Culturally Appropriate Public
Health Training Series
Josephina Campinha-Bacote
Cultural Competency Model
Cultural Desire
Cultural Awareness
Cultural Knowledge
Cultural Skill
Cultural Encounters
Cultural Desire
You are here!
Cultural desire is the motivation of the
healthcare professional to “want to” engage in
the process of becoming culturally aware,
culturally knowledgeable, culturally skillful and
seeking cultural encounters; not the “have to.”
Cultural desire is the spiritual and pivotal
construct of cultural competence that provides
the energy source and foundation for one’s
journey towards cultural competence.
Cultural Awareness
Cultural awareness is defined as the
process of conducting a self-examination
of one’s own biases towards other cultures
and the in-depth exploration of one’s
cultural and professional background.
Cultural awareness also involves being
aware of the existence of documented
racism and other "isms" in healthcare
– Source:
Cultural Awareness
Cultural Awareness
Start class by presenting and discussing some of the feedback from PHNs about their needs – to
kick off the class.
Here are some of the Challenging Cultural Scenarios presented by your PHN peers:
How to deal with misconceptions that others (coworkers) have about different cultures
Who is present at the exam (male/female attendants)
Male makes decisions for females; do you talk with male only when he speaks for wife
Want cultural perspectives on TB
Want to know how to give women optimal health care (e.g. birth control) in situations where males
are dominant and resist some health promoting intervention (e.g. limiting number of children)
Everyone has a dominant culture and our actions occur without thought when we are operating in
that dominant culture.
Increasingly we operate within a multicultural context and need to develop cultural competence to
effectively provide nursing care.
Barriers to cultural competence include stereotyping, prejudice and racism, ethnocentrism, cultural
imposition, cultural conflict and cultural shock. We are frequently unaware (have a blind spot) to
our own stereotyping and prejudice.
To start we’d like you to complete this questionnaire that is a self– assessment of cultural and
linguistic competency. This will take about 15 minutes to complete.
To Facilitator: Read directions at top of survey.
GIVE SURVEY – NOTE: Fatima is obtaining permission to use this survey developed by Tawara
Goode, Georgetown U.
Post-survey activity: Look your survey over for items you selected a “c”. Partner with person next to
you to discuss these areas; why you answered the way you did and ideas you both have for
changing/improving that action.
Cultural Awareness
Dr. Patty Hale
• Self-Assessment Checklist for Personnel
Providing Primary Health Care Services
• Self-Assessment Checklist for Personnel
Providing Services and Supports In Early
Intervention and Early Childhood Settings
Cultural Knowledge
Dr. Charlene Douglas,
Dr. Courtney H. Lyder
Dr. Bennie Marshall
Cultural Knowledge
• Definition - Health care professionals
seeking an informational base regarding
the worldviews of different cultural and
ethnic groups
– Also includes discussions of biological
variations, diseases and health conditions
found among ethnic groups
Areas To Be Covered In This
• Refugees vs. Immigrants
• Cultural Attitudes Related To:
Gender Roles/Authority
Child Care/Discipline
Communicable Diseases
Chronic Illness
Women’s Health and Family Planning
Cultural Perspectives
• Be Very Careful
– Human beings are far more similar than
– They love their families, value life and want the
– Life experiences, socioeconomic status, family
dynamics, religious influences, and specific
cultural influences will impact on matters of
health care
– For our clients, the culture of poverty is the
overwhelming thread of commonality across
races and cultures
Cultural Attitudes
– Cultural emphasis on maintaining
strong intimate,
and supportive relationships with both
nuclear and
extended families. Often a protective
– The Hispanic American has a very deep
awareness of
and pride in his/her membership in the
- The importance of family membership
and belonging cuts across class lines
and socioeconomic conditions.
– An individual’s self-confidence, worth,
security and
identity are determined by his/her
relationship to other family members
Cultural Attitudes
• Each feels an inner dignity (dignidad)
and expects others to show respect
(respeto) for that dignidad.
• When working with Hispanic families,
developing trust and
personal relationships will be critical.
Cultural Attitudes
Hispanic Gender roles/authority
• Machismo
– - to maleness or manliness
– - it is expected that a man be physically strong,
unafraid, and the authority figure in the family,
– Has an obligation to protect and provide for his family.
• Motherhood is an important goal for women
– Mothers are expected to sacrifice for her children and
care for elderly relatives.
Cultural Attitudes
• Child rearing very
important (family event)
• Often find explanation of
consequences less
effective compared to
other measures of
disciplining (time out,
withdrawing privileges).
Cultural Attitudes
• Second wave of Latino immigration to U.S.
in 1990s
– More Latino children are suffering from health
problems, obesity, learning disorders, panic
attacks and a series of other health issues
related to stress (i.e. fear of
deportation/separation, economic hardship of
going “underground”).
– Live in larger cohorts in smaller spaces.
Cultural Attitudes
• Many crimes against undocumented
immigrants goes unreported, including
robberies, burglaries, rape, violent crimes.
• They are often victims when trying to
purchase cars or rent apartments
from unscrupulous vendors
Cultural Attitudes
Asian Gender Roles/Authority
Patriarchy and Gender Inequality
Status and role of women in society –
culturally constructed
Norms of male and female behaviour
Patriarchal beliefs, values and
Unequal Power relationships
Example: KIRIBATI - legal recognition
of men as official head of household
Honor killings
Women not included in decision
making process
May experience challenges in “Patient
centered care”. Often passive patients.
Cultural Attitudes
Child care/discipline
Majority of child care is left to mother.
Very active in child’s achievements
Parents, especially the father, have the
ultimate authority or power over the
children. They act as supporters to
assist their children to fit into the social
There is always the hierarchy in the
family and between the relationship of
parents and children. Parents seem
somewhat more serious than friendly
and always apply a strict discipline to
the children, but are always prepared
to give encouragement and advice.
Cultural Attitudes
• When they have to use disciplinary means, they
do not hesitate to apply harsh punishments.
• Often physical punishment in Asian tradition is
not considered abuse
• Other members of the family, such as
grandparents, aunts, uncles, etc. also can
punish naughty children. In turn, the obligation of
children is to submit, obey, and respect their
parents and other relatives.
Cultural Attitudes
• Asian migration began over 100 years ago.
• Largest group pf Asians are Chinese
• Health is a balance of Western/Eastern
philosophies (Buddhism, Confucianism, Taoism
and Shamanism).
• Wide use of acupuncture, moxibustion and
herbal remedies.
• Time orientation is to the present.
Refugees vs. Immigrants
• May be similar or widely different
• Refugees
– May be fleeing war experience
– May have suffered torture, wounds,
– May have lived in refugee camps
– Females from the Middle East and Africa
may be circumcised
– They may have minimal education, and
may be illiterate in their own language
• Have visas
• Eastern Europeans
– Religious persecution
– Infrastructure in place
• Muslims may have
multiple wives
– Can declare just one
– Financial strain
– Resist passing
judgment on this
Muslim Women Wearing Veils
Muslim Women
• Veils are not oppressive, they are a religious
– They vary by region and their practice of Islam
• Wealth and assets are in your children
– Some families will have as many children as possible
• Fully veiled women will always be with a partner;
that will not be changed in this generation
• El Savador is the primary country of origin,
but Asia, the Middle East and Africa are
also places of origin
• Young population, under 40 years
• Half of all Central Americans speak little or
no English
• Live primarily in suburbs where service
jobs are available
• We see a skewed, and impoverished,
sample of the population
• Almost half of immigrant children from
Central America live in homes owned by
their parents
• 77% of immigrant children in Virginia
are citizens and 41% are bilingual and
are an investment in this economy
Domestic Violence
• A sad reality in many women’s lives; middleclass, educated women live with domestic
• The Wheel of Power gives a framework for how
it develops
– A Muslim Wheel conveys some of the ways religion
can be distorted to justify abuse against women and
children in the family context
• The Cycle of Violence shows how it occurs day
to day
Immigrants and Domestic
• With immigrants, the above are fueled by:
Culturally endorsed male dominance
Lack of money
Difficult / strenuous working conditions
Undocumented status
High rates of substance abuse
• Ask “Who hurt you?” rather than “What
• Have an established referral system in your office
Domestic Violence:
Wheel of Power
Immigrant Women – Why They
• Fears exposure of immigrant status
• Sexual abuse of teen girls by
stepfathers is a real danger, mothers
stay with abusive husbands instead
• Practicing Catholics seek to preserve
marriage for a lifetime
• Getting help is difficult:
– Court papers arrive in English or a Spanish
that is not understood
– Legal exposure can result in deportation
Gender Roles / Authority
• Muslim women confined to home
– May be depressed
– Sees opportunities, cannot access them
• Female Arabic translators can be used and
may accompany women without partners
– Not widely available
– Men with women in the exam room is a
cultural practice that will continue
Inequalities Between Genders
• Manifested as dominance by boys and
men and acquiescence by girls and
• These inequalities make women more
vulnerable to:
– Lack of control of their reproductive life
– Domestic violence
– Coerced, unprotected, or unwanted sex
Child Care
• Pagil - Korean tradition
• Do not prepare for child
• Celebration only after
infants’ first 100 days of
• Before immunizations,
100 days was a good sign
that a child would survive
• Immune system now
working, could fight
Child Care / Discipline
• Research is contradictory and inadequate due
– Differing client / professional perceptions
– Not separating out poverty and culture
– Treating all cultures from different countries the
same [ethnic clumping]
• Culture of Poverty
– Atmosphere of violence with more corporal
punishment than the middle class
– “Hitting” used to encourage “respect”
– Ignorance around positive bonding behaviors
Hispanic Issues
• Very young children not under control in the
– Child care is often a neighbor/friend
– No real structure and many children
– They see their mothers very little; moms report
that they cannot control the children
• Older children
– Latinos are more likely to use an authoritarian
style of parenting and demand obedience and
respect from their children
– This combined with the culture of poverty [in our
clients] can result in CPS referrals
Teen Issues
• Teens are caught between cultures
– A more permissive dominant society and family rules
cause friction
– Everyone in the family works hard
– Teens are bilingual and are hired quickly in the service
– Often by-pass higher education for immediate work
• Teens are left alone when parents work
– Girls and boys at risk for gang activity
– CPS has no placement for troubled teens
– All traditional immigrant families may opt out of even
Family Life classes, but the teens are still sexually active
– Latinas have babies, Muslims have abortions due to
cultural pressures
• Culture of Poverty in U.S.
– Present time focus
– Limited money, resources
• Health care, child care, help for troubled children
– Will deal with whatever comes
• Some Spanish speaking countries do not use the future
tense in speaking
• Be leery of “Blaming the Victim”
– Many clients take multiple buses to appointments
– A client in a large SUV does not mean all clients are cheating
the system
– Encourage to call to cancel and to be on time
– Remember, your Dr. office and dentist calls to remind you of
your appt. – we do not have resources for that
• Rotavirus
– Suspect this with recurrent diarrhea / vomiting in
infants and young children
– Crowded multiple family dwellings can result in lax
overall sanitation
– Advise moms - Bottles and nipples must be kept
• Food Preparation
– Women are used to shopping every day with fresh
produce and meats – not in this country
– Many single men cook for themselves for the first
time in homes where they rent rooms
– This can result in kitchens that are unkept
Sanitation Issues
• In children new to this country
– If well nourished but remains anemic, with
failure to thrive
– Test for parasites
• Tap Water
– Clean in this country
– In countries of origin, causes illness
– They continue to buy bottled water in U.S.
• Bottled water expensive, no fluoride
• Unnecesary
• Vaccination Camps
– Still in operation
– Large # of people
– No written record
• Clients
– Know that they have
been immunized
– “You do not need any
more shots”
Strategies Related To
Prior immunizations?
In this country? Outside of this country?
Ask for written records
Acknowledge that they are telling the truth
Explain the need for a written record:
– For School
– For Work
– To make sure they are completely protected
against these diseases
• Encourage them to keep the new record
Special Issues With Ruebella
• Our clients can be incredibly shy
– Culture
– Lack of education
• Do not start with “When was your last period
– Vaccine is dangerous to your baby if pregnant
– We must make sure you are not pregnant
– When was your last menstrual period
• This is a child in
• Fear of TB is pervasive
in our client’s countries
• Infection vs. Disease is
not clear to our clients
• Take every opportunity
to educate
• Worldwide, TB is
greatest cause of death
by a single agent
PPD Testing After BCG
• Results will generally be inconclusive
• Second PPD and X-ray needed to
determine if infection is present
• Most clients with TB have an infection only
• 1/3 of the world’s population harbors TB
• If clients told they have an infection, they
believe they the disease
Infection vs. Disease
• If you are not the primary TB nurse, one or
two meds means infection
– NIH or Rifampin
• If they have the disease, they will be on
multiple medications
– INH, Rifampin, Ethamentol, PVA, B6
• The word TB means they cannot touch
dishes, touch babies, cook food, family may
be afraid of them
TB and Patient Education
• Take every opportunity to educate
• Infection does not mean infectious
• Taking medications as scheduled will
prevent TB infection from becoming
• Medications are often not taken correctly
• Reinforce schedule of medication
• Reinforce that they cannot pass TB
infection on to others while on their
Family Planning Issues
• In the traditional Latino culture, discussions of
sex reach the level of taboo
– Against cultural, social and religious mores
• Incredible shyness is lack of knowledge
About how the body works
Any information related to sex
How to discuss issues related to sex
Female role is not to ask or lead in any way
Exploring their bodies may be seen as shameful
and a source of embarrassment
Family Planning Issues
• Clients will state “I need to talk to my
• Often hungry for birth control information
– Women learn to “silence themselves” to avoid
• Strategy
– “It is fine to speak with your husband”
– “Why don’t you and I beginning talking now”
– Client’s faces “light up” when they are able to get
Family Planning Issues:
• Your wealth and assets rests with your
• Acknowledge your respect for family
• Discuss advantages of fewer children in
– Costs of food, clothes, housing
– Opportunities available to children
– Cultural values may over-ride birth control
• Women engage in risky sexual
behaviors in the name of emotional and
physical connections
• Women equate intimacy and trust with
not verifying a potential partner’s HIV
and STD status before having sex,
trusting in supposed fidelity, and
engaging in condomless sex
Sexually Transmitted Diseases
• Power differences between genders is even
greater in traditional societies
• These inequalities are fueling the HIV
epidemic and the rise of STDs in women
– Rates of Chlamydia are on a significant rise in
• Inequalities undermine the ability of women to
cope if they become infected
– Increases the possibility they will not seek
– Increases their unintentionally infecting others
Sexually Transmitted Diseases
Successful treatment is a challenge
Antibiotics are available over the counter
Clients self-prescribe
They share antibiotics and birth control
• Clients take meds until they feel better or
overt symptoms disappear
Intervention Strategies
• Immigrant women need specific medication
– Taking on a regular schedule
– Until the medication is gone
– Have women repeat the directions back to you
• Give information to women about sexual
health at every opportunity
– You speak openly, clearly – role model
– Show no embarrassment
• Important for their children
– Adolescents whose mothers discuss
condom use with them are more likely to
use a condom at their first intercourse and
regularly thereafter
– Children are learning about sex in school
– They need to talk, and often know more
than their mothers
– You may break an old cycle and initiate a
new, healthy level of communication
PAP Tests / HPV
• Men with multiple partners
– An issue in ALL cultures
– Including religious cultures
– Mores of purity apply to women
– These multiple partners put our female clients
at risk for STDs and HPVs
PAP Tests / HPV
• If gangs are present
– Girls are gang raped to be “jumped in”
• Many Hispanic teens are pregnant by
adult men, who have multiple partners
• Young sexually active women need annual
PAP tests
Female Circumcision
• This is a social custom,
1,400 years old
• Supported and refuted
with passages from the
• Increasingly under fire,
banned in some
African countries, but
still practiced
• African and Muslim women
• If embarrassed about the pelvic exam,
ask if they are circumcised
– Objective voice and facial expression
• Inform Midwife/MD
– Everyone, maintain control over facial
expression, body language
– Client may have fissures
• Screen for Hepatitis B
– Secondary to dirty instruments used
• Little resistance in foreign born clients
– Frame the discussion as an investment in
the family, keeping themselves healthy
• More resistance in African American
– Concerned about “looking for trouble”
• If your office promotes mammograms,
have referrals and access to local
programs available
Cultural Diversity and Nutrition
Denise DiCicco MSN, RNC, IBCLC,RLC
• Science that includes the study of how food,
nutrients & other substances interact with the
body to foster growth and development, health
or contribute to disease.
• Requires a knowledge and understanding of
social, economic, cultural and psychological
implications of food and eating behaviors.
• Adequate nutrition plays a critical role in the
maintenance and restoration of good health and
Nutrition (con’t)
• Factors that can affect an individual’s nutritional
status include:
personal preferences & habits
cultural, religious & family customs
social & environmental setting
economic & political circumstances
• Being aware of social and religious complexities can
help professionals working with families to meet
nutritional needs within the context of their own
cultural and religious beliefs.
Role of Health Professional
• To provide families with information and support
to meet their needs, not to change their beliefs
or choices whether they are personally or
culturally based.
• Accurately assess the nutritional status of
• Determine the family’s knowledge of nutrition &
provide appropriate resources
• Identify ways in which food is used and
• Ensure that families are adequately nourished
Overview of Normal Patterns of
• Water & electrolytes
Primary component of body tissue
Maintaining fluid balance is essential to good health
No specific recommended daily requirement for water
Infants can be susceptible to rapid variations in water balance
• Water losses may be due to;
– Illness can lead to significant water loss & dehydration. (i.e.
vomiting & diarrhea)
– Activity level (i.e. strenuous activity in warm, dry environment
requires additional water intake
– Altitude
– Temperature & dryness if ambient air.
– If > 10% of body weight is lost without replacement, dehydration
may be life threatening
• Involved in the regulation of;
Extracellular fluid volume
acid-base balance
membrane potential of cells
cell membrane transport pump
exchange with K+ in the intracellular fluid
• Loss occurs with Vomiting, diarrhea, & perspiration
• Typical North American diet far exceeds the minimum
requirements and thus it is not necessary to add sodium
to the diet.
• Most sodium is provided during the processing and
manufacture of foods.
• Maintains intracellular homeostasis
• Contributes to muscle contractility &
transmission of nerve impulses
• Hypokalemia (low K+) can lead to cardiac
arrhythmias & death
• Hyperkalemia (high K+) can cause cardiac
• Urinary & GI systems regulate K+ levels
• Extreme imbalances usually due to disease
process or medication rather than diet.
• Fruits, vegetables & fresh meat have K+
• Functions with Na+ to maintain fluid &
electrolyte balance
• Loss occurs with vomiting, diarrhea &
• Major source is salt added to foods during
• No recommended daily allowance
• Adequate amounts are ingested with a
normal diet
• Fundamental component of all body cells
• Broken down into amino acids which are important in
synthesis of body cell protein
• Required in some enzyme & hormone activity involved in
cell transport, tissue growth & development
• Essential amino acids are not synthesized by the body &
must be included in the diet
• Protein & amino acid deficiencies usually occur with
other dietary deficits (i.e. extreme stress, some disease
processes may deplete nitrogen, contributing to tissue
wasting & create increased demand for protein)
• Body’s major dietary source of energy
• Recommended that 45%-65% of children’s diet
include carbohydrates, and most should be in
complex form.
• Adequate carbohydrate intake is important for
protein synthesis
• Simple carbohydrates found in fruits, vegetables,
milk & prepared sweets.
• Complex carbohydrates found in cereal, grains,
potatoes, legumes & other vegetables.
Fats (lipids, fats, fatty acids)
• Used by the body to provide energy
• Facilitate absorption of fat- soluble vitamins
• Maintain integrity of cell membranes & myelin
• Essential fatty acids are not produced by the
body & must be included in the diet, & are found
in most vegetable oils
• There should be no fat restriction for children < 2
years of age
Fats (lipids, fats, fatty acids) (con’t)
• Children >2years of age should have 20%30% of total calories from fats
• Saturated fats should be <10%
• No more than 300 mg of cholesterol
• Excessive restriction of fat or caloric intake
may contribute to loss of essential
nutrients & result in growth failure
• Fat soluble (A,D,E, K)
– can be stored in body tissues for a long time
– temporary deficiencies may not affect growth &
– stable when heated & not destroyed in cooking
• Water soluble
– Vitamin C & B complexes stored in small amounts in
the body
– daily intake is necessary
• Major minerals are Calcium, Magnesium,
• Peak bone density is directly related to Ca+
intake during the years of bone mineralization
• Most mineralization takes place by the time a
person is 20 years old, but calcification can
continue for several years
• Dietary calcium should remain high until about
25 years of age.
Foods Eaten Around the World
• Every country & region of a country has it’s own
typical foods & ways of combining them into
• Components of meals vary across cultures but
generally include grains, meat or meat
substitutes such as fish, beans, tofu &
• Each culture has acceptable & unacceptable
foods. As an example, alligator, horses, turtles, &
dogs may be eaten in some cultures as
delicacies but unacceptable in other cultures.
Foods Eaten Around the World
• Sweetness is a universally acceptable
flavor, taste for salty, savory, spicy, tart,
bitter, & hot must be acquired
• When families leave their traditional ways
of eating patterns, they may encounter
different food choices than they are
accustomed to which may lead to obesity,
diabetes, & other health related conditions.
Food Pyramid
• The Food Guide Pyramid is a useful
teaching tool for families.
– Additional Food Guide pyramids have
been created as educational resources
for various ethnic groups & those eating
a Vegetarian diet.
• Vegans- eat only foods of plant origin (fruits,
vegetables, grains, nuts, seeds, legumes)
• Lacto-vegetarians-include milk & dietary
products as well as plant-based foods in their
• Lacto-ovo-vegetarians-eat eggs, dairy products
& all plant based foods in their diet
• “Sometimes” vegetarians-will eat predominantly
plant-based foods & occasionally eat fish,
chicken & some seafood
Vegetarians (con’t)
• Vitamin B 12 supplementation is required
because bio-available Vitamin B 12 is
found only in animal based foods.
• Lactose intolerance caused by lack of the
enzyme lactase is rare in infants, but
common in older children & adults from
Asian, Native American, Black & Hispanic
ethnic groups.
Food is often used to cure illness
“Cold” vs “Hot” foods
Cold Foods
Hot Foods
Aromatic beverages
Corn products
Dairy products
Expensive meats
(beef, water fawl,
fish, mutton)
Wheat products
Tropical fruit
Inexpensive meat
(goat, chicken, rabbit)
Hot & warm foods thought to digest easier than cold foods therefore foods are
warmed before eating.
• “ Chi” is energy present in all living things. Food is
transformed into “chi” & becomes either a cold “yin” or a
hot “yang” force.
• “Cold” foods are needed for “hot” conditions such as
• Wide range of foods found to be harmful or beneficial
between cultural groups
• Foods thought to play a part in cause & effect of disease.
• Women of east Asian & Southeast Asian cultures (
Cambodian, Chinese, Vietnamese) may follow a custom
of “doing the month”
• Women thought to be vulnerable to cold, wind, and
magic, and therefore stay home, avoid drafts, and dress
warmly in the first 30 days after childbirth.
Asian (con’t)
• Those eating traditional Chinese foods consume three
times the fiber, eat half the fat, and have lower
cholesterol levels than those eating the American way.
• Total amount of meat, fish, or egg is small with meals
centering on a staple starch such as rice.
• All food is cut into bite-sized pieces before cooking so
food cooks quickly with few nutrients destroyed.
• Deep fried foods are rarely eaten.
• Heavy use of condiments such as MSG and soy sauce.
(Estes, 2006)
Mediterranean Diets
• Limited consumption of dairy products/meats
includes abundance of vegetables, fruits,
legumes, & whole grains
• Olive oil is principle source of fat
• Average daily consumption of meat in U.S. is
more than half a pound per person per day. In
the Mediterranean region, it is about half a
pound per person per week
Religious Diets
• “Kosher” refers to a set of restrictions that orthodox Jews
place on selection & preparation of animal-derived foods.
Done as a religious commitment.
• Jews in different countries may eat different foods, but
the kosher rules apply to all.
• The rules of kosher do not provide any special health
• Beef may be eaten, but not pork
• Fish can be eaten, but not shellfish
• Milk & meat are prohibited in the same meal. Non-dairy
creamer is used as substitute in some meals that also
include meat.
Religious Diets (con’t)
• Blood is forbidden as food, therefore, kosher
rules govern methods of animal slaughter, cuts
that may be eaten & preparation rituals.
• During Lent, many Christians eat only
vegetarian meals, giving up meat until Easter.
May also have fasting days.
• The Mormon faith does not allow any alcohol,
coffee, or tea.
• Many Seventh Day Adventists consume no
meat, but eat eggs & milk products, no alcohol,
coffee, or tea.
Childhood Eating Behaviors &
• Important to note regarding children’s nutrition;
– Nutritional needs will vary as they grow, and are
influenced by their state of health (i.e. chronic illness)
– Wide range of food choices & feeding behaviors may
be used to meet nutritional needs
• Proper nutrition affects the child’s ability to interact with
their environment and is essential for normal growth &
• Recommended dietary allowances (RDA) are guidelines,
not absolutes. Children don’t need to eat the RDA of all
Childhood Eating Behaviors &
Nutrition (con’t)
• Appetite fluctuations & preferences are
typical of children
• Parents & caregivers are responsible for
establishing healthy eating patterns &
providing nutritionally adequate food
choices, therefore & must be well
Nutritional Recommendations for
• Breastmilk is the best source of nutrition for
• The AAP recommends whole milk for children
12-24 months of age. Note: 2% milk as part of a
varied diet can also contribute to adequate fat
intake & has no negative affect on growth or
body composition
• Variety of foods should be incorporated in child’s
• Iron-rich foods are essential especially for
infants & teenagers.
Nutritional Recommendations for
Children (con’t)
• Limit saturated fats, cholesterol, & sugars.
Include adequate fiber.
• Extra Calcium, Iron, & Folic Acid are important
for teenage girls.
• Advice & counseling should be offered within the
family’s belief system.
• Resources for intake patterns:
Breastfeeding and Culture
• Mothering through breastfeeding
transcends cultural & language
• Cultural & religious beliefs include ideas
about modesty & nursing in front of others
or how long a child should nurse.
LaLeche League Leaders
• “The primary goal is to provide each mother with good,
sound knowledge and allow her to proceed with the
rearing of her child according to her own beliefs, values,
and personality” -
• Breastfeeding problems often are rooted in culture
beliefs & practices that do not match the biological needs
of the mother & infant
• If new information challenges a mother’s culturally based
beliefs, she may mistrust it & have difficulty complying
with recommendations offered.
• Research has demonstrated that exclusive breastfeeding
for 6 months or longer is important in maintaining the
health of the mother & baby.
Benefits to Breastfeeding
• Benefits include;
– reduction in the incidence of acute illness in children
such as diarrhea, ear infections, pneumonia,
– lessens the occurrence of chronic disease &
conditions such as;
– SIDS (sudden infant death syndrome)
– obesity
– childhood leukemia
– asthma
– women have reduced rates of breast cancer
(Wolf, 2003)
Breastfeeding (con’t)
• The AAP recommends Breastfeeding for at least
one year and thereafter for as long as mother
and infant desire.
• WHO recommends breastfeeding for at least two
• Not only initiation, but exclusivity and duration of
breastfeeding is important
• A common trend is that women immigrating to
the U.S. are not continuing to breastfeed
(Weibert, 2002)
Breastfeeding Around the World
• Latin American/Mexican
– 80% of women breastfeed for at least 4 to 6 months
– After immigration to the U.S., the rates fall to 48%
• Colostrum considered dirty or stale milk and therefore infant
may not breastfeed for several days after birth
• Having the mother express a few drops of Colostrum then
placing the infant to the breast may help change this practice
and get the infant to breastfeed sooner
• Any stress or emotional upset may change the quality,
quantity, and even sour the breast milk, leading the mother to
give formula to avoid harming her baby
Breastfeeding Around the World
• Cold environments are thought to decrease milk
flow. Extreme heat makes milk curdle in the
infants stomach or mother’s breast.
• Hot and cold food classification is applied to the
infant as well. Evaporated milk is considered hot
food. Whole milk is considered cold food. Skin
rashes are thought to develop from hot foods,
(i.e., infant formula.) Mothers may prefer to give
infants whole milk.
• Having healthy children is highly valued in
the Japanese culture
• Breastfeeding is viewed as necessary for
the health of the child.
• Figurines and plaques may given to the
mother to help her prayers for sufficient
milk supply
South East Asian
• Excessive hot foods are thought to deplete the milk
• Colostrum is thought to be dirty & stale & is discarded.
• Infant may be fed by other, lactating women in the first
few days.
• Breastfeeding is considered more expensive than
bottlefeeding, because the quality of the mother’s milk
can only be enriched by eating expensive foods.
• Traditionally breastfeed until 2-3 years of age
• Early weaning to cups is not a cultural norm.
South East Asian (con’t)
• Solid foods introduced after 1 year.
• In rural areas of Vietnam, Cambodia or Laos,
infants typically breastfeed for 1 year.
• Breastmilk may be supplemented with prechewed rice paste.
• Women in urban areas are more likely to formula
• Following immigration to U.S., only 10% of
women continue to breastfeed.
• (
East African
• Breastfeeding is equated with motherhood.
Almost all mothers at least initiate breastfeed &
often continue for 2-3 years.
• Breastmilk is not offered in the first 24 hours and
the infant may be given sugar water, fresh cow,
goat, or camel milk in the first few days.
• Colostrum is thought to have little value or be
unhealthy & may be pumped & discarded.
• Teachings require mothers to breastfeed
children for 2 years.
• Even if divorced, father should pay
mother’s cost of living so her full attention
is on nursing the baby.
• Wet nurses may be used.
• While it is not possible to know the details about
each and every culture that is represented in our
community, we need to know the implications
that cultural diversity poses for the patient, their
families, and the health professionals entrusted
with their care.
• Health care professionals play an important role
in the care of families from diverse backgrounds.
Achieving an improved level of cultural
competence will lead to improved
communication with families and reduce
disparities in health and heath care utilization.
Cultural Competency and
Chronic Diseases
Chronic Disease Stats
• approximately 80% of persons over 65 have at
least one chronic condition and half have more
than one such condition (CDC, 2003).
• public health achievements have led to a
significant decrease in mortality due to infectious
disease and other acute illnesses
• the new challenge in this “epidemiologic
transition” is chronic diseases such as
cardiovascular diseases and cancer.
• Although increased age is
associated with chronic
diseases, certain broad racial
and ethnic groups have much
higher rates of incidence and
mortality for many chronic
conditions, even with a lower
life expectancy than nonHispanic Whites
Chronic Diseases
Heart disease
Kidney Disease
Health Disparities
• Rates of death from heart disease are 29%
higher among African American adults than
among White adults, and African American
adults are 50% more likely to die from a stroke
than White adults (OMH Web site, 2005b).
• Hispanics have higher incidence rates of
cervical and stomach cancer than Whites (OMH
Web site, 2005c).
Health Disparities (cont.)
• Mexican Americans, the largest Hispanic
subgroup, are more than twice as likely as
Whites to have diabetes (OMH Web site,
• Of all the racial and ethnic minority groups in the
U.S., American Indian/Alaskan Native
populations have the highest rates of depression
and suicide (Lipson & Dibble, 2005).
Culturally Sensitive Approaches
to Chronic Disease
• Consider the impact of each particular
disease on a particular cultural group
• Consider how “disease” and “illness”
are defined
• Review common fears associated with
particular terms and diseases, e.g tumor
vs cancer; HIV/AIDS
Behaviors that contribute to
chronic disease
• Poor eating habits
• Believe in spells or witchcraft
• Traditional methods of treating
disorders; home remedies; use of
herbal products;
• Smoking
• Alcohol use/abuse
• Coping mechanisms
Discussion Question
• What is the most dreaded chronic
disease? Explain why.
• Discuss with assigned small group. Report
on areas of consensus.
• Spanish/English language resources for staff
• Hire Spanish speaking outreach workers
– Clients feel more open and welcomed
• STD and safe sex negotiation literature
• The Latino culture is more expressive than
western cultures
– Greet clients with a smile and a “friendly” face
– Talk to them about their care
• They need the health education
• They are grateful for and appreciate the time
Cultural Skill
Ann Hershberger, PhD, RN
Rebecca Greer, MSN, RN
Definition of Cultural Skill
“the effective integration of cultural
awareness and cultural knowledge to
obtain relevant cultural data and meet
need of culturally diverse clients.”
(Stanhope,M, & Lancaster, J. (2004). Community and Public Health
Nursing. St. Louis: Mosby. p.156.)
Examples of Cultural Blunders
• Bilingual Hispanic son
translated explanation of
inappropriately. Mother
threatened to sue
Examples of Cultural Blunders
• 36-year old Mexican man. Failure to
communicate among nurses and wife
hinder’s client’s rehabilitation.
• 27-year old Arab man. Refused to let male
lab technician into wife’s room to draw
• Obtain relevant data
• Meet client needs
--cultural preservation
--cultural accommodation
--cultural repatterning
--cultural brokering
Skill: Cultural Assessment
• Cultural identity should be included
in all patient assessments. The
CONFHER Model can be used as a
systematic framework to obtain
information necessary to develop a
culturally appropriate plan for
meeting the client’s needs (Fong,
CONFHER Assessment Model
Communication Style
Family Relationships
Health Beliefs
Communication Style
• Language and
dialect preference?
• Meaning of nonvervbal behaviors?
• Ethnic behaviors
such as bowing of
• Is client agreeable
to avoid
• Ethnic identity
– Allow to identify own ethnicity
• Acculturation
– How long lived in United States? How
closely does client follow traditional
• Value orientation
– Human nature; humans and nature; time
orientation; purpose in life; people’s
relationships to one another
• Meaning of food
– i.e. “hot” and “cold”
• Preferences and
Family Relationships
• Client’s definition of
• Who is head of
• Importance of family
nearby when client is
• Important social
customs or taboos
• Life-style and living
Health Beliefs
Alternative Care
Health, crisis, and illness
Response to pain and hospitalization
Predisposition to certain diseases
Ask patient, “What do you think caused your
illness?” (Munoz & Hilgenberg, 2006)
• Ask patient, “What treatment do you think
will make you better?” (Munoz & Hilgenberg,
• Learning Style
• Occupation and socioeconomic level
Skill: Meet client needs using
Cultural preservation
Cultural accommodation
Cultural repatterning
Cultural brokering
Cultural Preservation
Encourage and support the incorporation of
scientifically supported cultural practices
along with the biomedical system.
• Acupuncture
• Acupressure
Cultural Accommodation
Support and facilitate cultural practices
which scientific study has not been found
to be harmful.
• Home burial of placenta
• Covering the baby’s head
Cultural Repatterning
Work with the client to rework or modify
cultural practices known to be harmful.
• Use of fried foods
• Teas for a strong baby
• Spouse abuse
Cultural Brokering
Advocate, mediate, and negotiate between
the client’s cultural norms and the
biomedical system.
• Ask client to describe health concern from
his or her perspective
• Involve client and family in care
• Negotiate with client to plan care that is
mutually acceptable to nurse and client
• When in doubt, ask politely.
Campinha-Bacote, J. (2003). The process of cultural competence
in the delivery of healthcare services: A culturally competent
model of care. Cincinnati: Transcultural C.A.R.E. Associates.
Fong, C. (1985). Ethnicity and nursing practice. Topics in Clinical
Nursing 7(3),1-10.
Munoz, C. & Hilgenberg, C. Ethnopharmacology: Understanding
how ethnicity can affect drug response is essential to providing
culturally competent care. Holistic Nursing Practice 20(5), 227234. Retrieved July 20, 2007 from Ovid database.
Stanhope,M, & Lancaster, J. (2004). Community and Public Health
Nursing. St. Louis: Mosby. p.156.)
Transcultural Nursing. (1997-2005). The Hispanic American
community. Retrieved August 8, 2007 from
Transcultural Nursing. (1997-2005). The Middle Eastern
community. Retrieved August 8, 2006 from
Cultural Encounter
Erin Cruise
Dr. Margaret Bassett
Dr. Scheherazade Taylor
Cultural Encounter
We are proposing that Giger and Davidhizer's cultural assessment be the organizing framework
for this section. We think that their model provides a useful tool that can be used with a variety of
cultures and lends itself to the more general discussion that we perceive to be intend of the first
workshop. Their assessment model has evolved over time to include consideration of the cultural
aspects of communication, space, social organization, time, environmental control and biologic
Some of the facilitator resources we are suggesting are:
Giger, J.N., & Davidhizar, R.E. (2007). Transcultural nursing: Assessment and intervention (5th
Ed.). St. Louis: Mosby. This new edition is due out in
early October.
Groper, R.C. (1996). Culture and the clinical encounter: An intercultural sensitizer for the health
professions. Yarmouth, ME: Intercultural Press.
This is a simple "how to" guide to improving clinical encounters with those from other cultures.
This is an extensive website on transcultural communication and health care practice from the
Royal College of Nursing, Britain. These sections have information on the Giger and Davidhizer
assessment model, with examples and suggested exercises.
• Charlene’s slides that may work
Just some slides for your use
Charlene Douglas, Ph.D., MPH, RN
Associate Professor
George Mason University
• Culture – a learned set of ideals and
values that are widely shared among a
• Values – principles and standards that
have meaning and worth to individuals,
groups or communities
• Norms – rules by which human behavior
is governed and are the result of cultural
• The Latino tradition
• At 15 years of age,
every young girl is
given a large party to
celebrate her entry
into womanhood
• Ethnocentrism
– The view that one’s culture’s way of doing
things is the right and natural way
– Other ways are inferior, unnatural, perhaps
even barbaric
• Cultural Imposition
– The belief in one's own superiority, or
ethnocentrism, and imposing those beliefs
on another
• Prejudice
– An emotional manifestation of deeply held
beliefs (stereotypes) about other groups
– Usually refers to negative feelings conjured
up by as a result of pre-judging, limited
knowledge about, or limited contact with an
individual or group
• Cultural Conflict - A perceived threat that may
arise from a misunderstanding of expectations
between clients and nurses when either group
is not aware of cultural differences
• Culture Shock - The feeling of helplessness,
discomfort, and disorienttion experienced by an
individual attempting to understand or
effectively adapt to a different cultural group
because of differences in practice, values and
• Enculturation – how patterns of cultural
behavior are learned; starts at birth,
parents and the community teach children
what it means to be a member of that
• Acculturation – Adapting to another
culture, for example, when one moves to
another country or community
Values and Health
• U.S. - Mastery over nature
– Battle heart disease
– Hospice difficult to institute in 70’s
• Dis-ease, imbalance with nature
– Massage, pressure, heat reasserts balance
• Beliefs regarding causes of illness
• Folk medicine and folk healers
• Seeking medical care
• Ethnicity – speaks to nationalism related to
customs and traits; ethnicity does not mean race
• Race is a social classification that relies on
physical markers such as skin color to identify
group membership
• Latino – persons descended from Spain or from
countries colonized by Spain; these persons can
have blonde hair or be very dark skinned
U.S. Asian and Pacific Islander
Countries of Origin for Spanish
Speaking People in the U.S.
Hispanic / Latino / Hispano
• Name created by U.S. Demographers
• Latino, Hispano
• Countries of origin, language & customs can be very
• 11th generation Mexican-American [Texas, CA] or new
• Argentina, Cuba, Central America
• 70% are born in the U.S.; do not make immigration
• Undocumented immigrant is a more professional and
appropriate term than illegal aliens
• Do not appear hurried; process is as important as the
goal [my book]
Latino Origins of Disease
• “Hot” and “Cold”
• Mal De Ojo [Evil Eye]
• Empacho - poorly digested food, sticking
to the stomach wall
Arab Americans
• 22 countries in the Middle East & North Africa
• Establish rapport and confidence, rather than presenting
yourself as an authority
• Ramadan – important religious month long holiday
Beginning of the calander year
Fasting during the day, medications
• Most respected: middle-aged & elderly male M.D.
• Medication expected as part of treatment
• Try to establish a direct contact with the mother, but do
not discount the father
• Christian population – Lebanon, Syria and Palestine
African-American Populations
• Eye contact
• Address family members formally, using titles
and last names, until given permission to be
more informal
• Recognize that poverty does not equate with
dysfunction many impoverished families manage
to provide strong, nurturing care for their
• More authoritarian child-rearing
Roles Of The Interpreter
• Conduit – exchange
one word for another
• Clarifier – adjust for
language complexity
• Culture Broker –
explaining cultural
• Advocate – providing for
clients’ unmet needs
Roles Of The Interpreter
• The roles proceed from simple to
• Inappropriate choices – Housekeeping,
avoid family if possible, other nonprofessionals
• Interpreters should be trained and their
work must remain confidential
• Translation Line, Tele-Interpreter
• The LAW requires interpreters

Culturally Appropriate Public Health Training Series