Defacement: Achi Patients' Experiences with Government Healthcare

Theoretical Background and research questions/hypothesis: Intercultural communication between health care providers and patients is wrought with challenges and involves issues of face and facework (Conquergood, 1988; du Pre, 2000; Graeff, Elder, & Mills Booth, 1993; Rodgers, 1995; Thompson, 1990).  Individuals from all cultures are constantly performing before others, through verbal and nonverbal communication, to maintain and manage multiple social identities through presenting a desired image of self to others (face) (Clark & Kashima, 2007).  Face threats are verbal and nonverbal communication that conflict with an individual’s face needs and are culturally defined.  Facework is the designing verbal and nonverbal messages to maintain, restore, or mitigate face threats (Carson & Cupach, 2000; Ho, 1976; Lim & Bowers, 1991; Oetzel, et al., 2001; Ting-Toomey, 2005b).  Face theories explain that people are expected to attend to, show regard for, and limit loss of the other’s face when engaged in a social interaction (Brown & Levinson, 1987, Goffman, 1959, Ho, 1976, Lim & Bowers, 1991).  Ho (1976) explained, “Anyone who does not wish to declare his social bankruptcy must show a regard for face.  (p. 881)” The following research question guided my data analysis:  In what ways does face and facework influence the provider-patient interactions for Achi patients?

Methods and Results (informing the conceptual analysis): This ethnographic qualitative study explores the patient experiences of the Rabinal Achi people, an indigenous Mayan people in Guatemala, through participant observation, twenty-five (25) informal interviews, and thematic analysis.  The transcriptions of the interviews consisted of over 74,000 words.  The method of analysis was an interpretive four-step process (Boyatzis, 1998) involving identification of potential themes in the field, initial theme identification, thematic analysis rigor, and thematic interpretation.  The existing face literature is inadequate to explicate the abundant themes of dehumanizing experiences emergent in the narratives of the Achi patients.  Therefore, a new construct is proposed: defacement, which extends beyond the failure to mitigate other-face threats to the purposeful destruction of other-face.  Defacement devalues the humanity and dignity of a person.  Through defacement, an interactant frames another as something less than human and places them outside the normative universe of moral protection (Hagan & Rymond-Richmond, 2008; Harris & Fiske, 2006).  As a result, the defacer does not risk social bankruptcy from mistreating, abusing, and neglecting another.                 Four types of defacement emerged from the data, and involve both verbal and nonverbal communication.  Each type increases in intensity and dehumanizing communicative content (figure 2): disregarding, degrading, regaño-ing, and abusing.

Disregarding	Degrading	Regaño-ing	Abusing
Ignoring	Mocking	Verbal flogging	Physical abuse
Lack of effort	Name-calling		Neglect
Dismissing

Conclusions: The findings reveal that access to healthcare is more complex than issues of clinic location and numbers of providers.  Improving health care for underserved populations requires addressing not only issues of availability but also issues of face and defacement including prejudice, abuse of power, and cultural respect. 

Implications for research and/or practice: Consistent with qualitative research, the findings illuminate the experiences of the participants and the generalizability is limited.  However, the intensity and frequency of defacement suggest the findings can potentially provide a useful lens for further studies with other indigenous and underserved populations.