An ethnography of nonadherence: culture, poverty, and tuberculosis in urban Bolivia

• Published in: Culture, medicine and psychiatry medicine and psychiatry, 2004-09, Vol.28 (3), p.401-425
• Main Author: Greene, Jeremy A
• Format: Article
• Language: English
• Subjects: Access; Access to health care; Adult; Andean languages; Antitubercular Agents - administration & dosage; Antitubercular Agents - economics; Attitude to Health - ethnology; Beliefs; Biomedicine; Bolivia; Compliance; Cultural Characteristics; Cultural differences; Cultural diversity; Culture; Discrimination; Ethnicity; Ethnography; Female; Health Behavior; Health Behavior - ethnology; Health care; Health care access; Health Care Utilization; Health services; Health Services Accessibility; Humans; Low income groups; Male; Marginality; Marginalized people; Medical anthropology; Medical model; Medications; Medicine; Noncompliance; Patient Acceptance of Health Care - ethnology; Patient Acceptance of Health Care - psychology; Patients; Physicians; Poverty; Professional-Patient Relations; Respondents; Science; Social sciences; Socioeconomic Factors; Therapy; Time Factors; Treatment Compliance; Treatment methods; Treatment Outcome; Treatment Refusal - ethnology; Treatment Refusal - psychology; Tuberculosis; Tuberculosis, Pulmonary - drug therapy; Tuberculosis, Pulmonary - ethnology; Tuberculosis, Pulmonary - psychology; Urban Population; Urban poverty
• ISSN: 0165-005X; 1573-076X
• DOI: 10.1023/B:MEDI.0000046429.55801.c8

The author conducted a focused descriptive ethnographic study of nonadherence with tuberculosis (TB) therapy among Aymara-speaking residents of the city of La Paz, Bolivia. A cohort of patient-informants was identified from the District III TB Control Registry of La Paz as having been nonadherent with their TB medication protocol. From June to August 1998, ethnographic material was collected through participant-observation and repeated interviews and visits in homes, workplaces, clinics, and the community. Ethnographic analysis revealed structural barriers to be more important than cultural differences in the production of nonadherence. Though informants maintained a variety of beliefs and practices related to Aymara medicine, the majority of patients were comfortable with a biomedical model of tuberculosis and maintained belief in the efficacy of antituberculosis chemotherapy and desire to finish treatment. Patients overwhelmingly cited hidden costs of treatments, poor access to care, ethnic discrimination, and prior maltreatment by the health system as reasons for abandoning treatment. These data suggest that overemphasis of cultural difference without exploration of other social dimensions of health care delivery can obscure a more practical understanding of nonadherence in marginalized populations.