Introduction
South Africa has a population of 51.8 million people of which 7.5% over the age of
five has a disability according to the latest census data (Statistics South Africa
2014). This statistic on the national prevalence of disability should be interpreted
with caution since psychosocial and neurological disabilities are not accounted for
(Statistics South Africa 2014). The most recent data on disability in South Africa
is from the national census of 2011, which defined ‘disability’ as:
… a physical or mental handicap which has lasted for six months or more, or is expected
to last at least six months, which prevents the person from carrying out daily activities
independently, or from participating fully in educational, economic or social activities.
(Statistics South Africa 2014)
In South Africa 38% of the population resides in rural areas, and 25% of the labour
force is unemployed (The World Bank 2014). At the time of the national census in 2011,
more than a quarter (26.3%) of all poor people in South Africa resided in KwaZulu-Natal
(KZN), most living below the per capita upper-bound poverty line of R620 per month
(Statistics South Africa 2014). The co-existence of poverty and disability reinforces
one another (Grech 2009; Sala-i-Martin 2005). High levels of poverty together with
the high incidence of disability and the large percentage of the population living
in rural areas, present challenges to providing ‘health for all’ in South Africa (Department
of Health [DOH] 2010; Schaay & Sanders 2008).
Rural health
Equitable access to health care is a right of every person with a disability (United
Nations [UN] 2008; Heapa, Lorenzo & Thomas 2009). A number of barriers to access in
rural areas such as long distances to hospitals or clinics and poor public transport
have been identified in the literature (Beatty et al. 2003; Harris et al. 2011; Maart
et al. 2007). In South Africa the attitudes of society, and practices and ideologies,
have been highlighted as important environmental barriers in rural areas (Maart et
al. 2007). Societal perceptions, practices and ideologies form the basis of cultural
beliefs, a known but less-explored barrier to accessibility of medical services in
rural areas (MacLachlan 2006).
Cultural beliefs
Cultural beliefs define who people are, how they interact with the world and how they
behave in certain situations, and can be considered a combination of religious beliefs,
socially accepted norms and traditions (Bailey, Erwin & Belin 2000; Omu & Reynolds
2012; Maart et al. 2007). Culture plays a central role in health related behaviours
(Carroll et al. 2007; Omu & Reynolds 2012). The importance of cultural beliefs regarding
health and health seeking behaviour has been well-documented (Bailey et al. 2000;
Carroll et al. 2007; Legg & Penn 2013; Maart et al. 2007).
Different cultural groups have vastly different perceptions of the causes of disability
and disease and these perceptions influence their health seeking behaviour (Bailey
et al. 2000; Legg & Penn 2013; Pronyk et al. 2001). According to the South African
Department of Health's Disability Survey, 3% of the population stated ‘bewitchment’
as the cause of their disability (DOH 2002). In a rural South African study the belief
that ‘bewitchment’ caused tuberculosis resulted in a delay in seeking Western health
care (Pronyk et al. 2001). Omu and Reynolds (2012) conducted a similar study into
health seeking behaviours in Kuwait, and although persons with disabilities believed
that their disability had a divine origin it did not stop them from utilising rehabilitation
services. It is thus imperative to understand how a specific cultural group's beliefs
influence their health seeking behaviour.
Rehabilitation
Rehabilitation plays an essential role in minimising the impact of impairments on
the activities of daily life and participation in their communities of persons with
disabilities (World Health Organisation [WHO] 2011). Rehabilitation is also commonly
used as an umbrella term for the therapy provided by different therapists and rehabilitation
workers working together towards the common goal of improved functionality and quality
of life for the person living with the disability. Physiotherapists have an important
role to play in primary, secondary and tertiary prevention of disability in developing
countries (Wickford & Duttine 2013). Rehabilitation is ideally provided by a multidisciplinary
team, but most often physiotherapists or occupational therapists are the only rehabilitation
workers servicing rural areas (Bateman 2012; WHO 2011). Human resources for health
have been identified as a key priority for rural health care in South Africa (Versteeg,
Du Toit & Couper 2013). Attracting and retaining staff to work in rural areas is a
problem worldwide, and understanding the difficulties health care professionals face
in these settings, is imperative to implementing retention strategies (Rural Health
Advocacy Project [RHAP] & Partners 2013).
Therapists’ perspective
Exploring the perspectives of the rehabilitation therapists aids in the understanding
of the challenges they face as well as gaining insight into difficulties with rural
rehabilitation. However, few studies explore the role of physiotherapists, occupational
therapists and speech therapists working in rural areas and their views on factors
that affect their services.
Rationale
Health promoting programmes in developing countries are often not successful because
of a lack of compatibility with culture specific beliefs (MacLachlan 2006).
Health care professionals’ lack of cultural awareness may lead to cultural imposition
(Campinha-Bacote 2002). In order to provide an effective and culturally responsive
health care service to the multi-cultural population of South Africa, health care
workers need to be culturally aware and competent (Carroll et al. 2007; Campinha-Bacote
2002). According to Campinha-Bacote cultural awareness is a study of your own cultural
biases and background in order to prevent imposing your own cultural beliefs on another
cultural group. Cultural awareness is also considered the cornerstone to become culturally
competent. According to Campinha-Bacote's (2002) model of cultural competence, becoming
culturally competent consists of five constructs namely cultural awareness, knowledge,
skill, encounters and desire of which cultural knowledge is a key factor. Cultural
awareness relates to self-exploration and reflection on your own beliefs regarding
culture. This process is an important step in trying to recognise your own biases
in order to avoid imposing your own cultural beliefs on others. Cultural knowledge
can be built by engaging with persons from different cultural backgrounds. The knowledge
component that this article relates to is an understanding of a specific cultural
group's worldview of their disability or disease, and how they make decisions regarding
their own health. Cultural skill refers to the health care provider's ability to perform
a physical assessment of a patient taking into consideration variations within different
cultural groups. Cultural encounters and desire refer to the individual's initiative
to experience difference cultures (Campinha-Bacote 2002). This article intends to
enhance cultural awareness by the exploration of therapists’ perceptions about cultural
beliefs.
The fact that cultural beliefs often lead to discrimination against persons with disabilities,
has been covered in the literature. In a study on the abuse of disabled children in
Ghana, the cultural belief that disabled children were cursed, led to such severe
stigmatisation that children were often hidden away by their parents, or left at a
river to die (Kassaha et al. 2012). However, more needs to be known about the perspectives
of physiotherapists, occupational therapists and speech therapists on factors that
affect their rehabilitation services in rural areas (Bateman 2012). Cultural beliefs
can be considered as personal factors within the International Classification of Functioning,
Disability and Health (ICF) framework that could potentially disable a person with
an impairment. Identifying personal and contextual barriers that are associated with
cultural beliefs will assist in minimising activity limitations and promote the integration
of persons with disability into society (WHO 2001).
The aim of this study was to explore the experiences of rehabilitation therapists
(physiotherapists, occupational therapists and speech therapists) working in a rural
area in Kwazulu-Natal (KZN). The theme of cultural beliefs as a barrier to rehabilitation
emerged so strongly in every focus group discussion, that it was explored in more
depth with probing questions. This article primarily reports on the perceived effect
of cultural beliefs on the utilisation of rehabilitation services in a rural community,
potentially raising cultural awareness amongst therapists. Although the patients’
perspective could be considered a more accurate view of the beliefs that affect their
utilisation of rehabilitation services, the view of experienced therapists working
in a rural area is also an important consideration. The therapists’ views might be
biased, but provide insight into their perceptions of cultural beliefs, and are important
for improving rehabilitation services (Suddick & De Souza 2007). Raising cultural
awareness amongst therapists working in rural areas could begin to address some of
the many contextual factors inhibiting patients from accessing rehabilitation.
Methodology
Research question
Do cultural beliefs affect the utilisation of rehabilitation services in a rural community
in South Africa?
Aim
To explore the cultural beliefs that affect the utilisation of rehabilitation services
in a rural community in South Africa from the therapists’ perspective.
Design
An explorative qualitative design was utilised because very little information is
available on the topic, and the problem is not well understood (Berg 2001). The primary
method of data collection was focus group discussions (FGDs). A focus group uses a
guided, interactional discussion as a means of formulating the details of complex
experiences and the reasoning behind individuals’ actions, beliefs, perceptions and
attitudes (Powell & Single 1996). Demographic information was also obtained and documented
for each participant at the start of the focus group, but will not be published in
order to respect the confidentiality of the participants.
Setting
This study was conducted in a rural district in the KZN province of South Africa.
The population in this district mainly represents the Zulu cultural group. Rurality
is poorly defined in the South African context, but is generally classified according
to the lack of infrastructure found in urban areas such as tarred roads, running water
and electricity supply (Department of Provincial and Local Government [DPLG] 2000).
Duncan, Sherry and Watson (2011:30) define rurality as the combination of multiple
factors affecting the quality of life of people living in sparsely habituated settlements
with limited access to public services. The Rural Doctors Association of South Africa
(2006) considers an area ‘rural’ when more than 50% of the population lives further
than five kilometres from a tarred road, and 25% of the population has to collect
water from natural sources.
Participants
The sampling frame for the study consisted of all rehabilitation therapists working
at five district hospitals in a rural community in South Africa. All available therapists
who agreed to participate at the time of the discussion were included. A total of
17 rehabilitation team members were conveniently selected to participate in the FGDs
that were conducted at each of the five hospitals. The 17 participants included eight
physiotherapists, seven occupational therapists, one dietician and one speech therapist.
Data collection procedure
The head of the therapy department at each hospital was contacted telephonically,
and appointments were made at a time that was convenient for most of the staff members,
bearing disruption of their normal duties in mind. Data was collected by the researcher
in person. The purpose and aim of the study was explained to all participants, and
participating members signed an informed consent form agreeing to be audio-taped.
Each participant completed the demographic survey. All five the FGDs were conducted
at the therapy departments of the respective hospitals, and voice-recorded.
Method of data collection
The focus group discussions were started with one grand question: ‘Can you please
tell me more about your experiences as a rural therapist/rehabilitation team member?’.
Participants freely shared any experience that they chose and the discussion flowed
from the first participant's comments. The topic of how cultural beliefs affected
the therapists’ experiences and especially the patients’ health seeking behaviour
was raised by the therapists at each FGD, and probing questions were asked to explore
this topic in more depth in subsequent FGDs. The fact that this topic was raised in
every FGD without initial prompting from the researcher enhanced the relevance of
it to this rural area, and the importance of cultural awareness to the therapists.
Data analysis
The qualitative data was analysed using Creswell's (2009:185) eight step process of
analysis. According to Creswell, following these steps from working with raw data
to interpreting the meaning of themes assists in validating the accuracy of the information
obtained from qualitative research studies. The interviews were transcribed verbatim,
and checked for any mistakes or missed words against the audio recording. Checking
of transcripts improves the trustworthiness of the findings (Gibbs 2007). All the
interviews were conducted in English. The transcriptions were read and re-read several
times by the researcher in order to gain an overall understanding of the data before
commencing with the coding process. Making use of open and axial coding (Creswell
2009), transcripts were coded to identify common concepts within the participants’
responses. Codes were grouped into categories, and similar categories were analysed
and emerging themes identified.
Ethical considerations
Ethical clearance to conduct the study was obtained from the senate research committee
at the University of the Western Cape. Permission was obtained from the relevant provincial
Department of Health and the management of all the hospitals involved in the project.
All participants gave informed consent in writing and agreed that their voices could
be recorded. Participants were guaranteed that their identity would be kept confidential,
and pseudonyms (P1–P17) were used in the transcription of the data instead of the
participants own names. Only the researcher and the person who did the transcriptions
had access to the voice-recordings. Participants were ensured that they could withdraw
from the study at any time during the interviews without any consequences, and that
they could inform the researcher if in hindsight they decided that what they had said
could not be used for research purposes. No therapist made use of this opportunity
or asked that anything that they shared should not be included in the study.
Trustworthiness
A summary of each focus group discussion was sent back to the participants for review
to establish that their comments were not misinterpreted by the researcher and to
ensure dependability. The confirmability of the research was enhanced by asking an
independent reviewer to analyse the raw data and compare the various categories and
themes. An independent reviewer cross-checked the codes to determine inter-coder agreement
and improve the trustworthiness of the findings (Creswell 2009). The specific findings
of this study do not have high transferability, because the cultural beliefs mentioned
in the study might only be representative of the specific cultural group. The general
influence of cultural beliefs on utilisation of rehabilitation services might however
be applicable to other cultural groups in rural regions of South Africa.
Findings
Participants
The mean age of the participants was 27 years at the time of data collection. The
racial distribution of participants was almost equal. Nine Caucasian and eight African
staff members participated in the discussions. Of the 17 participating therapists,
10 were female, and 7 were male. The mean years of experience working in a rural area
was five years for permanent staff members, and three and a half years when taking
the community service therapists (contract staff) into consideration.
According to therapists working in this area, cultural beliefs play a major role in
the utilisation of rural health services. In this specific Zulu community different
beliefs affecting rehabilitation services were identified. These beliefs were grouped
into two themes: cultural beliefs preventing patients from accessing rehabilitation
services, and cultural beliefs affecting the rehabilitation process of the patient
when utilising the service.
Cultural beliefs preventing the utilisation of rehabilitation services
Several cultural beliefs seemed to prevent patients from utilising rehabilitation
services. These factors were categorised into beliefs about the cause of a disease,
stigma and community perception of a person's worth.
Beliefs regarding cause of disease
The therapists reported that patients believed that their pain and disease is of a
spiritual nature and that Western medicine cannot cure them in the spiritual realm.
This belief often leads to the refusal of hospital treatment, with patients opting
to consult a ‘spiritual’ or traditional healer. One therapist reported patients saying:
‘I had a dream last night that somebody stood on me in my dream and now it's a curse
that's been put on me [therapist quoting a patient's description of how his pain started]
(P6)’.
‘…[Y]ou can't separate traditional and cultural factors from your treatment but you
can do as much as you can in the hospital and if the family decides to go and consult
with a traditional healer you can only advocate this much…you can't judge it either,
you can't say you are doing the wrong thing and you are going to kill this person
if you do this’ (P6).
Stigma
Therapists highlighted that patients often do not attend therapy because it is too
difficult for them to get to the hospital or clinic as a result of the stigma attached
to being disabled. Taxis and cars will not stop to provide transport for persons with
disabilities because they believe that the person might be cursed; so if people with
disabilities do not own a car or is not able to drive themselves, they cannot attend
therapy. According to Participant 4:
‘Some people discriminate against moms with disabled children because they are “strange”
and they don't like having them in their cars … it's not always just money, its people's
attitudes towards disabled people’.
Community perception of worth
Persons with disabilities were perceived to be less valuable in their communities
or household if they were dependent on carers and could not continue contributing
towards the household. This was more evident when the patient did not receive a disability
grant. Subsequently therapists reported that their condition often deteriorated at
home:
‘…[Y]ou find, at home the people who are supposed to be looking after the patients,
you know, usually lose that kind of care for the patient, because now the patient
has to depend on them foreverything, so you find that most of those patients, their
condition usually get worse’. (P10)
Cultural beliefs affecting the utilisation of rehabilitation services
In some cases patients did commence rehabilitation, but cultural beliefs played an
important role in the patients’ conviction regarding the efficacy, continuity and
quality of rehabilitation, from the therapists’ perspective.
Lack of conviction about the efficacy of rehabilitation
Patients did not belief that rehabilitation would be effective in decreasing their
disability, because they do not understand the cause of their problem, or they believe
that it has a mystical origin:
‘I had specifically a girl that has a psychological gait pattern, she was telling
me that people don't want her to walk, and that people have cursed her … So we've
sent her to the psychologist to see what it was, he told us that she has the ‘ukuthwasa’
or the calling to become a sangoma, and if you deny that calling, then it will manifest
physically in your body as a disability. You can do whatever you want for her, but
if she believes that this is ‘ukuthwasa’ and unless she goes that route it will not
be sorted out (P11).
To go now [and advise the patient] you need to go do these exercises after you [the
patient] think you've got this pain because you had this dream or you've been bewitched
or something is a very, very challenging thing’ (P6).
Continuity of rehabilitation
Often patients come for rehabilitation but their cultural roles prevent them from
complying with therapy or rehabilitation; for example, only women traditionally fetch
and carry water on their heads. If a female injured her neck or suffers from arthritis,
she is culturally not allowed to modify her behaviour in order to rehabilitate her
injury. ‘Women are expected to “twala” [carry] everything so if they are sick they
understand, but still continue with the work’ (P7).
Patients in rural areas also seemed to have a cultural misconception that therapists
from their own culture were less qualified or less capable of providing a good service
than therapists from other cultures. They would sometimes stop rehabilitation if they
realised that the therapist was someone they knew from the area, or if they were from
their own race:
‘…[B]ecause we are black, people they undermine us. If you are from the local area
… they say, oh, you know me …’ (P8).
‘…[S]o that is the kind of perception that they'll have that …hey, you don't write
on my file if you are, you know, my own race!’ (P10).
‘[I]t's just the kind of perception that they have, you know, the only educated person,
you know is the white person, especially with the old age group [older person]’ (P10).
Quality of rehabilitation
Most therapists felt that the quality of the rehabilitation services that they provided
was compromised by cultural beliefs. This was true for therapists from the same and
different cultures. Therapists from a different culture who did not speak the local
language rely on translators to assist with the diagnosis and treatment of the problem.
Therapists felt that the local translators modified what they said to the patients
because they did not believe or understand what the therapist was trying to explain
to the patient. ‘The way that the translators will translate … it's like you say this
long like sentence and they [the translator] just say like two words … they don't
understand’ (P1).
Cultural beliefs also made the provision of certain services impossible. Therapists
felt that mental health problems were especially difficult to negotiate:
‘As an OT [occupational therapist] for mental health issues … I don't even go there
because there are so many cultural beliefs involved … there's so many, to do that
through a translator as well, I find it very difficult’ (P2).
Therapists became discouraged and felt that lack of conviction about the efficacy
of therapy and lack of belief that therapy can improve the patient's quality of life
negatively affected the quality of services they provided. 'Their [the patients’]
attitudes [towards the service] affect the services we are giving … they don't see
the meaning of what we are doing’ (P8).
Discussion
The finding relating to the cultural belief that disability has a spiritual or mystic
origin that was evident in this study corresponds with the findings of Madden et al.
(2013), the DOH (2002), Carroll et al. (2007) and Bailey et al. (2000). All these
studies noted that in many cultures people still believe that their disability or
disease manifests itself as a result of wrongdoing against their ancestors, and are
spiritual in origin. Legg and Penn (2013) also reported that patient explanations
of the causes of aphasia after a stroke were strongly influenced by cultural beliefs.
They report that patients with aphasia believed that misfortune or other spiritual
causes resulted in them having a stroke and subsequently aphasia. This perception
of the cause of the condition negatively affected this population's health seeking
behaviour. In a study conducted by Kassaha et al. (2012:695) in Ghana regarding abuse
of disabled children, these children were often killed based solely on the cultural
belief that they were ‘supernatural’ or ‘cursed beings’. These studies support the
perception of therapists in this study that patients’ cultural beliefs regarding their
disability play an important role in the utilisation of, and belief in, the efficacy
of rehabilitation.
The establishment in this study that beliefs regarding aetiology of diseases affect
health seeking behaviours correspond with the findings of Pronyk et al. (2001). In
his South African study on the health seeking behaviour of patients with tuberculosis,
Pronyk reported that the patients’ cultural beliefs regarding the aetiology of tuberculosis
was a strong barrier to the utilisation of health care services.
Cultural beliefs regarding the causes of disability do not only affect the health
seeking behaviour of patients living in rural areas, but also their conviction about
the effectiveness of therapy services. Therapists reported that if patients believed
that their disability was caused by an ancestral curse, the patients would not comply
with doing exercises because they would not be able to rationalise how it could remove
the curse in order to heal them. This finding is resonated by Madden et al. (2013)
who reported that physiotherapists had very little success in treating patients with
lower back pain in a very similar rural setting. One of the reasons given for this
finding in this study, was because of the patients’ cultural beliefs regarding the
cause of their back pain. It was noted that patients rarely adopted the suggested
exercises or treatments since they did not believe in the efficacy of it, in light
of their beliefs regarding the cause of their pain.
Therapists expressed the view that cultural expectations affected compliance with
therapy. In order to relieve the patient's pain, the therapist has to ask the patient
to make certain lifestyle changes or modify their behaviour, for example, to stop
carrying heavy buckets of water on their heads. The cultural expectation in the Zulu
culture is that it is the female's responsibility to fetch and carry water (Madden
et al. 2013). Madden also described similar findings in relation to females with back
pain carrying heavy buckets of water on their heads. The role of the female in the
traditional Zulu culture is to serve her husband, and care and provide for her family.
Therapists found that patients simply could not comply with recommendations to stop
carrying heavy 25 litres buckets on their heads due to cultural expectations (Madden
et al. 2013). Even though cultural roles and beliefs could play a role in preventing
lifestyle changes, socio-economic factors and structural poverty could also affect
these decisions (Bohrat & Kanbur 2006). Lack of access to running water might force
a female to continue fetching water especially if the males are working in cities
as migrant workers as it is often the case in rural areas (Coovadia et al. 2009).
Madden et al. (2013) reported that physiotherapists in South Africa were generally
ill-trained and unprepared for the cultural and contextual factors that influence
rehabilitation in rural areas. Culture specific knowledge regarding the aetiology
of disease in rural communities is vital in promoting rehabilitative services in these
areas. The cultural beliefs of this specific community also impacted negatively on
the perceived quality of rehabilitation provided by the therapists. In this rural
district in South Africa there is still a tremendous need for health education regarding
the cause of disability where very few persons with disabilities are currently seeking
rehabilitation. Therapists do recognise that cultural beliefs regarding the aetiology
of their disability are only one of many barriers to accessing rehabilitation services
in this setting. The list of environmental barriers such as lack of infrastructure,
the poor public transport system, high unemployment rates and poverty are all factors
limiting accessibility (Madden et al. 2013; Maart et al. 2007).
All therapists were aware of these factors and indicated that a community based rehabilitation
(CBR) approach would be far more beneficial in meeting the needs of the community
(WHO 2010). They did, however, note that staff shortages and lack of vehicles for
therapists to do home and clinic visits were amongst the main barriers to implementing
a more effective CBR programme. Currently no new community health workers are being
employed or trained in order to implement CBR in this rural district. Only community
caregivers were employed by the DOH, and they were not trained or allowed to do CBR.
In one of the rural hospitals eight therapists (four permanent and four community
service therapists) are employed to service approximately 100 000 people over a surface
area of 3000 square kilometres (Kwa-Zulu Natal Department of Health [KZN DOH] 2001b).
This amounts to a therapist to patient ratio of 1 to 12 500, with each therapist being
responsible for approximately 375 square kilometres of rural surface area. At this
specific hospital therapists were aware of one community health worker that was still
employed by the hospital to cover all 3000 square kilometres – and this person was
also blind. Because of the large distances that have to be covered in order to provide
an effective CBR service, more trained staff and community health workers as well
as vehicles that can accommodate rural terrain will be beneficial.
Stigmatisation of persons with physical disabilities is well-documented (Bagenstos
2000; McMaugh 2011; Tyrrell et al. 2010; Wang & Dovidio 2011). According to Bagenstos,
society has historically discriminated against persons with disabilities based on
their ‘abnormal’ appearance. In this study, therapists identified that stigmatisation
of persons with disabilities made it very difficult for these patients to obtain transport
to attend therapy. The prejudice against persons with disabilities in this study also
seemed to be largely related to the fact that they looked different and as a result
the cultural belief that a person was ‘bewitched’.
Accessibility and lack of transport is a major barrier to the utilisation of medical
services in rural communities (Gallagher et al. 2011; Goins et al. 2005; Gordon 2009;
Maart et al. 2007) and in this study therapists specifically mentioned that people
would not allow persons with disabilities to make use of public transport due to the
stigma. In some of the communities, persons with disabilities would be allowed onto
the taxi, but would have to pay double if they had a wheelchair or even an assistive
device. Therapists mentioned that the ability to pay the extra fee sometimes stopped
patients from returning for therapy; especially mothers of children with cerebral
palsy would simply not even be allowed into an empty taxi. According to the therapists,
persons with physical disabilities were more stigmatised than those with visual or
mental impairments. This is, however, an area that could be explored in more depth.
Persons with disabilities living in rural areas are doubly disadvantaged with regards
to their ability to access rehabilitation services. The geographical as well as the
attitudinal environment (WHO 2001) were barriers to them accessing rehabilitation
services. More importantly, re-engineering of primary health care (PHC) should ideally
include a policy shift by DOH towards structural and intersectoral support for community
based rehabilitation (WHO 2010). Such support would release therapists from hospitals
to work at the coalface in people's lived environments. It would also include the
development of a cadre of rehabilitation community workers to deliver home based services
under the direction of rehabilitation therapists.
Therapists also reported that patients usually deteriorated at home once they were
discharged from the hospital. They attributed the patient's deterioration to the cultural
belief that a person with a disability could not contribute to the household and was
not worthy of care and limited financial resources. This finding directly contradicts
recent disability literature which states that persons with disabilities are valued
as a result of their potential to qualify for disability grants of approximately R1200
per month (Leclerec-Madlala 2006; Penn 2014). The fact that the therapists discussed
this issue could either indicate that not all rural families are aware of disability
grants, or possibly cannot access it due to problems with the system or lack of personal
identification documents (ID) (Penn 2014; Social Assistance Act
2004). According to the Social Assistance Act (2004) an ID is a requirement for applying
for a disability grant. Therapists did mention that they would encourage persons with
disabilities to apply for a disability grant, but that obtaining an ID is a challenge
when people have to travel to the nearest Department of Home Affairs to apply for
it. Poverty and a poor public transport system are noted in the literature as some
of the main reasons why patients do not return for follow-up visits (Gallagher et
al. 2011; Maart et al. 2007). As discussed earlier, this problem could potentially
be addressed if basic resources such as transport which could accommodate rural terrain
was available for therapists to provide a service that is more aligned with a CBR
approach.
An interesting observation that could be unique to the South African context was that
patients were resistant to being treated by therapists from their own culture and
race. This finding is contrary to the Rural Health Strategy for South Africa (DOH
2006) which advocates the training of local people to strengthen the health care workforce
in rural areas. The therapists in this study reported that patients believed that
only white people could be educated enough to be doctors and therapists and that their
‘own people’ were not seen as competent. This belief could also be unique to the area
since most of the rural hospitals in this district originated as ‘missionary hospitals’
that were predominantly staffed by European volunteers (KZN DOH 2001a; 2001b).
Therapists also felt that the quality of their rehabilitation services was negatively
impacted on by the cultural beliefs of their patients. They felt that since some of
them had to make use of translators who would change what they said to fit the cultural
context, they could not educate or counsel patients sufficiently. The value of using
formally trained interpreters in cross cultural encounters is reiterated by Campinha-Bacote
(2002). This finding is resonated by Carroll et al. (2007:362) who notes that it is
often difficult to provide health care services making use of translators as the ‘…
translation may not fully represent cross-cultural differences in conceptualizations
of health’.
Recommendations
Therapists intending to follow a career in rural health care – or even ‘community
service therapists’ – should be aware and sensitive to the cultural beliefs that could
potentially have an impact on their services. Currently rehabilitation therapists
working in this area try and do ‘roadshows’. These events serve to educate the community
about the causes of disability and to raise awareness about the importance of rehabilitation.
If therapists are more aware of how cultural beliefs could affect the utilisation
of their services, they could potentially assist in changing cultural perceptions
about health. Unfortunately as a result of staff shortages in rural areas this does
not happen often. It is vital to advocate for the attraction and retention of more
rehabilitation therapists to work in rural areas in order to facilitate a more effective
CBR approach. Decentralisation of rehabilitation services will improve the utilisation
of services by removing some of the structural poverties which undoubtedly affect
access to rehabilitation.
Limitations of the study
The views explored in this study are only representative of the rehabilitation therapists
working in rural hospitals and not necessarily the only reason for poor utilisation
of rehabilitation services, but are in their perception a major contributing factor
in this specific area.
Conclusion
In this study from the therapists’ perspective, the cultural beliefs regarding the
aetiology of disease and disability impacted negatively on the utilisation of rehabilitation
services. This finding provides valuable insight into the perceptions of the therapists
working in this rural community. Their perceptions on how cultural beliefs affect
the utilisation of their services can also assist to inform education and health promotion
programmes specifically in a rural South African context.
It is the responsibility of all health care providers to ensure that they become culturally
aware, knowledgeable and competent in order to provide the best possible services
that meet the needs of the intended community. It is also a call to institutions of
higher education to better prepare undergraduate health care professionals for working
in the rural context as well as the national DOH to consider providing the necessary
human and structural resources which could assist therapists to follow a CBR approach
and truly provide ‘health for all’.