Effective TB Interviewing for Contact Investigation: Self-Study Modules
The Concept of Culture
What we refer to as culture often consists of numerous variables for an individual, including but not limited to
- Geographic origin or location
- Spirituality, religion, or faith
- Sexual orientation
- Language or dialect
Specific life events and factors can influence the way in which the above variables for the person or his or her family are integrated into one’s life. These factors can include
- Political values and affiliation;
- History of oppression;
- Experience of discrimination;
- Socioeconomic status;
- Language and the arts;
- Religious practices;
- Family roles and structure;
- Degree of opposition to acculturation;
- Settlement in outside environments through immigration and migration;
- Education and employment history; and
- Military experience.
Culture is individual, and information about it should be obtained directly from the patient. While a variety of information exists on various races, ethnicities, religions, and other categories of cultural groups, it is important to note that not all persons identified by the same label have the same beliefs and behaviors. For example, a person who identifies himself or herself by a particular ethnicity may not behave similarly to all others in that ethnic group. This person may have lived away from members of this ethnic group or may have been raised by someone from another ethnic group. The person’s own identification, name, or physical characteristics could suggest an ethnicity even though the person’s beliefs and behaviors do not fit the accepted image of that group.
Despite the fact that cultural characteristics are specific to a patient, it is valuable to learn about different cultures to develop a general understanding of how a person’s perceptions, beliefs, and values may vary. While these characteristics will not always pertain to the individuals who are deemed a part of a certain culture, it is important for interviewers to be aware of differences. For example, noting that particular hand gestures may have negative connotations in certain cultures can indicate that one should use care when using any hand gestures in communications with patients.
The interviewer should communicate respect for the patient, both verbally and non-verbally. This is best achieved by being observant of and sensitive to the many variables that can affect the interaction between the interviewer and the patient. A patient’s reaction to the interviewer may be a reflection of the patient’s values or views of certain relationships. For example, the gender of the interviewer may affect the patient’s comfort level. If the interviewer senses a patient’s discomfort, changing to an interviewer of the same gender would be preferable, if possible.
The interviewer’s culture (e.g., race or ethnicity) can also affect the interaction between the interviewer and the patient. However, each patient’s preference is individual. A patient may prefer an interaction with someone of the same culture, while for others this is undesirable. The interviewer should be aware of how comfortable the patient is by noting verbal and non-verbal cues.
Nature of the Interviewer’s Job
It is important to keep in mind that the role of an interviewer may have some inherent negative connotation, especially since he or she is asking personal questions. A patient may have had negative experiences with the healthcare system or government authorities in the past. The interviewer, representing both of these entities, should remain sensitive to this connotation and clarify that his or her role is to protect the public’s health and the health of the patient and the people close to the patient.
Observing Customs and Practices
While conducting an interview, the interviewer should honor customs observed by the patient. For example, if the interview takes place in the patient’s home and it is observed that shoes are kept outside the home, the interviewer should remove his or her shoes prior to entering. Seating arrangements are also important. An interviewer should wait to be asked to sit in a certain location, to make the patient feel more comfortable. In some cultures, a male may be the spokesperson for the family. If an interview is being conducted with a female patient, but a male in the home is speaking for her, respect for this practice should be given. It is important, however, to maintain rapport with both the patient and spokesperson and to explain that you wish to gain information exclusive to the patient, from her viewpoint. If the interviewer is uncomfortable, another interview can be suggested with just the female patient.
A patient’s understanding of or beliefs about TB may differ from the medical model in which most healthcare workers are trained. This may include how to treat TB, how TB is transmitted, and the specific significance the disease has for the affected person. It is important to respect different health beliefs, and provide the correct information in non-judgmental fashion. As with any TB interview, the provision of education and an emphasis on reasons for contact identification are important. In regard to other health beliefs, the interviewer should refer any treatment or diagnostic concerns to the patient’s clinician or case manager for further follow-up.
The diagnosis of TB may carry a particular stigma or negative connotation in some cultures. The patient may even deny that he or she has TB or that the treatment offered is curative. The interviewer should always acknowledge the fact that a patient may feel ashamed or fearful of the diagnosis of TB. In a contact investigation, having to probe for information about persons to whom the patient may have spread TB may cause even further distress. Again, it is important to acknowledge the patient’s stress, explain why it is important to conduct the TB interview, and emphasize its confidential nature. For example, an elderly person with TB may recall many cases of TB in the past among friends and family members. These cases were treated differently than today’s cases, due to the fact that medical regimens were limited in the past and many people eventually died. The current TB patient may fear having TB and have trouble accepting the way disease is being treated because of his or her past experiences. The interviewer should be sensitive to these issues.
Health Seeking Behaviors and Beliefs
Cultural attitudes about illness may complicate determination of a patient’s infectious period. A patient may have been symptomatic for longer than he or she may acknowledge. TB symptoms may have been attributed to other illnesses for which various remedies or care were sought. The interviewer should attempt to discover any and all instances of TB symptoms, especially coughing, to accurately determine the infectious period. Asking about specific symptoms can be helpful. Also, asking what remedies were sought to resolve symptoms can assist in remembering when symptoms may have occurred.
Source, Treatment, and Cure of Illness
Beliefs about how TB is spread and its causative agents can vary. The long history of TB has created various theories about its cause, including beliefs that certain behaviors such as smoking, breathing polluted air, and hard labor may cause TB and contribute to its progression. Furthermore, remedies for symptom relief and cure of the disease can vary. If discussion about treatment occurs, the interviewer should keep in mind that traditional or folk medicine can be complementary to Western medicine, but should be overseen by the treating clinician. It is also important to be sure of the patient’s understanding of terminology. For example, for some, the word “infection” may suggest something much more serious than the word “disease.” Effectively communicated patient education can help resolve these issues.
Communication with the patient can be affected by many different factors, of which the interviewer must be observant. This is covered further in Module 2, “Communication and Patient Education.” However, cultural differences can also influence this communication. The interviewer should be mindful of the following cultural factors that may affect the patient interview.
When greeting a patient, even if unsure of the pronunciation of a patient’s name, an attempt should be made to pronounce it. The patient should then be asked for the correct pronunciation. Making this sincere attempt demonstrates respect and assists in rapport building. Asking for clarification on pronunciation and not being able to pronounce all names is not a bad reflection on the interviewer. Also, sometimes learning a common greeting, such as, “Hello” or “How are you?” in a patient’s language, can ease any tension and show the interviewer’s sensitivity to culture.
Accent and Dialect
The presence of a foreign accent or of dialect differences can cause difficulty in understanding for both the patient and interviewer. If the patient’s language is limited, then an interpreter is necessary.
If conducting an interview in which the interviewer or the patient is having difficulty in understanding the discussion because of accent or dialect, some of the following techniques may be used:
- Speak slowly and clearly.
If the pace of the interview is slowed, then the patient may also slow his or her speech to make the information more understandable.
- Use nontechnical words and phrases.
Many individuals who speak more than one language will internally translate phrases into the language with which they are most comfortable. Some phrases, especially “sayings” with figurative meanings, change in meaning when translated. When working with an interpreter, avoiding local jargon and excessive medical language will ease communication.
- Ask the patient if anything is not understood.
Even if a patient affirms information by nodding his or her head or verbally acknowledging information, the interviewer should encourage the patient to ask questions and summarize what he or she has heard. If the interviewer has trouble understanding the patient, he or she should politely ask for clarification. Conversely, the interviewer may not always be understood and may be asked for a rewording of what was said.
- Use written information.
While English may not be the primary spoken language for many people, it may be easy for them to write. If the patient cannot write in English, the interviewer should obtain phonetic spellings of names and addresses of contacts based on what the patient states. That is, the interviewer should write items in the closest way to which the patient pronounces them. This can assist the interviewer during the re-interview, if he or she must ask additional details about certain contacts. This can also provide assistance to the healthcare worker who must go into the field and interact with any named contacts later.
Presence of Additional Individual(s) During the Interview
During the interview, there may also be another family member present. Often times, a patient, while proficient in the language in which the interview is being conducted, feels more comfortable communicating through a family member or having this member speak for him or her. The interviewer should explain to the patient and the family member that direct communication with the patient would be most accurate and questions would be best answered if they came directly from the patient. While this is not preferred, interviewers can collect baseline information (names, phone numbers, or addresses) can be collected from a family member. If the family member is present throughout the interview, a re-interview should be scheduled at a time when the family member is not present to ensure privacy. If either party is uncomfortable with this arrangement, then the interview should proceed under circumstances with which all parties are comfortable.