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U.S. Department of Health and Human Services


TB Challenge: Partnering to Eliminate TB
in African Americans

Fall 2003

The Social and Cultural Dimensions of Health-Seeking Behaviors
Joseph Kinney, Project Director, South Carolina Department of Health and Environmental Control

In August 2002, the South Carolina Department of Health and Environmental Control (DHEC) received supplemental CDC funding designated for  “Intensification of TB Prevention, Control, and Elimination Activities in African-American Communities in the Southeastern United States.” South Carolina recognized that to intensify and target activities toward US-born African-Americans, and to accelerate the decline and elimination of tuberculosis, it was necessary to examine the social and cultural dimensions of health-seeking behaviors as shaped by knowledge, beliefs, and values and their associations with TB health delivery systems. 

A retrospective study was done by the University of South Carolina, Institute for Families in Society, to identify the knowledge, beliefs, and values of African Americans diagnosed with or at risk for TB in the Northeast Corridor of South Carolina.  Fifty-two face-to-face interviews of patients were completed and twenty key informant interviews were completed with community and governmental stakeholders.

In summary, the socioeconomic factors (a strong association between poverty, rural residence, lower educational attainment, unemployment, and lack of access to health care) serve as determinants in tuberculosis cases.  Disparities between African Americans with tuberculosis and other racial groups place this group at higher risk for poor health outcomes and for nonadherence to treatment. The data suggest that the elimination of tuberculosis may be achieved only through an effort that addresses these factors with local networking and public-private partnerships. 

When the clinical/biomedical factors are examined within the context of the socioeconomic findings, they suggest a possible association between these two factors and the identification and treatment of tuberculosis. As an example, low educational levels play a role in the inability of patients to understand the treatment of tuberculosis. A TB nurse or physician may misinterpret patients not following instructions as “noncompliance.” Yet, the reason may be the lack of understanding of the terms, unfamiliarity with medical systems, or the inability to read the materials provided as reinforcement for clinical visits.

The lack of funding to address tuberculosis educational and outreach efforts may contribute to the perception within the African-American community that TB is not important or is no longer a public health priority. 

The preliminary cultural factors identified suggest the need for careful attention to the training of nurses and related personnel working with tuberculosis, with increased emphasis on patient education through the use of culturally appropriate materials that foster cross-cultural communication between patients and providers. Stigma and the legacy of relationships in the South cannot be ignored - - TB is a disease that has traditionally been associated with issues of disparity. 

Several recommendations and a summary recommendation are as follows: 

  • Develop and implement an awareness and educational campaign to
    1. raise levels of information and awareness about tuberculosis disparities;
    2. promote changes in consumer behaviors to foster best health practices and improve quality of life; and
    3. encourage and promote culturally based and culturally competent health care practices and interventions by health care providers.
  • Involve and use the community more effectively. Include minorities in key roles where significant minority input may be missing and needed.
    • Reinforce collaborative efforts to build partnerships with agencies, community groups, and faith-based organizations.
  • Develop and reinforce multidisciplinary approaches to TB management.
    • Establish linking and contract arrangements with other health department professionals, i.e., health educators, nutritionists, social workers.
  • Expand the use of current resources by
    • Facilitating greater use of minority and mainstream media to educate and report on TB health care issues.

We believe these steps will enhance the identification, adherence, and treatment of tuberculosis among African Americans in South Carolina.


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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CDC/Division of Tuberculosis Elimination
Communications, Education, and Behavioral Studies Branch
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