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The Purnell Model for Cultural Competence

Article  in  Journal of Transcultural Nursing · August 2002

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The Purnell Model for Cultural Competence

Larry Purnell, PhD, RN, FAAN

The twenty^-first centujy has ushered ir\ an era of mul- the Model are presented. The primary) and secondary}
ticulturalisrn and diuersity in health care. Cultural compe- characteristics of culture that determine the degree to
tence, an essential component within the multidisciplinary which people adhere to their dominant culture are also
healthcare team, has become a major initiative. The included.
Purnell Model of Cultural Competence is proposed as an Cultural general knowledge and skills ensures thai
organizing framework to guide cultural competence providers have a process for "becoming" cuituraily com-
among mu/t/discip/inary members of the healthcare team petent. This manuscript presents definitions of essential
in a variety? of primar\;, secondary/, and tertiary settings. terminology for understanding culture and the Purnell
First, essential definitions for understanding culture and Model for Cultural Competence.
cultural concepts are introduced. A brief overview of the
Purneil Model for Cultural Competence including pur- KEY WORDS: Purnell Model; Primary character-
poses, underlying assumptions, and major components of istics; Secondary characteristics.

H
ealthcare professionals and healthcare organi- employment settings from multiple perspectives.
zations are avidly addressing multicultural Increasing one's consciousness of cultural diversity
diversity and racial and ethnic disparities in improves the possibilities for healthcare practitioners to
health. Almost every health journal now has provide culturally competent care, and therefore
articles addressing "cultural competence." Healthcare improved care. Cultural competence is a conscious
professional societies and organizations have some type process and not necessarily linear. To add to the com-
of standards, initiative, or statement encouraging its mem- plexity of learning culture, no standardization of terminol-
bers to become culturally sensitive and/or culturally com- ogy related to culture and ethnicity exists. The definition
petent. Moreover, one can now find workshops that of cultural sensitivity presented by one person or group is
address culturally sensitive and culturally competent care the same definition that another person or group defines
from a plethora of organizations and individuals. The as cultural competence or awareness. In an attempt to
stress on culture and diversity is good because cultural reach consensus and standardize definitions of these and
competence improves the health of the country's citizens. other terms commonly used in health care, the American
However, culture is an extremely demanding and complex Academy of Nursing Expert Panel on Cultural
concept, requiring providers to look at themselves, their Competence has been developing over the last two years
patients, their communities, their colleagues, and their a White Paper that addresses this issue. This manuscript
presents definitions of essential terminology as a starting
point for understanding culture and the Purnell Model for
Cultural Competence.

Larry Purnell, PhD, RN, FAAN, Professor, DEFINITIONS

University of Delaware, College of Health and
Nursing S c i e n c e s , Department of Nursing, Although anthropologists and sociologists have pro-
McDowell Hall, Newark, Delaware. posed many definitions of culture Purnell defines culture as

THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005

 ...the totality of socially transmitted behavioral pat- broader cultural group, creating uncertainties for health-
terns, arts, beliefs, values, customs, lifeways, and all care providers. For example, what is the politically correct
other products of human work and thought charac- term: Hispanic or Latino? According to the Office of
teristics of a population of people that guide their Minority Health (2004), both terms are acceptable.
worldview and decision making. These patterns may However, some individuals prefer the term Hispanic, oth-
be explicit or implicit, are primarily learned and trans- ers prefer the term Latino, and for others, neither term is
mitted within the family, are shared by most members apporpriate and the person self-identifies with another
of the culture, and are emergent phenomena that term more appropriate to the country of origin or ethnici-
change in response to global phenomena. Culture is ty. Many times it is not necessary to label a person; how-
learned first in the family, then in school, then in the ever, when it is necessary, simply ask the person how
community and other social organizations such as the he/she wishes to be identified.
church. (Purnell, 2003,p.3). Cultural competence has several characteristics and
includes knowledge and skills as well as the following:
Within all cultures are subcultures, ethnic groups, or
ethnocultural populations, groups who have experiences • Developing an awareness of one's own culture,
different from those of the dominant culture with which existence, sensations, thoughts, and environment
they identify; they may be linked by nationality, language, without letting them have an undue influence on
socioeconomic status, education, sexual orientation, or those from other backgrounds;
other factors that functionally unify the group and act col- • Demonstrating knowledge and understanding of
lectively on each member with a conscious awareness of the client's culture, health-related needs, and
these differences (Purnell, 2003). Additionally, subcultures meanings of health and illness;
differ from the dominant cultural group and share beliefs • Accepting and respecting cultural differences;
according to the primary and secondary characteristics of • Not assuming that the healthcare provider's
culture (defined later in this manuscript). A specific exam- beliefs and values are the same as the client's;
ple of how two people from the dominant American cul- • Resisting judgmental attitudes such as "different
ture may vary follows; is not as good;" and
• Being open to cultural encounters;
Susan Jones, age 62, is an uninsured, single, • Being comfortable with cultural encounters;
white Catholic lesbian who makes $20,000 a • Adapting care to be congruent with the client's
year and practices aromatherapy. William culture;
James, age 28, is an insured, heterosexual, mar- • Cultural competence is an individualized plan of
ried, white male with 4 children and makes care that begins with performing an assessment
$200,000 per year and believes strongly in high- through a cultural lens.
technology health care.
Organizational cultural competence is also important
While these two people both come from the "domi- and essential for healthcare educational and service
nant American culture," their worldview is probably very organizations. At a minimum, for an organization to be
different due to their subcultures and primary and sec- culturally competent, the following should be in place.
ondary characteristics of culture such as age, gender, sex-
ual orientation, marital status, parental status, and socioe- • The mission and philosophy must address diver-
conomic and insurance status. sity initiatives;
Culture is largely unconscious and has powerful influ- • Culture must be included in the orientation pro-
ences on health and illness. Healthcare providers must gram of all new employees;
recognize, respect, and integrate clients' cultural beliefs • Diversity workshops must be provided on an on
and practices into health prescriptions. Thus, the provider going basis;
must be culturally aware, culturally sensitive, and have • Interpretation and translation services must exist,
some degree of cultural competence to be effective in especially in the languages of the population they
integrating health beliefs and practices into plans and serve;
interventions. Cultural awareriess, essentially the objec- • Cultural brokers must include mentors for
tive material culture, has more to do with an appreciation employees unfamiliar with the culture of the
of the external signs of diversity, such as arts, music, dress, patients;
and physical characteristics. Cultural sensitivify has more • Directional signs must be posted in languages of
to do with personal attitudes and not saying things that the populations who use the facility;
might be offensive to someone from a cultural or ethnic • Culturally congruent meals are provided for
background different from the healthcare provider's. patients;
Moreover, culturally sensitive, politically correct language • An array of culturally diverse artwork and other
changes over time, within ethnic groups, and within the objective signs of culture are displayed;

8 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005

 • The ethics committee has representation from the are strange, bizarre, or unenlightened, and therefore
community and from the ethnocultural groups wrong (Purnell, 2003). Most of the literature in nursing
served; addresses only the negative aspects of ethnocentrism.
• A concerted effort is made to recruit employees However, there is a positive aspect of ethnocentrism from
representative of the populations they serve; and the patient's, family's, and community perspetives.
• Any number of culturally specific services: e.g. a Ethnocentrism is responsible for cultural self-survival and
hospital that serves the orthodox Jewish commu- helps people maintain self-worth and self-survival. These
nity programs elevator doors to open automati- positive attributes can be negative when one uses his/her
cally and on each floor on the Sabbath and to own worth in relation to others who are perceived to be
provide kosher meals. inferior (Walker & Avant, 1995).

The word race has become a very controversial word, Culture as a Process
at least in the United States. The Human Genome Project
(2004) demonstrates that all human beings share a genet- Cultural competence is a process, not an endpoint
ic code that is over 99 percent identical. Some people (See figure 1). One progresses (a) from unconscious
minimize or dispute the concept of race and others stress incompetence (not being aware that one is lacking knowl-
its importance given the major initiatives addressing racial edge about another culture), (b) to conscious incompe-
and ethnic dispartiies in health care. However, the con- tence (being aware that one is lacking knowledge about
troversial term race must still be addressed. Race is genet- another culture), (c) to conscious competence (learning
ic in origin and includes physical characteristics that are about the client's culture, verifying generalizations about
similar among members of the group, such as skin color, the client's culture, and providing culturally specific inter-
blood type, hair and eye color. Difference among races is ventions), and finally (d) to unconscious competence
significant when conducting health assessments, investi- (automatically providing culturally congruent care to
gating hereditary and genetic diseases, and prescribing clients of diverse cultures). Unconscious competence is
medication. People from a given racial group may, but do difficult to accomplish and potentially dangerous because
not necessarily, share a common culture or subculture: individual differences exist within specific cultural groups.
e.g., most African Americans have black skin but a person To be even minimally effective, culturally competent care
with white skin and no ancestry with people with black (really an individualized plan of care) must have the assur-
skin may self-identity with the African American culture. ance of continuation after the original impetus is with-
drawn; it must be integrated into and valued by the cul-
Healthcare providers must assess the patient's and
ture that is to benefit from the interventions.
family's beliefs for effective health maintenance and well-
ness, illness and disease prevention, and health restora- Each healthcare provider adds a new and unique
tion. A belief is something that is accepted as true, espe- dimension to the complexity of providing culturally com-
cially as a tenet or a body of tenets accepted by an indi- petent care. The way healthcare providers perceive them-
vidual or group. A common belief among cultures is that selves as competent providers is often refiected in the way
health, either good health or bad health, is ''God's Will." they communicate with clients. Thus, it is essential for
Beliefs do not have to be proven; they are consciously or healthcare professionals to take time to think about them-
unconsciously accepted as truths and must be included in selves, their behaviors, and their communication styles in
the client's individualized plan of care, regardless of what relation to their perceptions of culture. Cultural self
the provider thinks about them. awareness is a deliberate and conscious cognitive and
All groups have similar or the same values but they emotional process of getting to know yourself: your per-
vary in the degree and the intensity by which they are sonality, your values, your beliefs, your professional
held by the group and by the individual. Values are prin- knowledge standards, your ethics, and the impact of these
ciples and standards that have meaning and worth to an factors on the various roles played when interacting with
individual, family, group, or community. Major cultural individuals who are different from yourself. The ability to
values include individualism versus collectivism, being understand oneself sets the stage for integrating new
versus doing, hierarchial versus egalitarian status, youth knowledge related to cultural differences into the profes-
versus elders, cooperation versus competetion, ascribed sional's knowledge base and perceptions of health inter-
versus achieved status, change versus tradition, and for- ventions. Even then, traces of ethnocentrism may uncon-
mality versus informailty, to name a few. The more one's sciously pervade one's attitudes and behavior.
values are internalized, the more difficult it is to avoid the
tendency toward ethnocentrism. Ethnocentrism, the uni- STEREOTYPING VERSUS GENERALIZATION
versal tendency of human beings to think that their ways
of thinking, acting, and believing are the only right, prop- Stereotyping, an over simplified conception, opinion,
er, and natural ways, can be a major barrier to providing or belief about some aspect of an individual or group of
culturally competent care. Ethnocentrism perpetuates an people is a common occurrence among people, and
attitude in which beliefs that differ greatly from one's own occurs at the intra-individual level, inter-individual level.

THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005

and inter-group level (Stevens & Fiske, 1995). THE PURNELL MODEL EOR
Stereotyping has both cognitive (categorization) and CULTURAL COMPETENCE
motivational components, which bolsters self-esteem
(Baumeister, Smart, & Boden. 1996; Fiske. 2000; Turner, The Purnell Mode! for Cultural Competence (See
1987). Stereotyping is a normal function and people Figure 1) started as an organizing framework in 1991
accentuate differences between categories and minimize when the author was teaching undergraduate students
differences within categories (Capozza & Nanni, 1986). A and discovered the need for both students and staff to
stereotype can be positive, "all Asians are good in math," have a framework for learning about their cultures and
or negative, "all African American teenagers are sexually the cultures of their patients and families. Comments from
promiscuous." Obviously these statements are example of staff and students made it dear that ethnocentric behav-
subjective essentialism and entitativity (Yzerbyt, Corneille, ior and tack of cultural awareness, cu!tural sensitivity, and
& Estrada, 2001) because not all Asians are good at math cultural competence existed. The Purnell Model was
and not all African American teenagers are promiscuous. designed as a wholistic organizing framework with specif-
However, stereotyping has advantages, including saving ic questions and a format for assessing culture that could
perceivers' mental resources to allow them to operate be used across disciplines and practice settings.
under a cognitive load (Pendry, 1998). A stereotype is, All healthcare discip!ines value communication and
however, an endpoint. need to know their client's ethnocultural beliefs. Although
Given that stereotyping is a common occurrence, physicians, nurses, nutritionists, therapists, technicians,
healthcare professionals must concentrate on impression morticians, home health aides, and other caregivers need
management and validate cultural group generalizations. similar culturally specific information, the manner in
Generalization, rules that groups adopt about other which the information is used may differ significantly
groups, is a point, and the healthcare provider must see if based on the discipline, individual experiences, and spe-
the individual fits the cultural pattern. Impression man- cific circumstances of interacting with the client. Each dis-
agement begins with self awareness and is a conscious cipline has its own unique knowledge base to support its
process through which providers must cognitively engage ways of knowing its clients as well as techniques, ro!es,
to control stereotypical thinking (Pacquiao, 2000; norms, va!ues, ideo!ogies, attitudes, and beliefs, which
Schneider, 1981). The value in making generalizations interlock to make a reinforced and supportive system
about cultural groups is that the healthcare provider within its defined practice. An understanding of ethnocu!-
knows what questions to ask. For example, in collectivist tural diversity improves the effectiveness of all healthcare
cultures, such as Korean, Chinese, Filipino, and providers.
Vietnamese to name a few, ingroup harmony is essential The Purnell Model has been classified by three well-
to ingroup loyalty and conformity to standards of behav- known nurse theorists as holographic and complexity the-
ior. If the provider automatically assumes that the previ- ory because it includes a model and organizing frame-
ous statement is tme, then that person is stereotyping the work that can be used by all healthcare providers in vari-
person based on the characteristics of east Asian cultures. ous disciplines and settings. Additionally, these nurse the-
Adopting such a generalization is a beginning point from orists early in 1998 confirmed that the Purne!! Model was
which the provider must determine the extent to which not a conceptua! framework, but rather a grand theory.
the patient and/or family adheres to these cultural charac- Although the professiona! community recognizes that
teristics. scholarly controversy exists in distinguishing between a
conceptual framework and grand theory, the va!ue and
Some authorities believe that learning the charactris-
utility of the Purnell Model has been documented in
tics of cultural groups and that research on cultural groups
developing cultural competence across disciplines and in
can reinforce stereotyping (Dreher & MacNaughton,
stimulating further inquiry and knowledge quest.
2002). These authorities maintain that the provider needs
to only know a genera! cultural approach for assessments The Model is a circle, with an outlying rim represent-
and may disregard cultural specific information. If the ing globa! society, a second rim representing community,
provider does not know cultural specific characteristics, a third rim representing family, and an inner rim repre-
e.g. Mexican clients may use curanderos, masajistas, and senting the person. The interior ofthe circle is divided into
sobadores (folk healers) for generic health care, they 12 pie-shaped wedges depicting cu!tural domains and
would not know to specifically ask about them; and there- their concepts. The dark center of the circ!e represents
fore, essential information may be missed. Knowing both unknown phenomena. Along the bottom of the mode! is
the genera! and specific characteristics of the cultural a jagged line representing the nonlinear concept of cultur-
group leads to an improved assessment allowing one to al consciousness. The 12 cultural domains (constructs)
make an individualized plan of care. provide the organizing framework of the mode!.

10 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005

Figure 1 - The Purnell Model for Cultural Competence

§ S ^ G ^.§

Unconsciously Incompetent - Consciously incompetent - Consciously competent - Unconsciously competent

Primary characteristics of culture: age, generation, nationality, race, color, gender, religion
Secondary characteristics of culture: educational status, socioeconomic status, occupation, military status, political beliefs, urban versus
rural residence, enclave identity, marital status, parental status, physical characteristics, sexual orientation, gender issues, and reason for
migration (sojourner, immigrant, undocumented status)

THE JOURNAL OF MULTIOULTURAL NURSING & HEALTH 11:2 Summer 2005 11

Healthcare providers can use this same process to under- • Learning culture is an ongoing process that
stand their own cultural beliefs, attitudes, values, prac- develops in a variety of ways, but primarily
tices, and behaviors. through cultural encounters (Campinha-Bacote,
2004).
The purposes of the Purnell Model are to • Prejudices and biases can be minimized with cul-
tural understanding.
• Provide a framework for all healthcare providers • To be effective, health care must reflect the
to learn concepts and characteristics of culture; unique understanding of the values, beliefs, atti-
• Define circumstances that affect a person's cul- tudes, lifeways, and worldview of diverse popu-
tural worldview in the context of historical per- lations and individual acculturation patterns.
spectives; • Differences in race and culture often require
• Provide a nnodel that links the most central rela- adaptations to standard interventions.
tionships of culture; • Cultural awareness improves the caregiver's self-
• Interrelate characteristics of culture to promote awareness.
congruence and to facilitate the delivery of con- • When individuals of dissimilar cultural orienta-
sciously sensitive and competent health care; tions meet in a work or therapeutic environment,
• Provide a framework that rcfiects human charac- the likelihood for developing a mutually satisfy-
teristics such as motivation, intentional ity, and ing relationship is improved if both parties in the
meaning; relationship attempt to learn about each other's
• Provide a structure for analyzing cultural data; culture.
and • Culture is not border bound. Fteople bring their
• View the individual, family, or group within their culture with then when they migrate.
unique ethnocultural environment. • Professions, organizations, and associations have
their own culture, which can be analyzed using a
The explicit assumptions upon which the Model is grand theory of culture.
based are
METAPARADIGM CONCEPTS
• All healthcare professions need similar informa-
tion about cultural diversity. The macro aspects of this Model include the tradi-
• All healthcare professions share the metapara- tional nursing metaparadigm concepts of global society,
digm concepts of global society, family, person, community, family, and person. Although not all nurse
and health. theorists support the nursing metaparadigm concepts
• One culture is not better than another culture; (Leininger, 1997}, this author has found them to be
they are just different. immensely valuable because they provide a wholistic and
• Core similarities are shared by all cultures. global perspective. The theory and model are conceptu-
• Differences exist within, between, and among alized from biology, anthropology, sociology, economics,
cultures. geography, history, ecology, physiology, psychology,
• Cultures change slowly over time. political science, pharmacology, and nutrition as well as
• The primary and secondary characteristics of cul- theories from communication, family development, and
ture determine the degree to which one varies social support. The Model can be used in clinical practice,
from the dominant culture. in formal and continuing education education, in
• If clients are coparticipants in their care and have research, and in the administration and management of
a choice in health-related goals, plans, and inter- healthcare services.
ventions, their compliance and health outcomes Phenomena related to a global society include world
will be improved. communication and politics; conflicts and warfare; natu-
• Culture has a powerful influence on one's inter- ral disasters and famines; international exchanges in edu-
pretation of and responses to health care. cation, business, commerce, and information technology;
• Individuals and families belong to several cultur- advances in the health sciences; space exploration; and
al groups. the expanded opportunities for people to travel around
• Each individual has the right to be respected for the world cind interact with diverse societies. Global
his or her uniqueness and cultural heritage. events that are widely disseminated by television, radio,
• Caregivers need both cultural-general and cultur- satellite transmission, newsprint, and information technol-
al-specific information in order to provide cultur- ogy affect all societies, either directly or indirectly. Such
ally sensitive and culturally competent care. events create chaos while consciously and unconsciously
• Caregivers who can assess, plan, intervene, and forcing people to alter their lifeways, worldviews, and
evaluate in a culturally competent manner will acculturation patterns.
improve the care of clients for whom they care.

12 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005

 In its broadest definition, community is a group of CONSTRUCTS AND CONCEPTS
people having a common interest or identity and living in
a specified locality. Community includes the physical, On a micro level, the Model has an organizing frame-
social, and symbolic characteristics that cause people to work consisting of 12 domains, constructs, and their con-
connect. Bodies of water, mountains, rural versus urban cepts, which are cotnmon to all cultures, subcultures, and
living, and even railroad tracks help people define their ethnic groups. These 12 domains are interconnected and
physical concept of community. Today, however, technol- have implications for health. The utility of this organizing
ogy and the Internet allow people to expand their com- framework comes from its concise structure, which can be
munity beyond physical boundaries. Economics, religion, used in any setting and applied to a broad range of empir-
politics, age, generation, and marital status delineate the ical experiences and can foster inductive and deductive
social concepts of community. Sharing a specific language reasoning in the assessment of cultural domains. They can
or dialect, lifestyle, history, dress, art, or musical interest be used to formulate questions and statements for con-
are symbolic characteristics of a community. People ducting research. Once cultural data are analyzed, the
actively and passively interact with the community, neces- practitioner can fully adopt, modify, or reject healthcare
sitating adaptation and assimilation for equilibrium and interventions and treatment regimens in a manner that
homeostasis in their worldview. Individuals may willingly respects the client's cultural differences. Such adaptations
change their physical, social, and symbolic community improve the quality of the client's healthcare experiences
when it no longer meets their needs. and personal existence.
A family; is two or more people who are emotionally
connected. They may, but do not necessarily, live in close THE 12 DOMAINS OF CULTURE
proximity to each other. Family may include physically
and emotionally close and distant consanguineous rela- The 12 domains and their concepts essential for
tives as well as physically and emotionally connected and assessing the cultural attributes of an individual, family, or
distant non-blood-related significant others. Family struc- group are as follows:
ture and roles change according to age, generation, mar-
ital status, relocation or immigration, and socioeconomic • Overview, inhabited localities, and topography
status, requiring each person to rethink individual beliefs includes concepts related to the country of origin,
and lifeways. current residence, the effects of the topography of
A person is a biopsychosociocultural being who is the country of origin and current residence, eco-
constantly adapting to his or her environment. Human nomics, politics, reasons for emigration, and
beings adapt biologically and physiologically with the value places on education.
aging process; psychologically in the context of social rela-
tionships, stress, and relaxation; socially as they interact • Communication includes concepts related to the
with the changing community; and ethnoculturally within dominant language and dialects; contextual use
the broader global society. In highly individualistic of the language; and paralanguage variations
Western cultures, a person is a separate physical and such as voice volume, tone, intonations, reflec-
unique psychological being and a singular member of tions, and willingness to share thoughts and feel-
society. The self is separate from others. However, in high- ings. Nonverbal communications such as the use
ly collectivist Asian cultures, the individual is defined in of eye contact, facial expressions, touch, body
relation to the family, including ancestors, or another language, spatial distancing practices, and
group rather than a basic unit of nature. acceptable greetings; temporality in terms of past,
Health, as used in this article, is a state of wellness as present, or future worldview; clock versus social
defined by people within their ethnocultural group. time; and the use of names are also important
Health generally includes physical, mental, and spiritual communication variables.
states. The concept of health, which permeates all meta-
paradigm concepts of culture, is defined globally, nation- • Family roles and organization includes concepts
ally, regionally, locally, and individually. People can speak related to the head of the household and gender
about their personal health status or the health status of roles; family roles, priorities, and developmental
the nation or community. Health can also be subjective or tasks of children and adolescents; childrearing
objective in nature. practices and roles of the aged and extended
In the center of the Purnell Model Is an empty circle. family members. Individual and family social sta-
This circle represents unknown phenomena, practices, and tus in the community; and views toward alterna-
characteristics of the individual or the group. In the case of tive life styles such as single parenting, sexual ori-
healthcare providers, this circle can expand or contract entation, childless marriages, and divorce are
depending upon the providers cultural self awareness and also included in this domain.
the knowldege and skills they possess for working with cul-
tually diverse clients, families, and communities. • Workforce issues include concepts related to

THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005 13

 autonomy, acculturation, assimilation, gender PRIMARY AND SECONDARY OF CULTURE
roles, ethnic communication styles, and health-
care practices from the country of origin. Major influences that shape peoples' worldview and
the degree to which they identify with and adhere to their
• Biocultura! ecology includes variations in specific cultural group of origin are called the primary and sec-
ethnic and racial origins such as skin coloration ondary characteristics of culture. The primary characteris-
and physical differences in body stature; genet- tics are nationality, race, color, gender, age, and religious
ic, hereditary, endemic, and topographical dis- affiliation. Primary characteristics cannot easily be
eases; and the differences in the way drugs are changed. If these characteristics such as religion or gender
metabolized by the body. are changed, a significant stigma may attach to the indi-
vidual from society.
• High-risk behaviors includes the use of tobacco, The secondary characteristics include educational sta-
cilcohol, and recreational drugs; lack of physical tus, socioeconomic status, occupation, military experi-
activity; increased calorie consumption; nonuse ence, political beliefs, urban versus rural residence,
of safety measures such as seatbelts, and hel- enclave identity, marital status, parental status, physical
mets; and engaging in risky sexual practices. characteristics, sexual orientation, gender issues, reason
for migration (sojourner, immigrant, or undocumented
• Nutrition includes having adequate food for sat- status}, and length of time away from the country of ori-
isfying hunger; the meaning of food; food choic- gin. People who live in ethnic enclaves and get their work,
es, rituals, and taboos; enzyme deficiencies; and shopping, and business needs met without learning the
how food and food substances are used for language and customs of their host country may be more
traditional than people in their home country.
health promotion and wellness and during illness
Immigration status influences a person's worldview. For
example, people who voluntarily immigrate generally
• Pregnancy and childbearing practices includes
acculturate more willingly; i.e., they modify their own cul-
fertility practices; culturally sanctioned and
ture as a result of contact with another culture. Moreover,
unsanctioned methods for birth control: views
acculturation has different degrees in different contexts.
toward pregnancy; and prescriptive, restrictive,
For example, a person my acculturate in the workforce in
and taboo practices related to pregnancy, terms of language and practices, but speak their native
birthing, and postpartum. language and adhere to traditional practices when at
home. Similarly, they assimilate, that is, gradually adopt
• Death rituals includes how the individual and the and incorporate the characteristics of the prevailing cul-
culture view death, rituals, and behaviors to pre- ture more easily than people who immigrate unwillingly or
pare for death, and burial practices. Bereavement as sojourners. Sojourners, who immigrate with the inten-
behaviors are also included in this domain. tion of remaining in their new homeland only a short
time, or refugees, who think they may return to their
• Spirituality includes religious practices and the home country, may not perceive the need to acculturate
use of prayer, behaviors that give meaning to life, or assimilate. Additionally, undocumented individuals
and individual sources of strength. (illegal aliens) may have a different worldview from those
who have arrived with work visas as "legal immigrants."
• Healthcare practices includes the focus of health
care such as acute or preventive; traditional,
magicoreligious, and biomedical beliefs; individ- CONCLUSION
ual responsibility for health; self-medicating
practices; and views toward mental illness, Today, each subgroup has the right to be respected
chronicity, rehabilitation, and organ donation for its unique individuality. Most health-related education-
and transplantation. Additionally, one's response al programs and service providers have statements
to pain and the sick role are shaped by culture. addressing multicultural diversity. Organizations and indi-
Barriers to health care are included in this viduals who understand their clients' cultural values,
domain. beliefs, and practices are in a better position to be co-par-
ticipants with their clients and provide culturally accept-
• Healthcare practitioners concepts include the sta- able care. Accordingly, multidisciplinary healthcare pro-
tus, use, and perceptions of traditional, magi- fessionals can use the Purnetl Model as a guide for assess-
coreligious, and Western biomediccil healthcare ing, planning, implementing, and evaluating interven-
providers. Additionally, the gender of the health- tions. Through a systematic appraisal for each client and
individualizing care, improved opportunities for health
care provider may have significance in some cul-
promotion, illness and disease prevention, and health
tural groups.
restoration occurs. To this end, healthcare providers need

14 THE JOURNAL OF MULTICULTURAL NURSING & HEALTH 11:2 Summer 2005

both general and specific cultural knowledge. One cannot ensures that providers have a process for "becoming" cul-
possibly know all the diverse world cultures and their turally competent.
characteristics. Cultural general knowledge and skills

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