Purnell Model the Book the

Purnell Model The book the Spirit Catches You and You Fall Down describes the healthcare travesty of a hospital not knowing enough about the culture of its patients. Anne Fadiman wrote that book in 1998, and some changes have taken place in hospitals across the United States in terms of recognizing health disparities.

Yet much more headway must take place, especially with the rapidly changing demographics that are occurring in the country and the speed of globalization that is making the world "flat." As the National Institute of Child Health and Human Development (NICHD, 2000) reports, it is necessary to have an understanding of how and why certain minority and ethnic populations have better health outcomes than others, particularly given the many unfavorable circumstances of their lives.

In 1995, Larry Purnell (1998) developed a cultural model, with 12 cultural domains set within the influence of family, community, and global society, which has become a valuable assessment tool for healthcare providers. Although this paper uses the Mexican-Americans as an example of Purnell's model, it should be recognized that healthcare disparity will only be resolved when the biological, physical, social, individual, and community forces that contribute to the earliest beginnings of health disparities (NICHD, 2000) are understood for all American cultures.

The Purnell Model for Cultural Competence "provides a comprehensive, systematic, and concise framework for learning and understanding culture" (Purnell & Paulanka, 1998a, p. 8). Its empirical structure is designed to help healthcare providers, managers and administrators in any health area offer holistic, culturally competent therapeutic interventions, health education promotion and maintenance, and illness and disease prevention.

The model's purpose is to: 1) Provide a framework to teach concepts and characteristics of culture; 2) Define circumstances affecting a person's cultural worldview in regard to historical perspectives; 3) Provide a model linking culture's most central relationships; 4) Interrelate characteristics of culture to promote congruence and facilitate the delivery of consciously sensitive and competent health care; 5) Provide a framework reflecting human characteristics such as motivation, intentionally, and meaning; 6) Provide a structure to analyze cultural data; and 7) View the individual, family, or group within their unique ethnocultural environment.

The Purnell (1998a) model includes both macro and micro aspects. The macro interactional model consists of the metaparadigm concepts of a global society, community, family, person, and conscious competence and is created from biology, anthropology, sociology, economics, geography, history, ecology, physiology, psychology, political science, pharmacology, and nutrition in addition to communication, family development, and social support.

The micro model consists of 12 domains and their concepts, which are common to all cultures: 1) Overview, inhabited localities, and topography; 2) Communication; 3) Family roles and organization; 4) Workforce issues; 5) Biocultural ecology; 6) High-risk behaviors; 7) Nutrition; 8) Pregnancy and childbearing practices; 9) Death rituals; 10) Spirituality; 11) health-care practices and 12) Health-care practitioners. Mexican-Americans are a varied culture that does not have any specific set of characteristics, but rather certain commonalities that distinguish them as an ethnic group.

Although "Hispanic" is a common term used to describe Spanish speaking Americans, many people would rather be described as Mexican-Americans (Purnell & Paulanka, 1998). According to Reinert (as cited in Purnell & Paulanka, 1998) "Few other ethnic minority groups have been as persistent in maintaining their language, cultural beliefs, and traditions as have the Mexican-Americans." In the U.S., Mexican-Americans are often stereotyped and lumped together despite their diversity.

The movie Selena (Nava, 1997) demonstrates the struggle that Mexican-Americans often have to establish their identity and develop a pride in their now mixed heritage. Selena, raised as a Jehovah Witness in Corpus Christi, Texas, but playing in a Tex-Mex band by the age of 5, was loved for her fusion of many cultures and display of the different selves that characterized the American-Mexican culture. According to Purnell and Paulanka (1998), only 43.6% of Mexican-Americans aged 25 or older graduated from high school, compared to 80.5 of non-Hispanics.

Many Mexican-Americans live in substandard housing in overcrowded conditions and are either unemployed or working in low-paying jobs. It is noted by NICHD (2000), it is imperative for healthcare providers to examine the early home and school events of Hispanic children at risk for educational and developmental disabilities. Next to Spain, Mexico is the largest Spanish-speaking country in the world (Statistical Abstracts as cited in Purnell & Paulanka, 1998, p. 399). However, the National Institute of Anthropology and History reports that Mexico has 54 indigenous languages and over 500 different dialects.

Mexican-Americans appreciate sharing their thoughts and feelings with those they know and place much importance on family togetherness, including when in a long-term care facility. They may not open readily to healthcare providers who are not personally known. To demonstrate respect, compassion and understanding, healthcare providers need to welcome Mexican-American clients with a handshake. Once establishing a rapport, they may further show respect through backslapping, smiling and affirmative nods of the head. Direct eye contact for any length of time is not acceptable.

Mexicans are present-oriented and perceive time as relative rather than fixed; deadlines and commitments are flexible. They may arrive late for appointments, and this needs to be taken into consideration. In addition, many Mexican-Americans respond to direction and delegation differently than European-Americans. More recent immigrants are used to traditional autocratic managers who assign tasks but not authority and may have difficulty assuming responsibility and accountability for decision making.

In the movie Selena (Nava, 1997), it was possible to see the varying relationships and ties that she had with her family while going through childhood to becoming a young adult. The typical Mexican-American family has been patriarchal, with men playing a much stronger role than women. Women are expected to adhere to decisions their husbands or fathers make. Selena's father was open to her music suggestions, but completely against her relationship with Chris at first.

However, 30% of Latino families live in poverty and are headed by a single female parent (Purnell & Paulanka, 1998). Since the Hispanic cultural norm is for pregnant females to marry, Mexican-Americans are more likely to marry when young. Bioculturally, Mexican-Americans are as varied as they are culturally and linguistically, with a heritage from Spaniards and various North American and Central American Indian tribes.

Their physical traits are not distinct; some persons with a predominant Spanish background may have light-colored skin, blond hair and blue eyes, but those with Indian backgrounds may have black hair, dark eyes and cinnamon-colored skin. Medically, cyanosis and decreased hemoglobin levels are more difficult to detect in dark-skinned Mexican-Americans, and the practitioner needs to examine the sclera, conjunctiva, buccal mucosa, tongue, lips, nailbeds, palms and soles. Jaundice similarly is difficult to detect (Purnell & Paulanka, 1998).

To healthcare providers, obviously the Mexican-American in relationship to such factors as diseases and health conditions is of considerable importance. In Mexican-Americans who are living in impoverished areas, infectious, communicable and parasitic diseases are common, and tuberculosis rates are higher than norm. Intestinal parasitosis, amoebic dysentery and bacterial diarrhea, as well as syphilis, gonorrhea, chlamydia, HIV infection and hepatitis B are sometimes significantly higher in the Mexican-American migrant workers than European-Americans. Malaria may be a concern with those who lived in coastal lowland swamp areas.

Healthcare providers need to take such factors into consideration when screening for symptoms as anemia, lassitude, failure to thrive and weight loss. Higher rates of hypertension, heart disease and diabetes are also reported. Mexican-Americans have five times the rate of diabetes mellitus. Because of their mixed heritage, it is often difficult to determine therapeutic dosage of specific drugs, with differences in absorption, distribution, metabolism and excretion of the medicine (Purnell & Paulanka, 1998).

Due to the important role that alcohol plays in the Mexican-American culture, as pictured in the movie Selena (Nava, 1997), alcoholism is a crucial health problem and represents the primary reason for seeking psychiatric help. It may be that low acculturation and incorrect application of the machismo may cause some of these alcoholic problems and high rate of suicide. Marijuana is the second most common drug that Mexican-Americans use since it is readily available. Further, the decline of cigarette smoking in the U.S. may not be as prevalent with Mexican-Americans.

Responsibility for health promotion and safety may be quite difficult (Burk, as cited in Purnell & Paulanka, 1998) for those of Mexican heritage who are used to being dependent on the family unit and traditional means of providing healthcare. Disparities in health-seeking behaviors have been reported in many studies. Similar to many other ethnic groups, food is a major part of Mexican-American holidays and celebrations. Mexican foods are rich in color, flavor and spiciness.

Because food is a primary form of socialization, Mexican-Americans may have problems adhering to prescribed diets for illnesses such as diabetes mellitus and cardiovascular disease (Monrroy, as cited in Purnell & Paulanka, 1998). The staples of the diet are rice, beans and tortillas made from corn and calcium is derived from cheese and other milk products. The diet is also rich in eggs, pork, chicken, sausage lard, mint, chili peppers, onions, tomatoes, squash, canned fruit and drinks such as beer, high-in-sugar beverages, sweetened cereals, and sweet desserts.

A dominant healthcare practice for many Mexican-Americans is the hot and cold theory of food selection, where illness or trauma may require adjustments in the hot and cold balance of foods to restore body equilibrium. In lower socioeconomic groups is a wide-scale deficiency of vitamin a and iron, as well as lactose intolerance. Mexican-American birth rates are 3.45 per household compared to 2.6 per household among other minority groups (Chapa & Valencia, 1993 as cited in Purnell & Paulanka, 1998). Multiple births are common, particularly in the economically disadvantaged groups.

Men see a larger number of children as evidence of their virility. If a woman does not conceive by the age of 24, it may be considered too late. Given their predominant Catholic beliefs, the tendency is only to use acceptable forms of birth control, although many will use other unacceptable forms. Abortion is morally wrong. Family planning is an important area, where healthcare providers can identify more realistic outcomes that are consistent with current economic resources and family goals.

Since pregnancy is deemed natural and desirable, many women do not seek prenatal evaluations nor do many know that prenatal care is so essential. Healthcare providers need to encourage female relatives and husbands to accompany the pregnant woman for health screening and incorporate advice from family members into health teaching and preventative care services. Mexican-Americans often face death stoically as a natural part of life (Purnell & Paulanka, 1998), and death practices are an adaptation of their religious views.

Once again, family is very much involved with the event, spending time with the dying person and gathering together for a "velorio," a festive watch.