Case Study #1
Carol, a 35-year-old woman of African descent, comes to the clinic for a follow-up
visit after having an HIV test. Upon receiving her results through the post-counseling
interview, it is discovered that Carol is really Carl, a 35-year-old man who has
recently been released from prison.
Further discussion reveals that Carl participated in receptive anal sex while he was
incarcerated. When asked about his sexual orientation, he insists he is heterosexual
and goes on to explain that now that he is HIV positive he can never return to his
native country in the Caribbean because of the stigma attached to HIV/AIDS.
He gives a series of expressions in Patois (dialect of English) that would be used to
describe a person like him and what would be done to such a person. Clearly, Carol
is dealing with a series of issues that may pose a challenge to the health care
professional.
Discussion Questions
1. As a health care professional, what can you do to increase your
understanding of this patient’s culture so that you can get this patient into
treatment?
2. How can you find out the meaning of the Patois expressions to better
understand this patient’s issues and provide appropriate medical care?
3. Discuss other Cultural Competence issues that may impact retention into care and
treatment.
Case Study #2
Carmen, a 17-year-old Latina, shows up at a clinic for a gynecological exam.
Carmen has been sexually active for over a year, and because she does not use
condoms consistently, she is afraid that she may have contracted HIV or another
STI.
Carmen’s mother has insisted on accompanying her to the exam, which she
believes, is only to discuss an irregular menstrual cycle that Carmen has been
complaining about. When the provider asks Carmen if she would like her mother to
stay for the exam, her mother says, “Of course she would, she has nothing to hide
from me.”
As the provider begins to ask Carmen questions related to her sexual health, it
becomes obvious that Carmen is uncomfortable answering the questions in front of
her mother.
When the provider asks if Carmen has ever engaged in sexual intercourse, Carmen
glances over at her mother and then responds, “No, of course not.” Carmen- desperately wants to voice her concerns about the possible contraction of HIV or
another disease but she is ashamed to admit to her mother that she has been
sexually active, and therefore does not request the appropriate medical screenings.
Discussion Questions
1. What cultural beliefs and values contribute to Carmen’s unwillingness to
admit her sexual behavior in front of her mother?
2. How could the health care provider request that Carmen’s mother leaves the
exam room without offending her or implying that Carmen is hiding something
from her?
3. How could the provider successfully address Carmen’s health concerns and
provide Carmen with sexual health information without causing a great amount of
family discord between Carmen and her mother?
4. Discuss other Cultural Competence issues that may impact retention into care and
treatment.
Case Study # 3
• A Vietnamese woman was rushed to the hospital by her adult children. The
emergency room personnel discovered dark red welts running up her arms,
shoulders and chest, yet the only presenting complaint was dizziness. When
questioned, her son explained that he had rubbed her body with a quarter. A
nurse becomes concerned when she finds an elderly Chinese patient rubbing
himself with a quarter (she thought he was trying to hurt himself). When she took
the coin away from the patient, he became very upset, grabbed it back from her
and continued to rub his arms and legs, leaving dark red scratches.
• A Vietnamese girl in her first year at an American elementary school was not
feeling well one morning, so her mother rubbed the back of her neck with a coin.
When the school staff discovered the welts on the girl’s neck, they immediately
assumed they were seeing a case of child abuse and reported the family to the
authorities.
Discussion
In each case the patient was practicing a traditional form of healing known as coin
rubbing. There are several variations, including heating the coin, but they all involve
vigorously rubbing the body with a coin. This produces red welts, which can distract
medical staff from the real problem of treatment or be mistaken for child abuse. It is
important to recognize and become familiar with this practice, and not to be
distracted from the real problem or mistakenly make accusations of child abuse.
• Discuss other Cultural Competence issues that may impact retention into care and
treatment. - • Examine and identify the gaps of care/treatment
• From a “big picture” perspective (administration) what could be
implemented to ensure cultural competency is being implemented?
• How could this be handled better using cultural humility and sensitivity?
Case Study #4
Kerry, a 32-year-old Native American woman from a small reservation in Montana
presented to a large urban clinic in the Northwest for care. She was married at age
17 and had contracted HIV from prior IVDU (intravenous drug use). She has been
unemployed for the past 10 years. Her husband, Carlos, a Central American
immigrant, had been HIV tested and was negative, although Kerry admitted they
occasionally had unprotected intercourse.
Her medical history was complicated by periodic alcohol and crack binges, and
a history of abnormal Pap smears. Her family and social history revealed
childhood physical and sexual abuse, and chemical dependency.
Although she had a brother living nearby in the city, she was adamant that he and
family in Montana know nothing about her diagnosis or treatment as she feared
family revenge.
She did not want her family to try to take her back to the reservation – a place she
escaped from and she made it clear she didn’t want to return, even after death. Her
husband agreed with her decision not to return to the reservation, and noted that
her family did not like him, as he was an “outsider.”
Kerry knew that her brother Mike often called the primary care doctor for updates
on her condition. The patient reminded her physician that she wanted her diagnosis
kept confidential, even if that seemed harmful to others.
She was initially started on antiretroviral therapy, but frequently missed
appointments for medical and gynecological care. She occasionally spoke of wanting
to see a medicine person through the clinic, but did not follow through on this
because the healer was male, and because she occasionally needs drugs.
Her CD4(a type of cell to help with immunity) counts continued to decline, with
rising viral load, and she was admitted to the hospital’s intensive care unit with
opportunistic infection and cardiomyopathy.
She had previously expressed a strong desire to be a “no code,” but suddenly
changed her mind in the ICU(intensive care unit) just prior to her death. After her
death, her brother and elder aunt demanded to know her diagnosis. Then they told
her husband that “they were her blood family, and she - needed to be buried at home,” regardless of her wishes, and that he had no
legal or other rights to make any decisions.
Discussion Questions:
1. What are the barriers to care in this case?
2. What ethical decisions must the health care providers make concerning
her diagnosis and treatment
3. What course of action could the health care providers have taken for
more culturally competent care?
4. How can the issue of her burial be resolved?
5. Discuss other Cultural Competence issues that may impact
retention into care and treatment.
Case Study #5
A middle-aged Chinese patient refused pain medication following cataract
surgery. When asked, he replied his discomfort was bearable and he could
survive without any medication. Later the nurse found him restless and
uncomfortable. Again the nurse offered pain medication. Again he refused,
explaining that her responsibilities at the hospital were far more important than
his comfort and he did not want to impose. Only after she firmly insisted that the
patients comfort was one of her most important responsibilities did the patient
finally agree to take the medication.
Things to Consider
·Chinese are taught self-restraint. The needs of the group are more
important than those of the individual.
·Another factor that may be involved in Asian’s refusal of pain medication is
courtesy. They generally consider it impolite to accept something the first
time it is offered.
·The safest approach for the nurse is to anticipate the needs of an Asian
patient for pain medication without waiting for requests – Nurses should be
aware of Asian rules of etiquette when offering pain medication, food or
other services.
· If the patient continues to refuse medication, their wish should be respected.
Discussion - 1. Discuss other Cultural Competence issues that may impact retention into care
and treatment.
2. Identify the gaps of caring for the patient in a culturally sensitive manner.
3. As a healthcare provider how would you have handled this situation in using cultural
humility?
The text book is cultural diversity in health and illness ninth edition by
Rachael E Spector
