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U.S. Department of Health and Human Services


TB Challenge: Partnering to Eliminate TB
in African Americans

Addressing Cultural Issues in TB Prevention Programs

Walter Williams, MD, MPH, Associate Director for Minority Health, CDC

Nationally, CDC data show that persons born outside the United States have high rates of tuberculosis (TB) compared to the overall population, particularly those persons born in Africa, Southeast Asia, and Latin America. To effectively provide targeted testing and treatment of latent TB infection and of TB disease to persons from these populations, health departments must effectively identify those at risk in their communities and devise culturally effective communication and follow-up strategies to provide services that are tailored to community needs.

Social and cultural factors influence the successful control of TB. It is clear these factors influence health education, access to health services, accurate diagnosis and proper treatment, patient participation in treatment decisions, and adherence to treatment regimens. For example, communication and understanding are an essential part of patient-provider interaction. Communicating with patients assists the provider with diagnosis, assessment, and determination of treatment. Communicating with the provider gives the patient information needed to make decisions about his or her care. This can be difficult when there are cultural or language barriers. For example, the following situation may occur: A non-English speaking woman from Vietnam comes to a TB clinic for follow-up recommended after immigration. As the health care worker explains about TB, the woman nods her head as if in understanding, smiles, and looks down, never making eye contact. Although she appears to present “Western” nonverbal signs of understanding, she does not speak any English and does not understand what is being explained to her. The health care worker is not aware and continues to explain in English.

Culture often influences a person's initial perception and interpretation of health. This has an impact on how quickly an individual will seek health services and who he or she may choose to go to for these services. For example, Filipino parents may attribute their child's respiratory symptoms to a folk illness called “piang” rather than to TB. If the parents believe their child's illness is due to “piang,” they are more likely to take the child to a traditional healer for a cure through massage to correct presumed injury to the skeletal or muscular system. This results in long delays before the child is brought to the TB clinic.

Adherence to treatment is essential to TB control. Adherence, however, requires a patient to incorporate treatment into his or her daily life, but can become interrelated with culture and be affected by the treatment beliefs of patients as well. For example, a TB clinic that kept typical clinic hours was finding that many patients of Chinese descent were missing their appointments. These patients were shopkeepers and could not come to the clinic because they could not close their shops until after 10 p.m. Culture should also be considered when choosing incentives. Say, for example, a TB program provides ham and cheese sandwiches for patients who come in for their directly observed therapy (DOT). Patients from Somalia, a predominantly Muslim country whose people do not eat pork products, would find the sandwiches to be a disincentive.

It is critical that TB programs offer culturally and linguistically appropriate services. There are several ways to address cultural and linguistic barriers in TB control. Engage in culturally and linguistically appropriate dialogue. Openly discuss beliefs in a non-threatening manner, taking an interest in the cultural and folk remedies the patient uses. In many cultures, healing and religion are intricately linked. Use a trained interpreter or bilingual staff member for interactions with patients who are not proficient in English. Provide culturally and linguistically appropriate patient education. Provide information about TB, transmission, risk, and treatment that is culturally and linguistically appropriate. Use an interpreter or bilingual staff member who is familiar with the culture of the patient and can explain and answer questions. Be conscious of literacy level and be sure to offer services to read or explain all information that is written for patients. Collaborate with others to address cultural barriers. By working with a team of physicians, healers, social workers, patient advocates, interpreters, and even the patient's family, you can help a patient adhere to treatment. Tailor your services and your incentives and enablers to your patient. Consider the patient's culture, needs, and interests in determining what types of services, incentives, and enablers will work to help your patients adhere to treatment.

Taking these and other steps can help address cultural and linguistic barriers in TB control.

To access culturally and linguistically appropriate information on TB education and training resources, please visit the TB Education and Training Resources Web Site at


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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