MPH 504 Week 5 Cultural Competency Case Analysis Example

Cultural Competency Case Analysis: A Declined Latent TB Treatment Recorded as a Cultural Belief, and the Clinic Decisions That Shaped It

Student Name

Chamberlain University

MPH 504: Cultural Competency and Global Public Health

Instructor Name

Month Day, Year

Cultural Competency Case Analysis: A Declined Latent TB Treatment Recorded as a Cultural Belief, and the Clinic Decisions That Shaped It

The Case

A woman of 38, born in the Philippines and living in the United States for six years, was referred to the Alder County TB clinic after a positive tuberculin skin test at a pre-employment screening for a home health aide job. Her chest radiograph was normal. The clinic nurse offered nine months of daily isoniazid. She declined. The chart note read: "Patient refuses LTBI treatment. States positive test is due to BCG vaccine. Cultural belief; education provided." She was discharged from follow-up with a letter for her employer. Eight months later her younger brother, who lived with her, was diagnosed with pulmonary TB, and a contact investigation found her blood test, now done for the first time, to be positive. She accepted treatment then. This analysis asks what happened at the first visit and what the clinic, not the patient, could have done differently. The case is a composite drawn from common patterns in TB clinic practice.

What Was Recorded as Culture

The note attributes the refusal to a cultural belief. But the belief it records, that BCG caused the positive skin test, is not a cultural belief in the usual sense. It is a reasonable inference from her experience. She had been vaccinated with BCG as an infant, as most children in the Philippines are, and she had likely been told in the past that BCG explains a positive skin test. The skin test can in fact be falsely positive after BCG, which is why national guidelines prefer an interferon-gamma release assay, a blood test that is not affected by BCG, for people who have received the vaccine (Lewinsohn et al., 2017). Her objection was, in effect, a request for a better test. The clinic answered it with education about why she should accept the result of the worse one.

The Clinic's Decisions

Four decisions by the clinic shaped the outcome, and each was within its control.

The test. The clinic did not offer an interferon-gamma release assay at the first visit, although it was available and recommended for her. A positive blood test would have answered her objection directly.

The regimen. She was offered nine months of daily isoniazid, the oldest regimen. Since 2020, the national guidelines have ranked the short courses that contain a rifamycin ahead of it, whether twelve weekly doses of rifapentine with isoniazid, a daily rifampin course of four months or a daily two-drug course of three months; nine months of isoniazid alone is now an alternative rather than the first choice (Sterling et al., 2020). A home health aide starting a new job, with irregular shifts, was being asked to take a daily pill for nine months for an infection she did not believe she had.

The language. Her English was good enough for the pre-employment screening, so no interpreter was offered. When I spoke with her later, she said she would have preferred to discuss the medication and its side effects in Tagalog. A systematic review found that care with trained interpreters produced fewer communication errors and better patient comprehension than care relying on relatives or on no interpreter at all (Karliner et al., 2007), and preference for a language in medical discussions can differ from everyday ability.

The question not asked. No one asked her what she thought the test meant, what worried her about treatment or what would make treatment possible. Kleinman and Benson (2006) recommend a short set of such questions precisely so that clinicians learn what matters to the patient before deciding what the problem is. Her worries, it turned out, were about liver damage, which she had heard of from a cousin, and about missing work.

Where Culture Did Play a Part

Culture was not absent. Her trust in what she had been told about BCG came from a health system she grew up in, and her concern about liver damage came from her family's experience. Her wish to discuss medicines in Tagalog reflects her language and comfort. A good analysis does not deny these influences; it asks whether the clinic responded to them. In each case, a response was available: a blood test, a conversation about liver monitoring in her preferred language and a short regimen that would not disrupt her work. The clinic treated her culture as the cause of the refusal and stopped there, when it was better understood as information about what she needed.

Structural Competency

Metzl and Hansen (2014) argue that clinicians should look beyond cultural explanations to the structures, such as clinic procedures, payment rules and working conditions, that shape what patients do. In this case, the structures were the clinic's default regimen, its test ordering habits, its rule of offering interpreters only to patients with limited English, and a pre-employment process that made the visit about clearance for a job rather than about her health. None of these was a cultural trait of the patient, and all could be changed.

Recommendations Aimed at the Clinic

Five changes follow, each aimed at the clinic rather than at Filipino patients or the Filipino community.

1. Use an interferon-gamma release assay as the first test, or as a confirmatory test, for anyone who received BCG, in line with national guidance (Lewinsohn et al., 2017).

2. Make a short rifamycin-based regimen the default offer, with nine months of isoniazid reserved for patients who cannot take rifamycins (Sterling et al., 2020).

3. Ask every patient which language they prefer for discussing medicines and offer a professional interpreter on that basis, not on English ability alone.

4. Add three explanatory questions to the first-visit template: what the patient thinks the test means, what worries them about treatment and what would make treatment possible.

5. Replace the phrase "cultural belief" in refusal notes with a field for the patient's stated reason, so that reasons can be counted and the clinic can see patterns it could address.

Recommendations aimed at the community, such as education campaigns about BCG, would place the burden of change on patients whose main objection was correct. They would also repeat the original error, by treating a reasonable question as a misunderstanding to be corrected.

What the Clinic Should Measure

The clinic could check whether these changes work by tracking three figures over the next year: the share of BCG-vaccinated patients tested with a blood test, the share of patients offered a short regimen and the share of patients with a positive result who start and complete treatment. If refusals fall after the changes, that would be evidence that the earlier refusals reflected clinic practice rather than patients' culture.

References

Karliner, L. S., Jacobs, E. A., Chen, A. H., & Mutha, S. (2007). Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Services Research, 42(2), 727-754. https://doi.org/10.1111/j.1475-6773.2006.00629.x

Kleinman, A., & Benson, P. (2006). Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 3(10), e294. https://doi.org/10.1371/journal.pmed.0030294

Lewinsohn, D. M., Leonard, M. K., LoBue, P. A., Cohn, D. L., Daley, C. L., Desmond, E., Keane, J., Lewinsohn, D. A., Loeffler, A. M., Mazurek, G. H., O'Brien, R. J., Pai, M., Richeldi, L., Salfinger, M., Shinnick, T. M., Sterling, T. R., Warshauer, D. M., & Woods, G. L. (2017). Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: Diagnosis of tuberculosis in adults and children. Clinical Infectious Diseases, 64(2), e1-e33. https://doi.org/10.1093/cid/ciw694

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126-133. https://doi.org/10.1016/j.socscimed.2013.06.032

Sterling, T. R., Njie, G., Zenner, D., Cohn, D. L., Reves, R., Ahmed, A., Menzies, D., Horsburgh, C. R., Jr., Crane, C. M., Burgos, M., LoBue, P., Winston, C. A., & Belknap, R. (2020). Guidelines for the treatment of latent tuberculosis infection: Recommendations from the National Tuberculosis Controllers Association and CDC, 2020. MMWR Recommendations and Reports, 69(1), 1-11. https://doi.org/10.15585/mmwr.rr6901a1