Social Distance, Disability, and Culture

The term social distancing came into common usage in the past 18 months for reasons familiar to all of us. In the context of the global pandemic, social distancing involves limiting interactions with others to minimize the spread of a biological contagion, while physical distancing involves maintaining a minimum space between individuals during those interactions.1 There is much debate about the necessity and consequences of this type of distancing, with the arguments often focusing on the need to appropriately balance economic and health priorities. This article describes a different type of social distancing and the way that it can negatively impact clinical care. In sociological research, social distance refers to "the degree of sympathetic understanding that is experienced by every person with reference to every other person who comes into his field of social relations." 2 It has also been described as the "understanding and intimacy which characterizes personal and social relations…." 3 Social distance can be observed between individuals based on any difference, including age, education, class, and race. Negative perceptions of individuals who are different from us reduces the level of closeness we are willing to accept, and consistently maintaining social distance from them can reinforce these negative perceptions. Prejudice can be understood as an "instinctive and spontaneous disposition to maintain social distances," and all of us are prone to this type of thinking. 3 Our preconceived negative attitudes can impact interactions with anyone who is part of a group that we perceive as different and inferior. Experiencing this type of social distance can have serious economic and health consequences for those who are members of disadvantaged populations. The maintenance of social distance by a majority or more powerful group can restrict the options for those in minority groups, limiting their ability to participate in society and furthering the disadvantage they experience. For example, limiting the housing, employment, and educational options of individuals who are part of an immigrant population or who have a disability adds challenges to the struggle they may already experience as a result of language, cultural differences, or physical impairment. This type of social distance is often not recognized, particularly by those who are not directly negatively impacted by it. A Social Distance Scale Emory Bogardus, PhD, a sociologist from the University of Southern California, studied the concept of social distance by examining the ways people felt toward individuals of different races.3 Bogardus surveyed the attitudes of college students and graduates in 30 areas of the United States toward 30 different racial groups in 1926, 1946, and 1956. Respondents were asked how accepting they were of different groups of immigrants in various levels of relationships (Figure 1). Bogardus concluded that the Social Distance Scale "brings to the surface in measurable terms a significant picture of racial reactions at a given time," sheds light on "changes…that may be taking place," demonstrates the social direction of those changes, and can indicate the distance between groups, not just individuals. 2 This scale and others like it have been used by many researchers to examine social distance in a variety of contexts, including disability. A Disability Hierarchy In a 1970 paper, John Tringo, PhD, described the challenges faced by individuals with a disability when others react to them based on "their conceptions of disabled persons rather than the person himself." 4 Viewing people with different levels of physical or mental ability as inferior creates barriers to their integration into society that go beyond the limitations they already experience as a result of that disability. Because of common and persistent negative perceptions "the disabled can be considered an underprivileged minority group." 4 This view is currently more widely accepted than it was in 1970. Recall that the Americans with Disabilities Act, which "prohibits discrimination and guarantees that people with disabilities have the same opportunities as everyone else to participate in the mainstream of American life," was not passed into law until 1990. 5 Tringo developed a Disability Social Distance Scale "to investigate different attitudes toward specific disability groups by establishing the existence and composition of a hierarchy of preference towards these groups." 4 This research involved asking 455 subjects in six different sample groups to "indicate the degree of closeness you would allow" to individuals with 21 different disabilities. The subject sample groups included one group of high school students, and five other groups comprising undergraduate and graduate students and rehabilitation workers. The subjects did not rank the disabilities in relation to each other but indicated on a scale of one to nine the level of social closeness or distance they felt regarding each disability (Figure 2). The researchers used the mean social distance score of the respondents to establish a disability hierarchy. The research found that "a stable hierarchy of preference toward disability groups was evident despite substantial differences in the extent of social distance expressed toward specific disability groups" (Figure 3). 4 Tringo reported demographic differences in the degree of distance reported by the subjects. For example, "Females express less social distance (more acceptance) toward disability groups than do males," and "the high school students were significantly less accepting" than members of the other five subject groups.4 (The results from those five subject groups were so similar that the data from these groups was combined for analysis.) Tringo found that "demographic variables affect the extent of social distance expressed toward specific disability groups but do not affect the relative position of disability groups in the hierarchy." Tringo concluded that this consistency "indicates that the assumption of a stereotyped conception of each disability group is valid.... The existence of the hierarchy and the stereotyped conception of various disability groups thus support the contention that prejudice exists toward the disabled."4 O&P Patients and the Hierarchy There have been strong efforts in the past few decades to advocate for the rights of individuals with disabilities, provide more access, and support greater participation in everyday life. Despite the added legal protections (and some changes in attitude), a disability hierarchy remains in place in the general population. A paper published in 2000 reported on the attitudes of 171 university students toward 16 of the disabilities included in Tringo's 1970 list. The evidence showed that "the hierarchy of preference of disabilities proposed by Tringo over 30 years ago remains firmly entrenched. While some strides toward removing the hierarchy may be indicated by a slight reduction in expressed social distance, the hierarchy remains quite stable."6 In general, respondents in the Bogardus and Tringo studies reported the greatest social distance from brain-related injuries and those viewed as self-induced, and expressed reduced distance from individuals with physical disabilities compared to those with sensory disabilities.6 According to a 1997 paper on the sociospatial aspects of disability, the relative positions of three diagnoses that are commonly seen in O&P practice remained the same in social distance research that was conducted in 1970, 1979, 1985, and 1993.7 Amputation was more accepted than paraplegia, and acceptance of cerebral palsy was the lowest of the three diagnoses. Attitudes in Different Cultures Differences in attitudes about health and disability among different ethnic groups and cultures has been well established. A 1993 study by Westbrook et al. reported on research conducted in Australia to determine the attitudes of people with different cultural backgrounds toward individuals with disabilities. The researchers asked 665 health practitioners from six different ethnicities to "rate the attitudes of people in their communities towards 20 disability groups." 8 Participants were asked to identify the "the typical, usual, or average attitudes" they observed within their own ethnic community, not their personal attitudes.8 The respondents indicated whether an individual with each disability would be kept in an institution, avoided, or accepted as a coworker, friend, or marrying into their immediate family. The researchers found differences in acceptance of disability among the different ethnic groups, but "the relative degree of stigma attached to the various disabilities…was very similar…. These stigma hierarchies were remarkably similar to other hierarchies reported over the last 23 years." 8 The authors of this study caution that "frequently the attitudes of ethnic minorities regarding illness and disability differ from the values embodied in the healthcare system of the host society. This situation can lead to ineffective treatment and dissatisfaction both on the part of clients and healthcare providers." 8 Cultural Sensitivity Versus Prejudice Practitioners may feel caught in a Catch-22: There are real differences among individuals from different ethnic and cultural backgrounds but identifying and acting on those differences may reinforce negative perceptions and marginalization. Westbrook et al. address this issue. Stereotyping individuals based on their membership in a particular ethnic or cultural group can lead to inadequate medical care by "failing to appreciate their individual needs."8 However, "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." 8 According to Westbrook et al., "mismatches between health practitioners' and ethnic patients' expectations are most likely to occur when patients have had amputations or suffer from paraplegia, cancer, heart disease, cancer, [or] diabetes…." 8 These diagnoses are seen commonly in O&P practice, a profession in which a large percentage of US practitioners are white and male. The common view that practitioners should treat each patient individually, without regard to his or her cultural background, can contribute to misunderstandings about the nature and solution to health problems. 8 An awareness of beliefs, practices, and preferences among different cultural groups can sensitize us to problems that may arise in their care. A thorough assessment, including a frank and empathic discussion of sensitive topics, ensures that our treatment is consistent with individuals' perspectives about their condition, roles, and goals rather than assumptions based on their membership in a particular group. Discussion It can be difficult to know how to address attitudes about race and disability in our current environment of political division and strident public discourse. If we struggle as a society to agree on relatively simply strategies for limiting the spread of a virus, how likely is it that we will agree on ways to address intensely personal beliefs about accepting others from different cultures or those with disabilities? Perhaps this second challenge contributes to the first. However, the problems created by negative perceptions of disadvantaged groups and individuals are too serious to allow us to avoid open and frank discussion. As practitioners who work daily with individuals who have a variety of disabilities, we may consider ourselves more accepting of disability than members of the general population. However, our views are informed by our own culture and the broader, dominant culture in which we practice. We must be aware of how these perspectives can compound or mitigate how challenging it is for our patients to participate in society. These attitudes may affect our assessment of whether a patient could or should engage in particular activities and cause us to limit the options we provide patients and their caretakers. The good news is that our attitudes and prejudices do not have to determine our actions. Providing care that most effectively meets our patients' needs requires attention to their beliefs about their condition, as well as the attitudes we have toward them. Taking time to carefully consider our own social distance ratings and ranking for disabilities we commonly encounter can improve our sensitivity to the needs of individual patients and improve the care we provide. Author's note: Some of the language in the research quoted above is dated, and it may contribute to negative perceptions and prejudice. The original language is retained in order to report the findings accurately. Jo hn T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center (NUPOC). He has over 30 years of experience in patient care and education. References https://www.hopkinsmedicine.org/health/conditions-and-diseases/coronavirus/coronavirus-social-distancing-and-self-quarantine Bogardus, E.S. 1960. Trends in social distance in American life. Social Science 35(1):10-16. Wark, C., and J. F. Galliher. 2007. Emory Bogardus and the origins of the social distance scale. The American Sociologist 38(4):383-95. Tringo, J. L. 1970. The hierarchy of preference toward disability groups. The Journal of Special Education 4(3):295-306. https://www.ada.gov/ada_intro.htm#:~:text=The%20ADA%20is%20one%20of,to%20purchase%20goods%20and%20services Thomas, A. 2000. Stability of Tringo's hierarchy of preference toward disability groups: 30 years later. Psychological Reports 86(3):1155-6. Dear, M., R. Wilton, S. Lord Gaber, and L. Takahashi. 1997. Seeing people differently: the sociospatial construction of disability. Environment and Planning D: Society and Space 15(4):455-80. Westbrook, M. T., V. Legge, and M. Pennay. 1993. Attitudes towards disabilities in a multicultural society. Social Science & Medicine 36(5): 615-23.

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Social Distance, Disability, and Culture

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