MPH 504 Week 8 Course Reflection Example

Course Reflection: I Stopped Treating Culture as the Explanation of Last Resort and Started Treating It as the Last Explanation I Test

Student Name

Chamberlain University

MPH 504: Cultural Competency and Global Public Health

Instructor Name

Month Day, Year

Course Reflection: I Stopped Treating Culture as the Explanation of Last Resort and Started Treating It as the Last Explanation I Test

The Judgment That Changed

Before this course, when a patient in our tuberculosis program missed doses or declined treatment, I reached for culture first. At the time it felt less like a shortcut than like sensitivity: I was acknowledging that people born in the Philippines, Mexico, Vietnam or India might hold views about illness that differ from mine. What changed over eight weeks is the order in which I test explanations. I now ask first about things the program controls, such as the hour of a dose, the cost of getting to an appointment, the test we chose and the language we used, and I treat a cultural explanation as credible only after those have been ruled out and the patient has described the belief in their own words. That is a narrower change than a new worldview, and I think it is the honest size of what happened.

The change also has a limit I want to state plainly. I have not stopped believing that culture matters. Belief about BCG, about the meaning of a positive test, about who in a family decides, all of these shape what patients do. What I stopped doing is using culture as a conclusion I write in a chart before I have asked anyone anything.

The Evidence: My Week 2 Self-Assessment

The clearest evidence that something needed to change is the document I wrote in week 2. My score on the self-report instrument placed me one band below the top. When I set that number against a review of 40 of my own patient records, the picture was different. I had written down each patient's preferred language for health conversations in 31 records, and only 5 records held anything the patient had said about what TB was or why they had it. Six patients whose preferred language was not English had a relative, sometimes a teenager, interpreting at the first visit.

Those counts are not a measure of my attitudes. They are a measure of my questions. A clinician who believes culture explains behavior, and who rarely asks patients for their own account, will fill that gap with an assumption, and my note about the man on video therapy, which put his missed doses down to stigma when the cause was a 9 a.m. dose time after a night shift, shows the gap being filled. The instrument rewarded my intentions; the records showed my habits. Writing week 2 is when I first saw the difference.

Where the Course Material Did the Work

Three readings changed specific decisions rather than adding to a list of things I know.

Kleinman and Benson (2006) gave me a short set of questions about what a patient calls the problem, what worries them and what matters most. I had read about explanatory models before, but their argument that a cultural label can end a clinical conversation rather than open one described my own chart note almost exactly. In week 5, when I analyzed the case of the home health aide who declined latent TB treatment, their questions were the tool that exposed what the chart had missed: her worry was liver damage and lost work, not a belief that needed correcting.

Tervalon and Murray-García (1998) changed what I think the goal is. I had treated competence as a level to reach, which is what the week 2 instrument measures. Their idea of humility as a lifelong practice of self-critique, and of fixing power imbalances between clinician and patient, fit the chart review better than the score did. It is why my six-month goals are counts in my own records rather than a higher self-rating.

Wang et al. (2006) did the work in week 7. When I planned household contact screening for a partner city in the Philippines, their distinction between whether an intervention can be delivered somewhere and whether its effect will carry over made me separate the strong trial evidence from Vietnam (Fox et al., 2018) from the conditions in the partner city, where devolved governance and the cost of travel to radiography were real differences. Without that distinction I would have assumed the trial result transferred because the disease was the same.

From One Patient to a Population

The course moved my thinking from individual patients to populations, and that is where the changed judgment matters most. When a single clinician writes "cultural barrier" in a chart, one patient is misunderstood. When a program does it across hundreds of records, the pattern becomes a finding: a report might conclude that foreign-born residents of Alder County complete treatment less often because of cultural beliefs, and the program might respond with more education. The equity analysis I wrote in week 6 showed a different picture. Much of the gap in completion between residents born in the United States and those born elsewhere followed clinic hours, shift work and interpreter access, which are matters of program design.

The same lesson applies in global work. The Philippine national patient cost survey found that 42% of households affected by TB faced catastrophic costs (Florentino et al., 2022). A plan that read low attendance at radiography as reluctance rooted in culture would miss an economic barrier that an allowance can address. Abimbola and Pai (2020) add a further caution: partners from wealthy countries tend to define the problem for others. The week 7 plan answered that by making the city's TB coordinator the decision maker and first author, but the deeper point for me is that the habit of labeling a problem as cultural is one of the ways an outsider defines it.

What I Will Do Differently in Practice

The prompt asks how this will shape future practice. I will name three things I can be held to.

First, in my own caseload, I will open each first visit by asking the patient to describe an ordinary day and their understanding of the diagnosis, and I will record both before I schedule a single dose. The repeat chart review I set for six months from week 2 will show whether that happens; my target is a patient's own account in 30 of the next 40 records.

Second, in our program, I have proposed that the quarterly TB report include completion rates by interpreter use and by dose time, alongside place of birth. If completion differs more by dose time than by country of birth, the program will see a design problem that place of birth alone would have disguised.

Third, I will change how I write. When I document a reason for a missed dose or a declined treatment, I will record what the patient said and what the program offered, not an inferred belief. A note that says "declined nine months of isoniazid; worried about liver injury and missed work; shorter regimen not offered" leads to a different next step than "cultural belief; education provided."

A Question I Still Carry

I do not yet know how to act when a patient's explanation really is rooted in belief and the program has removed every practical barrier. The course gave me tools for asking, but not a rule for what to do when the answer is a belief that conflicts with the evidence. I expect that to be the hardest part of the work, and I would rather name it than claim the term settled it. What I can say is that I will reach that point less often, and later, than I used to, because I will have tested everything else first.

References

Abimbola, S., & Pai, M. (2020). Will global health survive its decolonisation? The Lancet, 396(10263), 1627-1628. https://doi.org/10.1016/S0140-6736(20)32417-X

Florentino, J. L., Arao, R. M. L., Garfin, A. M. C., Gaviola, D. M. G., Tan, C. R., Yadav, R. P., Hiatt, T., Morishita, F., Siroka, A., Yamanaka, T., & Nishikiori, N. (2022). Expansion of social protection is necessary towards zero catastrophic costs due to TB: The first national TB patient cost survey in the Philippines. PLOS ONE, 17(2), e0264689. https://doi.org/10.1371/journal.pone.0264689

Fox, G. J., Nhung, N. V., Sy, D. N., Hoa, N. L. P., Anh, L. T. N., Anh, N. T., Hoa, N. B., Dung, N. H., Buu, T. N., Loi, N. T., Nhung, L. T., Hung, N. V., Lieu, P. T., Cuong, N. K., Cuong, P. D., Bestrashniy, J., Britton, W. J., & Marks, G. B. (2018). Household-contact investigation for detection of tuberculosis in Vietnam. New England Journal of Medicine, 378(3), 221-229. https://doi.org/10.1056/NEJMoa1700209

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

Tervalon, M., & Murray-García, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125. https://doi.org/10.1353/hpu.2010.0233

Wang, S., Moss, J. R., & Hiller, J. E. (2006). Applicability and transferability of interventions in evidence-based public health. Health Promotion International, 21(1), 76-83. https://doi.org/10.1093/heapro/dai025