4. Basic World View
Collectivist
God guides life
Patriarchal
Women are expected to be submissive to men.
High level of respect for elders, health-care providers, and
religious leaders.
Hot and Cold therapy
Value education
Extended family serves as a support system.
(Purnell, 2013).
5. Geographic Origins
Inhabited by Taíno Indians
Found by Columbus during his second voyage to America.
Ruled by Spain for over 400 years.
Numbers of residents decreased due to infectious diseases and
warfare.
Became possession of U.S in 1898 after Spanish-American
war.
Jones Act of 1917 – all Puerto Rican’s became U.S. citizens.
(Purnell, 2013).
6. Current Life in America
Over 3 million living in U.S.
Many reside in Connecticut, Florida, Illinois, and New
York. (Purnell, 2013).
28% high school diploma
29% work in sales and office occupation (Centers for
Disease Control and Prevention, 2013).
28% live in poverty
Annual income is $25,000 a year
12% unemployment rate (U.S. Census Bureau, as cited by
Brown, 2013).
7. Beliefs Related to Individuals
• Collectivism is highly valued by this cultural group
• Children are the center of the family
• Familism-social pattern in which family tradition
assumes a superior position over individual rights and
interest (Purnell, 2013).
• Value the unity of family
• Women are considered the main caregivers
• Female mothers tend to be protective of their children
and may use physical punishment. (Purnell, 2008).
8. Beliefs Related to Family
• Most families expect their children to stay at home until
married or expected to pursue college.
• Male children are taught to be powerful and strong,
domineering over women.
• Female children are taught to assume the roles of
motherhood, home economics and family dynamics which
gives them a powerful social status.
• Elderly tend to live with their children and be cared for
financially and emotionally
(Purnell, 2013)
9. Beliefs Related to Family Continued
• Elderly see placement in a nursing home as inconsiderate.
• Family members are expected to be at the bedside of the ill.
• Taboo related to Homosexuality (Purnell, 2013).
• Personalismo in this culture is highly valued
• Health and disease may be deemed consequences of God’s
approval or disapproval of a person’s behavior (Chong,
2002).
10. Health Care Practices
Have a curative view of health
Puerto Rican’s tend to underuse health promotion and
preventive services
Use emergency health care services for acute problems
Good hygiene is a basic concept of health promotion
Folk and traditional practices
o Espiritistas - communicate with spirits
o Santeria – focus on health promotion
Botanicas – folk religious store
Family members- source of support and care (Purnell, 2013).
11. Health Care Practices cont.
May be loud and outspoken in expressing pain
Mental illness carries a stigma
Organ donation is seen as an act of good will and gift of life
Autopsy may be seen as a violation of the body
May have a gender or age bias against Health Care Providers
(HCP)
HCP seen as a wise authority figures
Barriers to health care
Insurance
Lack of access
Poor English-language skills
Low acculturation
Poor socioeconomic status
Lack of transportation (Purnell, 2013).
12. Health Care Practices cont.
High Risk Behavior Leading Cause of Death
Alcoholism
Marijuana
Tobacco
Cocaine
Lack of condom
(Chong, 2002).
Heart disease
Cancer
HIV
Accidents
Homicide
(Centers for Disease Control
and Prevention, 2013).
13. Health Care Practices cont.
Beneficial practices:
rubbing the stomach or back gently with cooking oil for empacho
(Centers for Disease Control and Prevention, 2013).
“cold” condition is treated with “hot” medication and vise versa
Use tea from alligator’s tail, snails, or savila (plant leaves) for
asthma and congestive heart failure
Also use boiled mint, tea, or lemon tree tea
Neutral practices:
Fanning the face or blowing into the patient’s face is believed to
provide oxygen and relieve dyspnea
Dysfunctional practices:
Alcolado (smelling or rubbing isopropyl alcohol) alleviate nausea
and vomiting (Purnell, 2013).
14. Food Preferences and Traditions
• Common Food: Fritters, pastas, breads, crackers, vegetables,
and fruits.
• Favorite side dish: Tostones, fried green or ripe plantains
• Most common viandas (roots vegetable) : celery roots, sweet
potatoes, dasheens, yams, breadfruit, breadfruit, breadnut,
green and ripe plantains, green bananas, tanniers, cassava, and
chayote squash or christophines (Purnell, 2013).
15. Food Rituals
Traditional Puerto Rican Families usually begin their
day with a cup of coffee or café con leche (coffee with
milk) such as espresso with lots of sugar before
breakfast. Many family introduce children to coffee as
early as 5 or 6 years of age.
A traditional Puerto Rican breakfast: oatmeal,
cornmeal, rice, wheat cereal cooked with vanilla,
cinnamon, sugar, salt and milk.
Lunch (noon) and dinner ( 5:00 or 6:00p.m.)
A cup of espresso-like coffee served : 10:00 a.m.
and 3:00 p.m. (Purnell, 2013).
16. Food Preferences and Traditions
Main dishes: Rice and stew habichuelas (beans), served as many as 12
side dishes.
Consider complete meal: rice cooked with vegetable or meat (Purnell,
2009, p. 415).
Seasonings for rice stew (guisado) : sofrito (cilantro, recao, onions,
green peppers, and other non spicy ingredients.
Traditional holiday dish : rice with gandules , pernil asado-pork, pasteles-
root vegetable, green plantain, bananas, or condiments filled with meat and
wraped with platain leaves (Purnell, 2013).
17. Hot-Cold Classification
Hot Illnesses:
Include: GI diseases (constipation, diarrhea, Crohn’s colitis,
ulcer; bleeding) pregnancy, menopause, rashes, acne,
headaches, heart disease; urological illnesses.
Treated with: cocoa products, alcoholic beverages, caffeine
products, hot cereals from wheat and corn, salt, spices and
condiments, beans, nuts and seeds.
Cold Illnesses:
Include: Osteomuscular disease (arthritis, rheumatoid arthritis,
multiple sclerosis), menstruation, respiratory illnesses.
Treated with: rice, milk, barley water, sugar, root vegetables,
avocado, fruits, vegetables, white meat, honey, onions (Purnell,
2013).
18. Dietary and Health Practices
Menstruation
Foods taboo: Avoid spices, cold beverages, acid-citric fruits and substances, chocolate and coffee.
Foods encouraged: Plenty of hot fluids, such as cinnamon tea, milk with cinnamon and sugar, teas
such as chamomile, anise seed, linden tea, mint leaves
Health practices: Avoid exercise and practice good hygiene, Do not walk barefoot. Avoid wind and
rain, Stay as warm as possible
Pregnancy
Foods taboo: Avoid hot food, sauces, condiments, chocolate products, coffee, beans, pork, fritters,
oily foods, and citric products.
Foods encouraged: Milk, beef, chicken, vegetables, fruits, ponches.
Health practice: Rest and get plenty of sleep. Eat plenty of food. Follow diet cautiously. Many avoid
sexual intercourse early in pregnancy. Practice good hygiene and take warm showers.
Lactation
Foods taboo: Avoid beans, cabbages, lettuce, seeds, nuts, port, chocolate, coffee, and hot food items
at all at times.
Foods encouraged: Milk, water, ponches, chicken soup, chicken, beef, pastas, hot cereals.
Health practice: Avoid cold temperatures and wind. A few may avoid showering for several days
during the cuarentena after birth. Great attention is paid to health of the mother.
Infant feeding
Food taboo: Avoid beans, too much rice, and uncooked vegetables (Purnell, 2013)
19. Dietary Practices for Health Promotion
Infancy – mothers tend to feed cow’s milk, canned milk, or
evaporated milk earlier than recommended. A baby, who is a little fat,
gordito, and a red cheek is seen as healthy.
Iron is considered as a “hot” food that is not usually taken during
pregnancy. Educating women about the importance of maintaining to
take daily iron supplement, even during pregnancy and lactation.
Elderly – fresh squeezed orange and grape juices and punches are
used as a nutrition support in immune-suppressed or ill elders.
Brandy may be added to black coffee for individuals who have low
blood pressure and are weak. (Purnell, 2013)
Most common herbs used by Puerto Rican women: black cohosh,
evening primrose, St. John’s wort, gingko, ginseng, valerian root,
sarsaparilla, chamomile, red clover, and passionflower (Purnell,
2009).
20. Traditions
El Dia de Reyes (Three Kings’ Day)
Domingo de Ramos
(Hede, 2013)
21. Education
Children are praised and encouraged to become educated
Educational system is similar to the mainland US for all
educational levels, nevertheless, when migrated to mainland
Literacy level is 94% both men and women
Universidad (university) refer to 4-years college institution
Agriculture as the primary locus of economic activity and
income
Sugar production as main source of income in agricultural
sector
High school completion rates are only 76.6% and a college
degree is only 16.5% (Purnell, 2013).
22. Religion/Spirituality
Roman Catholic – predominant religion (85%)
o Influence approach in health and illness
Espiritistas- communicate with spirits to promote spiritual
wellness and treat mental illness
Use azabache (small black fist) or Rabbits foot for good
luck
Use Rosary beads and patron saint figure from outside evil
sources (Purnell, 2013).
23. Religion/Spirituality cont.
Fertility practices
o Teenage pregnancy due to culturally imposed male behaviors and lack
of parental guidance or supervision
o Use of birth control methods is seen to be immoral because of Catholic
church
o Rhythm methods and abstinence is accepted
o Fertility control methods used are: tubal ligation also called La
Operacion (the surgery), oral contraceptives, hysterectomies, and
oophorectomies
o Refrain from tener relaciones ( sexual intercourse ) on first trimester
o Wish to have their bodies covered and limited number of internal
examinations for labor
o Cuarentena – avoiding cold and hot temperature and rest for 40 days.
o 10 to 11% of Puerto Rican women breastfeed (Purnell, 2013).
24. Religion/Spirituality cont.
Death Rituals
o News about deceased should be given first to the head of
the family
o it is important to extend burial rituals until all close family
members are present
o Expressing themselves through loud crying and verbal
expressions of grief is culturally acceptable
o Ataque de nervios – hearing about the death of the loved
ones (Purnell, 2013).
25. Community
Women viewed as: central role in the family and the
community, and the family is moving toward more
egalitarian relationships.
Priority over work: family responsibilities, pregnancy,
and the health of their children and other family members.
Puerto Ricans celebrate, mourn, and socialize around food.
Food is used:
1) To honor and recognize visitors, friends, family members, and
health-care providers
2) As an escape from everyday pressures, problems, and
challenges
3) To prevent and treat illnesses (Purnell, 2009).
26. Communication
Dominant Language and Dialects
Puerto Rico was the only Spanish speaking Latin American country in which
children beginning in kindergarten, learned to read and write English and Spanish
(Purnell, 2013).
Forced to learn English after the U.S. occupation in 1898.
Language is political issue.
Use standard form of Spanish, no dialects used.
Common expression of astonishment, surprise, lament, or pain phrased as: “!Ay
bendito!”
English and Spanish are both official languages.
Speech style: melodic, high-pitched, fast rhythm that may leave health-care
providers confused.
This pitch and these inflections applies when speaking English.
Feeling insulted if people comment on their accent.
The healthcare provider should avoid making comments about accent, use caution
when interpreting voice pitch, and seek clarification when in doubt about the content
and nature of a conversation that may seem confrontationa (Purnell, 2009).
27. Cultural Communication Patterns
Many individuals share sensitive information, options, and
decisions with close family members.
Verbal approval by: extended family or community member
who are knowledgeable in health matter.
Ask if verbal approval or consent from the partner should be
obtained first if a consent is needed from a woman.
Clarification of the information, language preference: verbal
and written
Allow time for the exchange of information when critical
decisions need to be made.
Value: simpatia, likeable, attractive, and fun-loving.
If confianza (trust) established, health-care providers can
establish open communication with a person and families
(Purnell, 2009).
28. Touch, Space, Eye Contact, Body Language, Modesty
• Acculturated and those born in the U.S., eye contact is
supported and is often encouraged.
• Women greet those who are familiar, with a strong hug
• Women greet family and friends with a strong hug and a
kiss.
• Men may greet men with a strong right handshake and use the
left hand to stroke the greeter’s shoulder (Purnell, 2008).
• Modesty is highly valued.
29. Concept of time
Have comparative views of time but do not feel
regular attendance and being on time is of importance
(Purnell 2013).
May interfere with being on time for
appointments.
present-oriented
External locus of control
Reliance on God
Coping mechanisms
30. Format for Names
• Greet clients with Señor, Señora, Doña or Don unless
otherwise directed.
• Single women prefer to use father and mother’s
surname
• Married women keep the fathers surname and take on
husbands last name with de in between the two.
31. Gender Roles
Males are expected to support the family financially in
traditional families. Decision makers.
Females are expected to respect and obey the men and to raise
and discipline children. Will gain status as they become older.
If both parent work, grandparent will take over role in rearing
grandchildren.
Male children are raised with a “macho” behavior
Dominance over women, pursuit high-paying jobs
Female children are raised to focus on home economics and
motherhood.
Children are to follow family traditions, get education, and
respect their elders and persons with high-status. (Purnell, 2013).
32. Genetic Characteristics (biocultural ecology)
Mixture of Native Indian, African, and Spanish.
Skin color varies from light to dark
Anemia and jaundice are more difficult to assess in
darker skin tones.
Mongolian spots are commonly seen on newborns and
infants.
Hispanics need lower doses of antidepressants and
experience more side effects. (Zoucha & Zamarripa,
2013)
33. Common Diseases
Leading causes of death: heart disease, malignant
neoplasms, diabetes mellitus, and AIDS.
Decrease mortality rates: lung, breast, and ovarian
cancers.
Increased incidence of stomach, prostate, esophageal,
pancreatic, and cervical cancers.
High incidence of: cardiopulmonary and
osteomuscular diseases for elderly.
Dengue fever from Aedes aegypti mosquito
Highest HIV incidence than other ethnic groups.
(Purnell, 2013).
34. Drug Metabolism
No information on differences in drug metabolism
African heritage:
Need higher doses of immunosuppressants
Respond poorly to beta blockers
Higher rate of angioedema with ACE inhibitors
Some Puerto Rican’s are short in stature, have higher
subscapular and tricep skin folds, long trunks, and
short legs. Caution for therapeutic dosages. (Purnell,
2013).
35. Nurses can provide culturally sensitive nursing care by
Developing mechanisms to integrate individual, family,
and community resources.
Offer weekend, evening, and late-night health-care
services in community based setting.
Incorporate the participation of the family in the care of
the ill.
Inquire about practices and encourage patients to bring
their medications every visit.
Acknowledge and incorporate traditional healing
practices into treatment regimen.
36. What can be done to enhance understanding regarding hospital stay,
surgery, medications, diet, medical treatment?
Use videos and literature in Spanish and with pictures
of Hispanics to help increase compliance with health
interventions (Purnell, 2009).
Use appropriate pain scale.
Provide interpreter in all points of contact.
Discuss client’s use of folk remedies to make sure they
do not conflict with current medical orders.
Become familiar with food practices when planning
culturally congruent dietary alternatives (Purnell,
2013).
37. What nurses can do to form positive relationship
Incorporate the concept of personalismo.
Engage in a friendly conversation.
Develop a trusting relationship.
Communicate with client using a soft tone of voice.
Project a professional image.
Discuss and incorporate their ethic folk practices that are
beneficial or neutral into their care.
Assess client’s religious practices and permit access to
religious leaders (Purnell, 2013).
38. Recommendations for future research
Find out barriers that Puerto Rican clients face while
receiving health care.
Promoting tobacco cessation to help decrease asthma
disparities in Puerto Rican children.
39. References
Brown, A. (2013). Hispanics of Puerto Rican Origin in the
United States. Retrieved from
http://www.pewhispanic.org/2013/06/19/hispanics-of-
puerto-rican-origin-in-the-united-states-2011/.
Centers for Disease Control and Prevention. (2013). Cultural
Insights: Communicating with Hispanics/Latinos.
Retrieved from
http://www.cdc.gov/healthcommunication/Audience/
AudienceInsight_CulturalInsights.pdf
Chong, Nilda, (2002). The Latino patient: a cultural guide for
health care providers. Yarmouth, ME: Nicholas Brealey
Publishing.
Purnell, L. D. (2008). People of Puerto Rican Heritage. In L.D.
Purnell and B. Paulanka (Ed.), Transcultural Health Care:
A culturally competent approached (3rd ed., pp. 395-
396). Philadelphia: F. A. Davis.
40. References
Purnell, L. D. (2009). People of Puerto Rican Heritage. In L.D.
Purnell (Ed.), Guide to culturally competent care (2nd ed.,
pp. 321-342). Philadelphia: F. A. Davis.
Purnell, L. D. (2013). People of Puerto Rican Heritage. In L.D.
Purnell (Ed.), Transcultural Health Care: A culturally
competent approached (4th ed., pp. 407-425). Philadelphia: F.
A. Davis.
Hede, M. (2013). The most important Puerto Rican Holidays.
Retrieved from: http://hispanic-culture-online.com/puerto-
rican-holidays.html
Zoucha, R, & Zamarripa, C. A. (2013), People of Mexican
heritage. In L. D. Purnell (Ed.), Transcultural health care: A
culturally competent approach, (4th ed., pp. 364-365).
Philadelphia: F. A. Davis.
