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Maya Thomas* and M.J Thomas

Cultural factors influence our attitudes towards most of the happenings around us, including our attitudes towards disability and rehabilitation. The term `handicap' is defined in relation to contextual factors that are predominantly cultural. Though the influence of cultural factors is great, many community based rehabilitation programmes fail to recognise them sufficiently. Western stereotypes of `community' are used in the planning of many CBR programmes in developing countries whose communities have their own individuality. These programmes expose themselves to a higher risk of failure because they tend to conflict with the cultural factors of the host country. In the following essay, an attempt is made to illustrate the significance of cultural influences on disability and rehabilitation, in the context of CBR.

In many developing countries, `individual rights' as expressed in industrialised nations, do not exist. Traditionally in these countries, an individual is born in a kinship group, with a network of relationships that involve mutual obligations with regard to religious and economic factors. People look towards their immediate kin for welfare and help, rather than at the traditional western types of formal services. Because of this kind of relationship, the process of `empowerment' of an individual in this society is more complex, irrespective of whether he is a disabled person or otherwise. Hence, during planning of rehabilitation programmes, one has to also consider the different aspects of cultural influences in these countries.

A paper by Rehman (1) about the influence of traditional and religious beliefs on the practice of CBR in the North West Frontier Province of Pakistan, illustrates this point well. This paper describes how cultural factors influence the outcome of CBR and explains how certain modifications were introduced in this purdah observing province of Pakistan, to align the CBR services appropriately to the traditions and customs prevalent there. A review by Coleridge (2) on the history of 'negative attitude' towards disabled people, concludes that `attitude' towards disabled people was not always 'negative', and that historically it had been a mixture of 'tolerance' interspersed with 'persecution'. These attitudes however, influence the perception of the causation of disability, reactions towards disabled people, child rearing practices, education and vocational rehabilitation of disabled people. In another review of cultural influences on planning, Miles (3) analyses the reasons for western misinterpretation of cultural variables, and the effects of this misinterpretation on South Asian disability planning.

'Cultural factors' are described in the broad sense as a set of variables related to tradition, ethnicity and religion, grouped together into a single entity. Even across the population of a single country, there are substantial differences in ethnicity, caste, religious practices and so on, which are recognised by different laws applying to different groups within the same nation. What seems to be ethically correct behaviour in one group of people, may not be recognised as such by a different cultural community. The recognition of these kinds of differences in the perception of 'normalcy' and 'disability' is very important in the case of rehabilitation, since what is considered a 'handicap' in one cultural context may be considered normal in another context. For example, Benares, a place of worship for Indians, had most of its blind people living in their homes and begging in the streets of the town during the day. They could earn more money begging and living at home, and preferred to do this, rather than stay in an asylum where begging was forbidden. Unless some one was truly destitute or handicapped, and unable to earn his living, one did not want to seek shelter in an asylum (4). If the western ideologies related to human rights and community based rehabilitation are applied in the community of these blind people without due regard to the indigenous concepts of community-accepted behaviour, it is more likely to fail in practice.

The International Classification of Impairments, Disabilities and Handicaps (ICIDH), a linear model of progression of disability from disease, impairment, disability to handicap, recognises 'handicap' as a social disadvantage resulting from impairment or disability (5). However, the more recent modification of ICIDH, yet to be adopted, views this definition of 'handicap' as deficient in the description of the influence of contextual factors, and suggests replacement of the term 'handicap' with the level of 'participation' in life situations. Many of these contextual factors that determine participation of a disabled person in his environment are culturally influenced. Plans to initiate rehabilitation services without consideration of these contextual factors leads to frequent failures in programmes.

In the past two decades, WHO, ILO and UNDP have made great efforts to promote a more cost effective, home-based rehabilitation service delivery system which is designed as a 'community therapy programme' called CBR, in developing countries. In the beginning, this model practised community located interventions, nearly identical to that of the clinical setting in institutions, dealing primarily with impairments. Gradually it was recognised that these programmes did not produce the desired impact unless the extrinsic cultural factors were recognised and goals modified accordingly. In 1994, the UN organisations, in their joint position paper, reviewed CBR in a different perspective and emphasised the contributions from external contextual factors. The goal of the CBR programmes was redefined as integration of the disabled person within his community, rather than relief of impairment or disability in disabled persons (6). This broader view of CBR in the community development perspective, reduces the importance of medical rehabilitation into a less significant peripheral activity.

In the past two decades, CBR programmes were actively promoted in different parts of the world. In the developing countries, the aim of this pattern of devolution of rehabilitation services was to increase coverage, and to gain access to the required resources from the community. However, there were scanty efforts at promoting community ownership in these programmes. As a result they were most often practised with a 'top-down' management style, and rarely did the practitioners take into account the relevance of cultural factors. The rural communities in developing countries are often exposed to severe economic pressures. During this time, their primary focus shifts to survival and overcoming poverty rather than dealing with disability. This can also be better understood from the explanations of Ranganathananda (7) about Indian democracy. 'Citizenship' as an identity entailing community responsibility is weak in much of South Asia. The members of the society expect the rulers to shoulder the entire responsibility of the society, while they consider themselves free of societal responsibilities. In these societies 'participation' and 'bottom-up' management styles are alien and can only be brought about by pre-planned strategies.

There are many other specific areas of cultural influences that affect disability and rehabilitation. Many of them have been recognised by different authors practising CBR in different parts of the world. For example, the Afghan society views 'empowerment' in a different light from the western societies. In Afghanistan as in many Asian countries, 'empowerment' of the individual as seen in the western context, is perceived as being selfish and undesirable. Being altruistic for the sake of the family and for the larger society has a higher value. The term 'empowerment' can at best be interpreted only as a right to access provisions and services on an equal footing as others. Similarly, women in Afghan society remain segregated from men, and 'integration' of disabled women into the 'community' is perceived in a different context from the west, as an integration into the subgroup of segregated women. Rehman (1) has written about CBR programmes that have been successfully practised in these conditions, by adopting unusual strategies that were suitable for the cultural context of the country in which the programmes operate. Another example is from the CBR programme in Rupununi, a Guyanese village, as reported by Pierre (8). The Rupununi villagers have a rudimentary style of living, which facilitates spontaneous rehabilitation of hearing impaired people as farmers, fishermen and cooks, and where blind persons can go fishing sometimes. The Rupununi CBR programme assimilated ideas from the spontaneous rehabilitation practices that had already existed in this community, to design training materials that were appropriate to their cultural requirements. There are also other reports of traditional 'attitudes' influencing the outcome of rehabilitation positively as well as negatively (9,10).

A quick perusal of the available literature identifies the influence of cultural factors on disability and rehabilitation, especially during the implementation of CBR programmes. Yet CBR planners give little respect to these factors during policy development and planning, risking failure of their projects. Decentralisation of rehabilitation services into the community and integration of disabled persons into their society, calls for closer interactions with cultural factors. Hence CBR policies require a greater understanding of the 'needs' of the community, which are in many instances biased by the traditional practices in that community. A 'needs analysis' of a community's needs with regard to rehabilitation, highlights the community's understanding of the causation of disability, the prevailing attitudes, the present practices in rehabilitation, the readiness of the community to accept the services, the level of priority assigned by the community for rehabilitation and so on. A community 'resource analysis', identifying the potential resources from the community, particularly traditional resources, along with the community's expressed needs, improves the relevance and efficiency of a rehabilitation policy manifold. In a recent article by Kalyanpur (11) the author illustrates how, many of the western ideas of 1970s in special education were exported to Asia in the 1980s, apparently with little awareness that Asian communities performed at a different threshold of economic, social and educational development, and how such a transplantation might have become problematic later.

Tradition, ethnicity and religion play a very important role in determining our behaviour in day to day life. These cultural factors influence our attitudes towards most of the happenings around us, including 'disability'. The term 'handicap', the most influential parameter for intervention in rehabilitation, is defined in relation to contextual factors that are predominantly cultural. The influence of cultural factors is so great, that many community based rehabilitation interventions fail as a result of scanty recognition of these factors. Yet the fact is that we recognise culture as only an insignificant determining factor for success, while planning our programmes. Western stereotypes of 'community' are used in the planning of many CBR programmes in developing countries whose communities have their own individuality. These programmes expose themselves to a higher risk of failure because they tend to conflict with the cultural factors of the host country. Rehabilitation is a gradual and long process that cannot escape the influences of local cultural factors, and hence it is difficult to propose a universal theory for all aspects of rehabilitation, just as it is difficult to have a universal model for interventions in rehabilitation.

*J-124, Ushas Apts., 16th Main, 4th Block, Jayanagar, Bangalore - 560 011, India.
Tel & Fax : 91-80-6633762,
E-mail : thomasmaya@hotmail.com

This paper is an adaptation of the one presented at the 7th European Regional Rehabilitation Conference of Rehabilitation International, Jerusalem, Israel, November 29-December 3, 1998.


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5. WHO : International classification of impairments, disabilities and handicaps. Geneva : World Health Organisation, 1980.

6. ILO, UNESCO, WHO : Community based rehabilitation for and with people with disabilities : Joint position paper. Geneva : United Nations, 1994.

7. Ranganathananda S : Enlightened citizen and our democracy. Indian Journal of Public Administration 1995, XLI, 609-612.

8. Pierre L : Working with indigenous peoples. In : O'Toole B, McConkey R, eds. Innovations in Developing Countries for People with Disabilities. Chorley, UK, Lisieux Hall Publications, 1995 : 39-50.

9. Thorburn MJ : Attitudes towards childhood disability in three geographical areas in Jamaica. Asia Pacific Disability Rehabilitation Journal 1998; 9 (1) : 20-24.

10. Khatleli P, Mariga L, Phachaka L, Stubbs S : Schools for all : National planning in Lesotho. In : O'Toole B, McConkey R, eds. Innovations in Developing Countries for People with Disabilities. Chorley, UK, Lisieux Hall Publications, 1995 : 135-160.

11. Kalyanpur M : The influence of western special education on community based services in India. Disability & Society 1996; 11 : 249-270.

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