The document discusses the importance of cultural competence in healthcare to address disparities faced by diverse populations in the U.S. and globally. It emphasizes that healthcare providers need to understand clients' cultural values and communication styles to improve patient care and outcomes. The text highlights ongoing challenges and the necessity for health organizations to enhance their cultural competency to reduce health inequities.

1. 1
Transcultural Diversity
and Health Care
Chapter 1
LARRY D. PURNELL
The Need for Culturally Competent
Health Care
Cultural competence in multicultural societies continues as
a major initiative for business, health-care, and educational
organizations in the United States and throughout most of
the world. The mass media, health-care policy makers, the
Office of Minority Health, and other Governmental organi-
zations, professional organizations, the workplace, and
health insurance payers are addressing the need for individ-
uals to understand and become culturally competent as one
strategy to improve quality and eliminate racial, ethnic, and
gender disparities in health care. Educational institutions
from elementary schools to colleges and universities also
address cultural diversity and cultural competency as they
relate to disparities and health promotion and wellness.
Many countries are now recognizing the need for
addressing the diversity of their society, including the
client base, the provider base, and the organization.
Societies that used to be rather homogeneous, such as
Portugal, Norway, Sweden, Korea, and selected areas in the
United States and the United Kingdom, are now facing sig-
nificant internal and external migration, resulting in eth-

2. nocultural diversity that did not previously exist, at least
not to the degree it does now. As commissioned by the
U.K. Presidency of the European Union, several European
countries—such as Denmark, Italy, Poland, the Czech
Republic, Latvia, the United Kingdom, Sweden, Norway,
Finland, Italy, Spain, Portugal, Hungary, Belgium, Greece,
Germany, the Netherlands, and France—either have in
place or are developing national programs to address the
value of cultural competence in reducing health dispari-
ties (Health Inequities: A Challenge for Europe, 2005).
Whether people are internal migrants, immigrants, or
vacationers, they have the right to expect the health-care
system to respect their personal beliefs, values, and
health-care practices. Culturally competent health care
from providers and the system, regardless of the setting in
which care is delivered, is becoming a concern and expec-
tation among consumers. Diversity also includes having a
diverse workforce that more closely represents the popu-
lation the organization serves.
Health-care personnel provide care to people of diverse
cultures in long-term-care facilities, acute-care facilities,
clinics, communities, and clients’ homes. All health-care
providers—physicians, nurses, nutritionists, therapists,
technicians, home health aides, and other caregivers—
need similar culturally specific information. For example,
all health-care providers engage in verbal and nonverbal
communication; therefore, all health-care professionals
and ancillary staff need to have similar information and
skill development to communicate appropriately with
diverse populations. The manner in which the informa-
tion is used may differ significantly based on the disci-
pline, individual experiences, and specific circumstances
of the client and provider.

3. Culturally competent staff and organizations are essen-
tial ingredients in increasing clients’ satisfaction with
health care and reducing multifactor reasons for gender,
racial, and ethnic disparities and complications in health
care. If providers and the system are competent, most
clients will access the health-care system when problems
are first recognized, thereby reducing the length of stay,
decreasing complications, and reducing overall costs.
A lack of knowledge of clients’ language abilities and
cultural beliefs and values can result in serious threats to
life and quality of care for all individuals. Organizations
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and individuals who understand their clients’ cultural
values, beliefs, and practices are in a better position to be
coparticipants with their clients in providing culturally
acceptable care. Having ethnocultural specific knowledge,
understanding, and assessment skills to work with cultur-
ally diverse clients assures that the health-care provider
knows what questions to ask. Providers who know ethno-
culturally specific knowledge are less likely to demon-
strate negative attitudes, behaviors, ethnocentrism,
stereotyping, and racism. Accordingly, there will be
improved opportunities for health promotion and well-
ness; illness, disease, and injury prevention; and health
maintenance and restoration. The onus for cultural com-
petence is on the health-care provider and the delivery
system in which care is provided. To this end, health-care
providers need both general and specific cultural knowl-

4. edge to help reduce gender and ethnic and racial dispari-
ties in health care.
World Diversity and Migration
The world’s population reached 6.5 billion people in the
year 2005 and is expected to approach 7.6 billion by 2020
and 9.3 billion by 2050. The estimated population growth
rate is 1.14 percent, with 20.05 births per 1000 popula-
tion, 8.6 deaths per 1000 population, and an infant mor-
tality rate of 48.87 per 1000 population. Worldwide, life
expectancy at birth is currently 64.77 years, with males at
63.17 years and females at 66.47 years (CIA, 2007).
As a first language, Mandarin Chinese is the most popu-
lar, spoken by 13.59 percent of the world’s population, fol-
lowed by Spanish at 5.05 percent, English at 4.8 percent,
Hindi at 2.82 percent, Portuguese at 2.77 percent, Bengali
at 2.68 percent, Russian at 2.27 percent, Japanese at 1.99
percent, German at 1.49 percent, and Wu Chinese at 1.21
percent. Only 82 percent of the world population is liter-
ate. When technology is examined, more people now have
a cell phone than a landline: 1.72 billion versus 1.2 billion.
Slightly over 1 billion people are Internet users (CIA, 2007).
We currently live in a global society, a trend that is
expected to continue into the future. According to the
United Nations High Commissioner for Refugees, there is a
global population of 9.2 million refugees, the lowest num-
ber in 25 years, and as many as 25 million internally dis-
placed persons. Migrants represent 2.9 percent or approxi-
mately 190 million people of the world population, up
from 175 million in the year 2000. Moreover, international
migration is decreasing while internal migration is increas-
ing, especially in Asian countries. Only two countries in
the world are seeing an increase in their migrant stock—
North America and the former USSR (CIA, 2007).

5. The International Organization for Migration com-
pleted the first-ever comprehensive study looking at the
costs and benefits of international migration. According
to the report, ample evidence exists that migration brings
both costs and benefits for sending and receiving coun-
tries, although these are not shared equally. Trends sug-
gest a greater movement toward circular migration with
substantial benefits to both home and host countries. The
perception that migrants are more of a burden on, than a
benefit to, the host country is not substantiated by
research. For example, in the Home Office Study (2002) in
the United Kingdom, migrants contributed U.S. $4 billion
more in taxes than they received in benefits. In the
United States, the National Research Council (1998) esti-
mated that national income had expanded by U.S. $8 bil-
lion because of immigration. Thus, because migrants pay
taxes, they are not likely to put a greater burden on health
and welfare services than the host population. However,
undocumented migrants run the highest health risks
because they are less likely to seek health care. This not
only poses risks for migrants but also fuels sentiments of
xenophobia and discrimination against all migrants.
2 • CHAPTER 1
What evidence do you see in your community that
migrants have added to the economic base of the
community? Who would be doing their work if
they were not available?
UNITED STATES POPULATION AND
CENSUS DATA
As of 2006, the U.S. population was over 300 million, an

6. increase of 16 million since the 2000 census. The most
recent census data estimates that 74.7 percent are white,
14.5 percent are Hispanic/Latino (of any race), 12.1 per-
cent are black or African American, 0.8 percent are
American Indian or Alaskan Native, 4.3 percent are Asian,
0.1 percent are Native Hawaiian or other Pacific Islander,
6 percent are some other race, and only 1.9 percent are of
two or more races. Please note: These figures total more
than 100 percent because the federal government consid-
ers race and Hispanic origin to be two separate and dis-
tinct categories. The categories as used in Census 2000 are
1. White refers to people having origins in any of
the original peoples of Europe, the Near East,
and the Middle East, and North Africa. This cate-
gory includes Irish, German, Italian, Lebanese,
Turkish, Arab, and Polish.
2. Black or African American refers to people having
origins in any of the black racial groups of Africa,
and includes Nigerians and Haitians or any per-
son who self-designates this category regardless
of origin.
3. American Indian and Alaskan Native refer to people
having origins in any of the original peoples of
North, South, or Central America and who main-
tain tribal affiliation or community attachment.
4. Asian refers to people having origins in any of
the original peoples of the Far East, Southeast
Asia, or the Indian subcontinent. This category
includes the terms Asian Indian, Chinese, Filipino,
Korean, Japanese, Vietnamese, Burmese, Hmong,
Pakistani, and Thai.

7. 5. Native Hawaiian and other Pacific Islander refer to
people having origins in any of the original peo-
ples of Hawaii, Guam, Samoa, Tahiti, the Mariana
Islands, and Chuuk.
6. Some other race was included for people who are
unable to identify with the other categories.
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7. In addition, the respondent could identify, as a
write-in, with two races (U.S. Bureau of the
Census, 2006).
The Hispanic/Latino and Asian populations continue to
rise in numbers and in percentage of the overall popula-
tion; although the black/African American, Native
Hawaiian and Pacific Islanders, Native American and
Alaskan Natives groups continue to increase in overall
numbers, their percentage of the population has
decreased. Of the Hispanic/Latino population, most are
Mexicans, followed by Puerto Ricans, Cubans, Central
Americans, South Americans, and lastly, Dominicans.
Salvadorans are the largest group from Central America.
Three-quarters of Hispanics live in the West or South,
with 50 percent of the Hispanics living in just two states,
California and Texas. The median age for the entire U.S.
population is 35.3 years, and the median age for
Hispanics is 25.9 years (U.S. Bureau of the Census, 2006).
The young age of Hispanics in the United States makes
them ideal candidates for recruitment into the health

8. professions, an area with crisis-level shortages of person-
nel, especially of minority representation.
Before 1940, most immigrants to the United States
came from Europe, especially Germany, the United
Kingdom, Ireland, the former Union of Soviet Socialist
Republics, Latvia, Austria, and Hungary. Since 1940,
immigration patterns to the United States have changed:
Most are from Mexico, the Philippines, China, India,
Brazil, Russia, Pakistan, Japan, Turkey, Egypt, and
Thailand. People from each of these countries bring their
own culture with them and increase the cultural mosaic
of the United States. Many of these groups have strong
ethnic identities and maintain their values, beliefs, prac-
tices, and languages long after their arrival. Individuals
who speak only their indigenous language are more likely
to adhere to traditional practices and live in ethnic
enclaves and are less likely to assimilate into their new
society. The inability of immigrants to speak the language
of their new country creates additional challenges for
health-care providers working with these populations.
Other countries in the world face similar immigration
challenges and opportunities for diversity enrichment.
However, space does not permit a comprehensive analysis
of migration patterns.
the Secretary’s Task Force’s report on Black and Minority
Health (Perspectives on Disease Prevention and Health
Promotion, 1985). Two goals from Healthy People 2010 are
to increase quality and years of healthy life and eliminate
health disparities (Healthy People 2010, 2005). In 2005,
the Agency for Healthcare Research and Quality (AHRQ)
released the Third National Healthcare Disparities Report
(Agency for Healthcare Research and Quality [AHRQ],
2005) that provides a comprehensive overview of health
disparities in ethnic, racial, and socioeconomic groups in

9. the United States. This report is a companion document
to the National Healthcare Quality Report (NHQR) that is
an overview of quality health care in the United States.
These two documents highlight four themes: (1)
Disparities still exist, (2) some disparities are diminishing,
(3) opportunities for improvement still exist, and (4)
information about disparities is improving. These docu-
ments address the importance of clinicians, administra-
tors, educators, and policymakers in cultural competence.
Disparities are observed in almost all aspects of health-
care, including
1. Effectiveness, patient safety, timeliness, and
patient centeredness.
2. Facilitators and barriers to care and health-care
utilization.
3. Preventive care, treatment of acute conditions,
and management of chronic disease.
4. Clinical conditions such as cancer, diabetes, end-
stage renal disease, heart disease, HIV disease,
mental health and substance abuse, and respira-
tory diseases.
5. Women, children, elderly, rural residency, and
individuals with disabilities and other special
health-care needs.
6. Minorities and the financially poor receive a
lower quality of care (AHRQ, 2005).
When ethnocultural specific populations are exam-
ined, although some disparities have shown improve-
ment, many have not improved and some have wors-

10. ened. With whites as the comparison group, the report
shows:
1. Blacks were 10 times more likely to be diagnosed
with AIDS, 59 percent less likely to be given
antibiotics for the common cold, 9 percent more
likely to receive poorer quality care, 17 percent
more likely to lack health insurance, 7 percent
less likely to report difficulties in getting care,
and 10 percent more likely to have worse access
to care.
2. Non-white Hispanics/Latinos were 3.7 times
more likely to be diagnosed with AIDS, 16 per-
cent more likely to receive poorer quality care,
2.9 times for under age 65 to lack health insur-
ance, 18 percent less likely to report difficulties
or delays getting care, and 87 percent more likely
to have worse access. However, they were 40 per-
cent less likely to die of breast cancer.
3. Asians were 57 percent more likely to report com-
munication problems with the child’s provider,
TRANSCULTURAL DIVERSITY AND HEALTH CARE • 3
What changes in ethnic and cultural diversity have
you seen in your community over the last 5 years?
Over the last 10 years? Have you had the opportu-
nity to interact with newer groups?
Racial and Ethnic Disparities
in Health Care
A number of organizations have developed documents
addressing the need for cultural competence as one strat-
egy for eliminating racial and ethnic disparities. In 1985,

11. the Department of Health and Human Services released
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40 percent less likely to report difficulties or
delays in getting care, and 20 percent more likely
to have worse access to care.
4. American Indians and Alaskan Natives were
twice as likely to lack early prenatal care, 67 per-
cent less likely to develop late-stage breast can-
cer, 8 percent more likely to receive poorer qual-
ity care, twice as likely for the under-age-65
group to not have health insurance, 23 percent
more likely to lack a primary-care provider, and 4
percent more likely to have worse access to care.
5. Data for Native Hawaiians and other Pacific
Islanders were not available for this report but
will be in future reports (AHRQ, 2005).
The health of the lesbian, gay, bisexual, and transgen-
der populations has not been addressed in the Healthy
People 2010 document or in other government publica-
tions. However, the Gay and Lesbian Medical Association
(www.glma.org) in 2001 developed Healthy People 2010
Companion Document for Lesbian, Gay, Bisexual, and
Transgender Health. Salient disparities are noted in this
publication. Gays and lesbians are more likely than their
heterosexual cohort groups to have higher rates of
tobacco, alcohol, and recreational drug use. Sexually

12. transmitted infections, HIV (especially for men), suicide
and suicide ideation, depression, being a victim of street
violence (especially for men) and home violence (espe-
cially for women), sexual abuse among men, hate crimes,
and psychological and emotional disorders are higher
among these groups. They are also more likely to be dis-
criminated against by health-care providers owing to
homophobia. Because of the stigma that alternative iden-
tity gender discrimination brings, especially among
racially and ethnically diverse populations (Purnell,
2003), these populations were less likely to disclose their
sexual orientations. They are also less likely to have
health insurance, have a primary-care provider, or take
part in prevention programs; in fact, 57 percent of trans-
gender people do not have health insurance (Healthy
People 2010 Companion Document for Lesbian, Gay,
Bisexual, Transgender Health, 2001; Purnell, 2003). To help
combat violence and crimes against lesbians, gays, and
transgender people, several cities such as Washington,
D.C.; Fargo, North Dakota; and Missoula, Montana, in the
United States have initiated Gay and Lesbian Crime Units
(Police Unit Reaches Out to Gay Community, Inspires
Others, 2006).
ethnic disparities in other countries. However, documents
that include other countries, conditions, and policies are
listed as a resource herein. Additional information on the
role of cultural competence on eliminating racial and
ethnic disparities includes:
1. Transcultural Nursing Society, International
(www.tcns.org)
2. U.S. Department of Health and Human Services
Office of Minority Health: Physician’s Toolkit
and Curriculum (http://www.omhrc.gov/assets/

13. pdf/checked/toolkit.pdf)
3. Institute of Medicine’s Unequal Treatment
study (http://www.iom.edu/?id=4475)
4. The Commonwealth Fund Report on Health
Care Quality (http://www.cmwf.org/)
5. Delivering Race Equality: A Framework for
Action (http://www.londondevelopmentcentre.
org/silo/files/577.pdf)
6. Protecting Vulnerable Populations (www.wcc-
assembly.info/en/news-media/news/english)
7. Canadian Institutes of Health Research:
Reducing Health Disparities and Promoting
Equity for Vulnerable Populations (www.cihr-irsc.
gc.ca/e/19739.html)
8. American Physical Therapy Association’s docu-
ment and monographs on cultural competence
(www.apta.org)
9. Health Inequalities: A Challenge for Europe that
includes health policies for the Czech Republic,
England, Denmark, Finland, Greece, Germany,
Hungary, Ireland, Latvia, the Netherlands,
Northern Ireland, Poland Portugal, Scotland,
Spain, Sweden, and Wales (www.fco.gov.uk/
Files/kfile/HI_EU_Challenge,0.pdf)
10. American Academy of Family Physicians docu-
ments on health disparities and cultural com-
petence (http://www.aafp.org)

14. 11. American Academy of Physician Assistants doc-
ument The Four Layers of Diversity (http://
www.aapa.org/)
12. Health Resources and Services Administration
publication “Indicators of Cultural Competence
in Health Care Delivery Organizations” and
Cultural Competence Works (www.hrsa.gov)
13. American Student Medical Association Culture
and Diversity Curriculum (http://www.amsa.org/
programs/diversitycurriculum.cfm)
14. American Academy of Nursing Standards of
Cultural Competence (in press).
15. Diversity Rx (www.diversityRx.org)
Self-Awareness and Health
Professionals
Culture has a powerful unconscious impact on health
professionals. Each health-care provider adds a new and
4 • CHAPTER 1
What health disparities have you observed in your
community? To what do you attribute these dispar-
ities? What can you do as a professional to help
decrease these disparities?
Only broad categories of health disparities are
addressed in this chapter. More specific data are included
in individual chapters on cultural groups. As can be seen
by the overwhelming data, much more work needs to be
accomplished to improve the health of the nation. Space
does not permit an extensive discourse on racial and

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unique dimension to the complexity of providing cultur-
ally competent care. The way health-care providers per-
ceive themselves as competent providers is often reflected
in the way they communicate with clients. Thus, it is
essential for health professionals to think about their cul-
tures, their behaviors, and their communication styles in
relation to their perceptions of cultural differences. They
should also examine the impact their beliefs have on oth-
ers, including clients and coworkers, who are culturally
diverse. Before addressing the multicultural backgrounds
and unique individual perspectives of each client, health-
care professionals must first address their own personal
and professional knowledge, values, beliefs, ethics, and
life experiences in a manner that optimizes interactions
and assessment of culturally diverse individuals.
Self-knowledge and understanding promote strong
professional perceptions that free health-care profession-
als from prejudice and allow them to interact with others
in a manner that preserves personal integrity and respects
uniqueness and differences among individual clients. The
process of professional development and diversity com-
petence begins with self-awareness, sometimes referred to
as self-exploration. Although the literature provides
numerous definitions of self-awareness, discussion of
research integrating the concept of self-awareness with
multicultural competence is minimal. Many theorists and
diversity trainers imply that self-examination or aware-

16. ness of personal prejudices and biases is an important step
in the cognitive process of developing cultural compe-
tence (Andrews & Boyle, 2005; Campinha-Bacote, 2006;
Giger & Davidhizar, 2008). However, discussions of emo-
tional feelings elicited by this cognitive awareness are
somewhat limited, given the potential impact of emo-
tions and conscious feelings on behavioral outcomes.
Culture and Essential Terminology
CULTURE DEFINED
Anthropologists and sociologists have proposed many
definitions of culture. For the purposes of this book, cul-
ture is defined as the totality of socially transmitted
behavioral patterns, arts, beliefs, values, customs, life-
ways, and all other products of human work and thought
characteristics of a population of people that guide their
worldview and decision making. Health and health-care
beliefs and values are assumed in this definition. These
patterns may be explicit or implicit, are primarily learned
and transmitted within the family, are shared by most
(but not all) members of the culture, and are emergent
phenomena that change in response to global phenom-
ena. Culture, a combined anthropological and social con-
struct, can be seen as having three levels: (1) a tertiary
level that is visible to outsiders, such as things that can be
seen, worn, or otherwise observed; (2) a secondary level,
in which only members know the rules of behavior and
can articulate them; and (3) a primary level that repre-
sents the deepest level in which rules are known by all,
observed by all, implicit, and taken for granted (Koffman,
2006). Culture is largely unconscious and has powerful
influences on health and illness. Health-care providers
must recognize, respect, and integrate clients’ cultural
beliefs and practices into health prescriptions.

17. An important concept to understand is that cultural
beliefs, values, and practices are learned from birth: first
at home, then in the church and other places where
people congregate, and then in educational settings.
Therefore, a 3-month-old male child from Korea adopted
by an African American family and reared in an African
American environment will have an African American
worldview. However, that child’s “race” would be Asian,
and if that child had a tendency toward genetic/hereditary
conditions, they would come from his Korean ancestry,
not from African American genetics.
TRANSCULTURAL DIVERSITY AND HEALTH CARE • 5
In your opinion, why is there conflict about work-
ing with culturally diverse clients? What attitudes
are necessary to deliver quality care to clients
whose culture is different from yours?
Self-awareness in cultural competence is a deliberate
and conscious cognitive and emotional process of getting
to know yourself: your personality, your values, your
beliefs, your professional knowledge standards, your
ethics, and the impact of these factors on the various roles
you play when interacting with individuals different from
yourself. The ability to understand oneself sets the stage
for integrating new knowledge related to cultural differ-
ences into the professional’s knowledge base and percep-
tions of health interventions.
What have you done in the last 5 to 10 years to
increase your self-awareness? Has increasing your
self-awareness resulted in an increased apprecia-
tion for cultural diversity? How might you
increase your knowledge about the diversity in
your community? In your school?

18. Who in your family had the most influence in
teaching you cultural values and practices?
Outside the family, where else did you learn about
your cultural values and beliefs? What cultural
practices did you learn in your family that you no
longer practice?
When individuals of dissimilar cultural orientations
meet in a work or a therapeutic environment, the likeli-
hood for developing a mutually satisfying relationship is
improved if both parties attempt to learn about each
other’s culture. Moreover, race and culture are not syn-
onymous and should not be confused. For example, most
people who self-identify as African American have vary-
ing degrees of dark skin, but some may have white skin.
However, as a cultural term, African American means that
the person takes pride in having ancestry from both
Africa and the United States; thus, a person with white
skin could self-identify as African American.
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IMPORTANT TERMS RELATED TO CULTURE
Attitude is a state of mind or feeling about some matter
of a culture. Attitudes are learned; for example, some peo-
ple think that one culture is better than another. One cul-
ture is not better than another; the two are just different,
although many patterns are shared among cultures. A
belief is something that is accepted as true, especially as

19. a tenet or a body of tenets accepted by people in an eth-
nocultural group. A belief among some cultures is that if
a pregnant woman craves a particular food substance,
strawberries, for example, and does not satisfy the crav-
ing, the baby will be born with a birthmark in the shape
of the craving. Attitudes and beliefs do not have to be
proven; they are unconsciously accepted as truths.
Ideology consists of the thoughts and beliefs that reflect
the social needs and aspirations of an individual or an
ethnocultural group. For example, some people believe
that health care is a right of all people, whereas others see
health care as a privilege.
The literature reports many definitions for the terms
cultural awareness, cultural sensitivity, and cultural com-
petence. Sometimes, these definitions are used inter-
changeably. However, cultural awareness has more to
do with an appreciation of the external signs of diversity,
such as arts, music, dress, and physical characteristics.
Cultural sensitivity has more to do with personal atti-
tudes and not saying things that might be offensive to
someone from a cultural or ethnic background different
from the health-care provider’s. Cultural competence
in health care is having the knowledge, abilities, and skills
to deliver care congruent with the client’s cultural beliefs
and practices. Increasing one’s consciousness of cultural
diversity improves the possibilities for health-care practi-
tioners to provide culturally competent care.
as the humanities. An understanding of one’s own culture
and personal values and the ability to detach oneself from
“excess baggage” associated with personal views are
essential to cultural competence. Even then, traces of eth-
nocentrism may unconsciously pervade one’s attitudes
and behavior. Ethnocentrism, the universal tendency
of human beings to think that their ways of thinking, act-

20. ing, and believing are the only right, proper, and natural
ways, can be a major barrier to providing culturally com-
petent care. Ethnocentrism, a concept that most people
practice to some degree, perpetuates an attitude in which
beliefs that differ greatly from one’s own are strange,
bizarre, or unenlightened and, therefore, wrong. Values
are principles and standards that are important and have
meaning and worth to an individual, family, group, or
community. For …
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Theories, Models, and Approaches
Larry Purnell, PhD, RN, FAAN
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Cultural Theories, Models, and ApproachesLeininger: First
nurse cultural theorist from early 1950s. She states it is for
nursing onlyCampinha-Bacote: basic simple model without
complex constructs but applicable to all healthcare providers.
Also has a Biblical based model.

21. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Cultural Theories, Models, and ApproachesGiger and
Davidhizar: Nursing onlyPurnell: For all health care providers
and is an example of a complexity and holographic conceptual
model with an organizing framework.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Cultural Theories, Models, and ApproachesPapadopoulous,
Tilki, and Taylor Model for Transcultural Nursing and Health
Andrews and Boyle Nursing Assessment Guide Spector’s Health
Traditions Model
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Cultural Theories, Models, and ApproachesRamsden's Cultural
Safety Model Jeffrey’s Teaching Cultural Competence in
Nursing and Health Care: Inquiry, Action, and Innovation

22. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger’s Theory of Cultural Care
Diversity and Universality
www.madeleine-leininger.com
Leininger described the phenomena of cultural care based on
her experiences.Began in the 1950s with her doctoral
dissertation conducted in New Guinea www.tcns.org and go to
theories and then to the Sunrise Enabler and her model is
displayed as well as publications.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Transcultural Nursing"Transcultural nursing has been defined as
a formal area of study and practice focused on comparative
human-care (caring) differences and similarities of the beliefs,
values, and patterned lifeways of cultures to provide culturally
congruent, meaningful, and beneficial health care to people.“
Leininger and McFarland text, 3rd ed.,2002, pp5-6.

23. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger: Purpose and GoalTo discover, document, interpret,
explain and predict multiple factors influencing care from a
cultural holistic perspective.The goal of the theory was to
provide culturally congruent care that would contribute to the
health and well being of people, or to help them face disability,
dying, or death using the three modes of action.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leninger: Theoretical TenetsLeininger’s tenets: Care diversities
(differences) and universalities (commonalties) existed among
cultures in the world which needed to be discovered, and
analyzed for their meaning and uses to establish a body of
transcultural nursing knowledge.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger: AssumptionsCare is essence of nursing and a
distinct, dominant, central, and unifying focus. Some would say

24. that caring is not unique to nursing. Care is essential for well
being, health, growth, survival, and to face handicaps or
death.Culturally based care is the broadest means to know,
explain, interpret, and predict nursing care phenomena to guide
nursing care decisions and actions.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger AssumptionsNursing is a transcultural humanistic and
scientific care to serve individuals, groups, communities, and
institutions worldwide.Caring is essential to curing and healing
for there can be no curing without caring.Cultural care concepts
meanings and expression patterns of care vary transculturally
with diversity and universality.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger AssumptionsEvery human culture has generic care
knowledge and practices and some professional care knowledge
that vary transculturally.Culture care values, beliefs, and
practices are influenced by the (rays of the sun see the
Model).Beneficial, healthy, and satisfying culturally based care
influences the health and well-being of individuals, families,
groups, and communities within the cultural context.

25. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger AssumptionsCulturally congruent care can only occur
when individuals’, groups’, and communities’ patterns are
known and used in meaningful ways.Culture care differences
and similarities between professionals and clients exist in all
human cultures worldwide.Culture conflicts, imposition
practices, cultural stresses, and pain reflect the lack of
professional care to provide culturally congruent care.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger’s Sunrise Enabler to
Discover Culture Care
To view the model go to:
http://leiningertheory.blogspot.com/

26. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Leininger Orientational Theory DefinitionsCultural Care
Preservation or Maintenance: all is well with the patient so
encourage to continue what has been doneCultural Care
Accommodation or Negotiation: Needs some change. What is
acceptable weight from the patient’s perspective Cultural Care
Repatterning or Restructuring: Practices are deleterious to
overall health and need restructured: sexually promiscuous and
has not been practicing safe sex
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Cultural Competence in the Delivery of Healthcare Services: A
culturally Competent Model of CareDr. Josepha Campinha-
Bacote but cannot display her model. Go to
http://www.transculturalcare.net
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Process of Cultural CompetenceCultural Competence is a

27. process not an event.The process consist of five inter-related
constructs: Cultural desire, cultural awareness, cultural
knowledge, cultural skills, and cultural encounter.The key and
pivotal construct is cultural desire.There is more variation
within a cultural group than across cultural groups.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Process of Cultural CompetenceThere is a direct relationship
between healthcare professionals level of cultural competence
and their ability to provide culturally responsive health
care.Cultural competence is an essential component in
delivering effective and culturally responsive care to culturally
diverse clients.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Cultural Desire. . . Cultural desire is defined as the motivation
of the healthcare professional to “want to” engage in the
process of becoming culturally competent; not the “have to”.

28. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Concepts Cultural awareness is the self-examination and in-
depth exploration of one’s own cultural background.Cultural
knowledge is the process of seeking and obtaining a sound
educational base about culturally diverse groups.Cultural Skills
is the ability to collect relevant cultural data regarding the
client’s presenting problem as well as accurately perform a
culturally based physical assessment.Cultural encounter is the
process which encourages the healthcare professional to directly
engage in face-to-face interactions with clients from culturally
diverse backgrounds.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
The Giger and Davidhizar Transcultural Assessment Model
Dr. Joyce Giger
Dr. Ruth Davidhizar (deceased)
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company

29. Giger and Davidhizar AssumptionsThe Giger and Davidhizar
Transcultural Model postulates that each individual is culturally
unique and should be assessed according to the six cultural
phenomena.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Giger and Davidhizar CommunicationCommunication embraces
the entire world of human interaction and behavior.
Communication is the means by which culture is transmitted
and preserved. Both verbal and non-verbal communication are
learned in one’s culture.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Giger and Davidhizar
SpaceSpace refers to the distance between individuals when
they interact. All communication occurs in the context of
space.Zones of personal space: intimate, personal, social, and
consultative and public. Rules concerning personal distance
vary from culture to culture.

30. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Giger and Davidhizar
Social OrganizationSocial organization refers to the manner in
which a cultural group organizes itself around the family group.
Family structure and organization, religious values and beliefs,
and role assignments may all relate to ethnicity and culture.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Giger and Davidhizar
TimeTime is an important aspect of interpersonal
communication. Cultural groups can be past, present, or future
oriented. Preventive health requires some future time
orientation because preventative actions are motivated by a
future reward.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition

31. Copyright © 2013 F.A. Davis Company
Giger and Davidhizar Environmental ControlEnvironmental
control refers to the ability of the person to control nature and
to plan and direct factors in the environment that affect them.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Giger and Davidhizar
Biological VariationsBiological differences, especially genetic
variations, exist between individuals in different racial groups.
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Boyle and Andrews Culturological AssessmentBiocultural
variations and cultural aspects of the incidence of
diseaseCommunicationCultural affiliations Cultural sanctions
and restrictionsDevelopmental
considerationsEconomicsEducational background

32. Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Boyle and Andrews Culturological AssessmentHealth related
beliefs and practicesKinship and social networksNutrition
Religion and spiritualityValues orientation
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Ramsden Cultural Safety"the effective nursing practice of a
person or a family from another culture, as determined by that
person or family", while unsafe cultural practice is "any action
which diminishes, demeans or disempowers the cultural identity
and wellbeing of an individual" (Nursing Council of New
Zealand (NCNZ).
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Ramsden Cultural Safety
http://culturalsafety.massey.ac.nz/RAMSDEN%20THESIS.pdfA
ssumes that nurses and the culture of nursing is exotic to people

33. Gives the power of definition to the person served Concerned
with human diversity Focus internal on nurse or midwife,
exchanges power, negotiated A key part of Cultural Safety is
that it emphasises life chances rather than life styles
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Papadopoulos, Tilki, and Taylor
Cultural Awareness
Self awareness
Cultural identity
Heritage adherence
Ethnocentricity
Stereotyping
Ethnohistory
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Papadopoulos, Tilki, and Taylor
Cultural Knowledge
Health beliefs and behaviours
Anthropological, Sociological,

34. Psychological and Biological understanding
Similarities and differences
Health Inequalities
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Papadopoulos, Tilki, and Taylor
Cultural Sensitivity
Empathy
Interpersonal/communication skills
Trust
Acceptance
Appropriateness
Respect
Transcultural Health Care: A Culturally Competent Approach,
4th Edition
Copyright © 2013 F.A. Davis Company
Papadopoulos, Tilki, and Taylor
Cultural Competence
Assessment skills
Diagnostic skills
Clinical Skills

35. Challenging and addressing prejudice, discrimination, and
inequalities