samples the respondent had to identify him or herself as a member of that ethnic community and to have some involvement in providing health care to community members. Health practitioners were chosen as subjects because they were seen as community representatives competent to report on both the cultural and disability issues being investigated. Fifty percent of the respondents were males but this ranged from 60% for the Italian sample to 59% for the Arabic, 49% for the Chinese and Greek, 44% for the Anglo and 42% for the German sample. The average ages of the groups differed significantly. The Germans were the oldest (49 years) followed by the Arabs (41), the Chinese (40), the Italians and

618

MARY

T.

WESTBROOK

Anglo-Australians (39) and the Greeks (38). The proportion of the community samples born in Australia were as follows: Anglo (79%), Greek (57%), Italian (54%), German speaking (17%), Chinese (7%) and Arabic speaking (7%). The average ages at which practitioners who were migrants had arrived in Australia were: Anglo Australians 22, Greeks 14, Italians 13, Germans 25, Chinese 24 and Arabs 26 years. These figures reflect the migration histories of the various communities. The average number of professional qualifications held by respondents was 1.3 degrees or diplomas. There was no significant difference between the communities in terms of the number of qualifications held. The major practitioner groups represented in the sample were medical practitioners (19%), allied health professionals such as physical and occupational therapists (IS%), nurses (13%), dentists (13%) and social welfare and community health workers (12%). However there were significant variations in the proportions of practitioner groups making up the various samples. To some extent these reflected the educational status of community members at the time of migration. Chinese and German migrants have tended to be of higher socio-economic status than migrants from the other groups. Career preferences for second generation members of the ethnic communities also differ. Nurses are more highly esteemed in the Anglo than in many Australian ethnic communities [24]. Nurses comprised 25% of the Anglo sample, 18% of the Chinese, 14% of the German and between 3-4% of the other community groups. The allied health professions are more usual career choices for Anglo-Australians. These therapists made up 23% of the Anglo sample and between 1 l-1 5% of all other samples except the Arabic (3%). The Arabic respondents came from fewer professions than any other community; 40% of the group were medical practitioners and 22% were welfare or community health workers. Medical practitioners made up 23% and 22% of the Italian and Greek samples respectively, 16% of the German. 13% of the Chinese and 10% of the Anglo sample. Welfare workers comprised 14% of the Greek sample and 1 l-8% of all other groups apart from the Arabic (22%). Dentists were overrepresented among the Chinese (23%), underrepresented among the Arabs (5%) and comprised IO-12% of all other groups. Procedure

The survey was conducted during 1991 in Sydney, Australia’s largest city. The ethnic samples were recruited by consulting lists of ethnic health practitioners and by contacting ethnic health, welfare and social organizations to request names of health pracAnglo-Australians were contacted via titioners. professional groups and telephone directories. Additional names of possible respondents were also requested from those who completed the question-

et al.

naire. When sampling, an attempt was made to obtain ethnic representatives from all health professions. However this proved particularly difficult with regard to the Arabic community. Initially most respondents were contacted by telephone to ask if they would participate in the survey. Questionnaires were then mailed to the respondents who returned them anonymously. Some respondents who had participated in a previous survey were mailed the questionnaire with a covering letter. Altogether 1156 questionnaires were distributed and 665 were returned. The return rates for the various communities were as follows: Anglo-Australian (65%) Chinese (60%), Italian (58%), Greek (54%), German speaking (52%) and Arabic speaking (40%). Analyses of variance were performed to examine whether there were overall differences in the attitudes of the six communities toward the various disabling conditions. As the number of respondents answering each item varied slightly, the number of degrees of freedom for the various analyses differed. If the result of an analysis of variance was significant, planned contrasts were conducted to compare the ratings of each of the ethnic communities with those of the Anglo-Australians. As multiple tests were being carried out, the Bonferroni adjustment was made to control for type 1 errors in the statistical analysis as a whole. Each comparison was therefore deemed to be significant if it reached the tl = 0.01 level. The similarity between the stigma hierarchy of the Anglo-Australian community and those of each of the five ethnic communities was ascertained by calculating Spearman rank order correlation coefficients. This method was also used to compare the stigma hierarchy of the total sample with four reported since 1969 by other researchers [35-381.

RESULTS

As shown in Table 1, the results of the analyses of variance revealed the existence of significant differences in community attitudes toward people with 19 of the 20 disabilities investigated. No difference was found between the communities’ attitudes toward people with arthritis. The planned contrasts revealed that the attitudes of Anglo-Australians differed significantly from at least one of the other communities regarding 16 of the disability groups. The German community was significantly more accepting than were Anglo-Australians of people with five disabilities: amputation, stroke, cerebral palsy, psychiatric illness and mental retardation. Compared to Anglo-Australians the Italians were less accepting of people with five conditions: asthma, amputation, blindness, paraplegia and AIDS. The Greek community was less accepting of people with ten disabilities: asthma, diabetes, heart discancer, stuttering, blindness, ease, amputation, epilepsy, paraplegia and AIDS. The Arabic speaking

(I) (2) (3) (4) (5) (6) (7) (8) (9) (IO) (11) (12) (13) (14) (IS) (16) (17) (18) (19) (20)

4.64 4.53 4.42 4.29 3.94 3.75 3.74 3.70 3.64 3.48 3.37 3.34 3.28 3.13 2.75 2.70 2.20 2.01 1.97 1.93 3.34

Anglo (2) (1) (3) (4) (5) (6) (7.5) (7.5) (9.5) (II) (9.5) (13) (12) (14) (15) (16) (17) (19) (18) (20)

4.48 4.62 4.43 4.41 4.25* 4.04 4.00 4.00 3.90 3.73 3.90* 3.49 3.59 3.27 2.96 2.85 2.63. 2.40’ 2.50. 2.12 3.59.

German (2) (I) (4) (3) (8) (IO) (7) (6) (II) (9) (5) (12) (13) (14) (16) (15) (18) (19) (17) (20)

4.30’ 4.41 4.23 4.28 3.54* 3.51 3.57 3.58 3.26’ 3.53 3.60 3.09 3.06 2.67* 2.51 2.54 2.15 2.05 2.22 1.53’ 3.19’

Italian (2) (I) (4) (3) (6) (II) (10) (5) (8) (7) (9) (12) (13) (15) (14) (16) (17) (19) (18) (20)

4.26’ 4.29* 4.038 4.15 3.42* 3.19* 3.21’ 3.52 3.34’ 3.25 3.24 3.00’ 2.97 2.67. 2.85 2.20’ 2.19 1.89 1.99 1.16* 3.02’

Arabic

(ranks

(1) (2.5) (4) (2.5) (8) (9) (6) (7) (II) (IO) (5) (13) (12) (14) (15) (16) (17) (19) (18) (20)

4.24’ 4.22’ 4.07’ 4.22 3.42. 3.39’ 3.46* 3.44 3.26* 3.35 3.55 2.96* 3.08 2.70, 2.65 2.54 2.24 2.04 2.17 1.60* 3.15*

Greek

mean social distance ratings’

W&l distance ratings range from 5 (high acceptance) to I (low). bd/ranged from 5/654 to 5/644 for individual disabilities and were 5/607 for the average ratings. lt ccmtrast between ethnic and Anglo-Australian ratings yielded P < 0.01.

Asthma Diabetes Heart disease Arthritis Amputated arm or leg &“WX Stuttering Facial scars, birthmarks Blindness Deafness Stroke Epilepsy Multiple sclerosis Paraplegia Dwarf Alcoholism Cerebral palsy Psychiatric illness Mental retardation AIDS Average rating

Disability

Community

(2) (I) (4) (3) (8) (IO) (9) (5) (II) (6) (7) (12) (14) (15) (13) (16) (17) (19) (18) (20) 4.31. 4.34. 4.15. 4.18 3.48* 3.42. 3.48’ 3.89 3.32’ 3.55 3.54 3.20 3.07 2.76* 3.15. 2.45 2.39 1.89 2.23. 1.518 3.19.

Chinese

in brackets)

Table 1. Results of analyses of variance comparing community social distance ratings of disabilities, planned contrasts comparing of other communities, and ranking of social distance ratings for each community

(2) (1) (4) (3) (6) (8) (7) (5) (II) (10) (5) (12) (13) (14) (15) (16) (17) (19) (18) (20)

6.38 4.77 6.57 I .25 12.12 7.15 6.20 4.23 7.23 2.65 4.82 3.55 3.96 6.37 5.88 3.97 2.71 3.10 3.91 15.90 9.24

Fb

of Anglo-Australians

4.39 4.40 4.23 4.25 3.66 3.54 3.57 3.68 3.44 3.47 3.50 3.18 3.16 2.86 2.80 2.55 2.27 2.02 2.14 1.65 3.24

Total Group

attitudes