Emily Meiring Donovan Reflection – Cultural Humility in New Delhi, India

Emily Meiring is a College of Health Professions student at MUSC. She was awarded a Center for Global Health Student & Trainee Travel Grant in early 2024 to pursue a project with Children Family Health International in Delhi, India. View more photos of Emily's time in India in this Flickr photo gallery. Also, view Emily's previous travel grant reflection published here.

Last year, I had the opportunity to see, experience, and learn about several non-governmental organizations throughout New Delhi, India. Throughout my visit, I was introduced and experienced first-hand many aspects of Indian culture and the powerful impact healthcare professionals have on patient outcomes just by taking time to explore the detours in conversation and sit with the clients with a cup of tea to discuss their thoughts and ideas as part of the care they were providing. I made lifelong connections that allowed me to request to return to India and take part of the program in a different capacity. The outline of this second experience involved observing and engaging with occupational therapists at the Tamana School of Hope for children with autism, and the Indian Spinal Injuries Center (ISIC). My specific learning objectives I identified prior to my trip were:

1. Apply global health concepts to clinical experiences with occupational therapy practitioners.
2. Analyzing how healthcare professionals in India integrate cultural humility into client/therapist interactions when working with individuals in vulnerable populations.
3. Collaborate with clinicians and healthcare professionals to build video-based cases surrounding culturally sensitive care within occupational therapy.

Tamana School of Hope

Tamana is a non-governmental organization that was founded by Dr. Shamaya Chona 40 years ago. After her daughter, Tamana was born, she was diagnosed with cerebral palsy and autism. Dr. Chona was inspired to create a place (now an internationally recognized organization), for children, adults, and all individuals like her daughter. She dreamt of a world of inclusion, and since its beginning in 1984, she has created Tamana, a non-governmental organization that supports individuals with intellectual and developmental disabilities. It started as one school, and has now evolved into the Tamana School of Hope, The Nai Disha Vocational Training Center for adults, and the Special Education Centre for Adults.

At the Tamana School of Hope, truly all children with autism are accepted and welcomed. Most children at the school are non-verbal, engage in challenging behaviors, and have been rejected from typical schools in the area. The team of counselors, therapists, teachers, and administration work tirelessly every day to foster an inclusive environment and to make sure every child is seen and heard no matter their abilities.

I had the wonderful opportunity to shadow the therapy team daily, which included occupational therapy, physical therapy, and therapy assistants. Because the school is created for children with autism, some of the typical goals that occupational therapists would address with children with autism such as social skills, brushing teeth, toileting, handwriting, and eating, were already being addressed in the school throughout the day. Therefore, the role of occupational therapy at Tamana School of Hope was mainly in sensory integration to support children with modulation of sensory information and their transitions throughout the school day. Additionally, in the initial evaluation with occupational therapy, the OT collects information from the caregivers related to the sensory profile for the child, as well as any difficulties the child has with their fine motor, gross motor, and activities of daily living to incorporate into treatment as well. This information is shared with the therapy team and with the school staff to best support the children in the classroom as well. The therapy team especially does an incredible job at advocating for each one of the kids they see. Every child has their own unique perspective of the world, differences in interpreting the sensory information in the environment, and various expressions of their joy and frustration. It is the job of the therapy team to understand that and to advocate for their needs and wants, and to help teach them how to communicate these things to others for themselves.

By integrating physical exercise (with physical therapy) and sensory integration (with occupational therapy) into the child’s day is such a powerful way that School of Hope accommodates and advocates for their students. Overall, the model of the school is holistic in nature allowing for the whole child to be considered, to include their academic, social, spiritual, and sensory needs to help positively impact their days and set them up for success in the classroom and at home.

My biggest takeaway from this experience at Tamana in providing culturally sensitive care was that less is more. We are constantly told as occupational therapists to use fewer words because we often explaining every thought that goes across our brain rather than providing only what is important. However, this experience truly taught me that saying less can be so much more impactful than saying every thought or idea. As stated before, individuals with autism take in all information around them differently. Especially with verbal and auditory information, a lot of instructions and words can be confusing, overwhelming and frustrating, and it can often lead to children engaging in challenging behaviors such as avoidance of tasks and aggression towards peers and therapists. It was beneficial for me in this setting to use one word, if any, to direct and instruct. This was beneficial for the children in terms of decreasing the auditory information given to them, but also beneficial because of the language barrier between me and the children. During my time in India, I was often very humbled by my lack of knowledge of the Hindi language, but it worked to my benefit at Tamana. While I knew some words and phrases to support my interaction with the children and therapy team, it was often better and more effective to use mainly visual, gestural, and physical instructions and cues.

Indian Spinal Injuries Center (ISIC)

The ISIC is a large hospital in New Delhi equipped with acute medical services, comprehensive rehabilitation services, research labs, and programs to train future healthcare professionals. I was provided a tour of the rehabilitation facility consisting of, multiple equipped therapy gyms, wheelchair mobility training, aquatic therapy, traditional medicine building, adaptive sports building, rehab psychologist office, splinting lab, assistive devices and technology center, and the occupational therapy program.
When ISIC says holistic healthcare, they mean it! When individuals come for therapy (both inpatient and outpatient), it is intensive, but also very effective. Each patient receives one hour of physical therapy, one hour of occupational therapy, and one hour of wheelchair mobility. Additionally, they have the opportunity to visit or schedule appointments with the traditional medicine clinic to support healing or the adaptive sports center to support engagement in community.

Within the rehabilitation center at ISIC is a rehab psychologist position. This individual provides therapy services to all individuals receiving therapy for their injuries and diagnoses. I had the opportunity to talk with her and she provided me with a wealth of knowledge regarding cultural perspectives surrounding mental health. While there have been strides made in India regarding normalizing the topic of mental health, there still remains a significant stigma associated with reaching out for help. The rehab psychologist discussed that her job is to support the rehab patients in their recovery at every stage. Additionally, she mentioned that family is usually such an important part of rehab so much so, that when looking around the gym at the patients participating in rehab, every patient had an accompanying family member. Having supportive and consistent family presence can positively impact the patient’s outcomes. However, the rehab psychologist mentioned that often the family members are the ones who are hesitant in pursuing support from the psychologist and dismiss the idea of the patient experiencing mental health difficulties. To combat these ideas, the psychologist talked about the importance of using her free time to wander the rehab floor and chat with each and every patient in the gym about small things and casually talk about how rehab is going to help build rapport with the patients in a non-threatening context before introducing the idea that she could offer more support mentally with their recovery, if they ever needed. This was such an interesting idea to me that there is a therapist who is specifically designated to working with patients in rehabilitation programs at the spinal injuries centre. I think I’m used to there being case workers in a hospital who is there to support the patients. Or as an occupational therapist, we are usually providing community resources for mental health. So, it was really interesting, especially in a culture that struggles to accept reaching out for help with mental health, that they have a psychologist focused on supporting patients as they navigate new diagnoses and traumatic injuries.

Learning Objectives

Regarding my objectives, I was able to apply global health concepts to clinical experiences with occupational therapy practitioners daily at Tamana and analyze how healthcare professionals in India integrate cultural humility into client/therapist interactions when working with individuals in vulnerable populations at both Tamana and ISIC. While I was unable to build video-case studies from cases in India, I was able to collaborate with the clinicians and healthcare professionals regarding video case resources surrounding culturally sensitive care within occupational therapy and the items it would be important to include. I was able to create a more comprehensive resource related to cultural humility from my experiences and conversations with the clinicians and healthcare professionals in India.

I observed culturally sensitive care in action throughout my time at Tamana and the ISIC. One of my favorite experiences was observing the effort that the teachers, counselors, therapists and administration took to provide spiritual and cultural experiences for the children. During Maha Shivratri, a day that honors Lord Shiva in Hindu culture, rather than going on with the day as normal and assuming the kids wouldn’t know the difference, they loaded up three buses and drove each one of the kids and staff members to a path just down the road that led to a temple. This path wasn’t just a short walk, it was about a half a mile in length, which might not sound like a lot, but with 80 kids and young adults with autism to keep track of, that is a far way to go. The staff and some parents engaged in the spiritual ceremony, providing offerings to Shiva and included the kids as much as possible: some were tearing flower petals into the offering, some were pouring milk, some were led in prayers. Other children were singing along to songs led by the drumming of another one of the students. The festivities at the temple concluded and the students and staff were brought back to the school, where rather than attempting to re-engage in typical school activities right away, everyone was brought to the auditorium to sing and dance to celebrate Maha Shivratri. Especially with the population of individuals with autism, a field trip like this can throw off their day due to the disruption in routine and schedule. However, it was addressed and carried out in a way that allowed room for the children to process the changes and be themselves rather than forcing expectations, both at the temple and after returning from the temple. I learned that in this culture, they find a way. Rather than bringing the celebration and ceremony to the kids, they found a way to do it just as everyone else does.

Cultural humility is the dedication to the lifelong learning of culture and interactions with people. The humility piece of it is that we will never be fully competent in all cultures or any one culture because the world and the people in it are always changing. Even though I have been to India twice now, there is still so much more to learn and understand about the Indian culture and how aspects of it can differ from state to state, how past stigmas and biases surrounding disabilities persist, and how cultural perspectives can impact and influence healthcare.