The development of a measure of enculturation for Native American youth

Tobacco product use and cultural connectedness among Native Hawaiian/Pacific Islander, Asian American, and Filipino American young adults in Hawai'i

Tobacco product use rates among Native Hawaiian/Pacific Islander (NHPI), Asian American, and Filipino American young adults in Hawai'i have risen rapidly in recent years following the introduction of electronic nicotine delivery systems. Though some research has examined tobacco use correlates for these demographics of young adults, research examining protective factors, such as cultural connectedness, is lacking. Additionally, research that disaggregates Asian Americans from Pacific Islanders is scarce, despite the differing risk and protective factors that have been determined for each group. This study separately examined cultural connectedness among NHPIs, Asian Americans, and Filipino Americans to help fill the gaps in the current tobacco product literature. The findings indicated that Asian Americans and Filipino Americans who identify more with their own cultures are less likely to use e-cigarettes; however, this relationship was not supported for NHPIs. No significant evidence was found to indicate a relationship between cultural connectedness and combustible cigarette use among any of the sampled groups. The lack of relationship between cultural connectedness and e-cigarette use among Native Hawaiians may be explained by measurement limitations in the study, and suggest the need for more culturally competent scales (e.g., an enculturation scale) that account for Indigenous status.

Cultural efficacy as a novel component of understanding linkages between culture and mental health in Indigenous communities

We used a novel measure of cultural efficacy to examine empirical pathways between enculturation, efficacy, and two wellbeing outcomes. Cultural factors are not consistently linked to better wellbeing in the academic literature despite widespread understanding of these processes in Indigenous communities. Healing pathways is a community-based participatory study with eight reservations/reserves in the upper Midwest and Canada. This study uses data collected in 2017-2018 (n = 453, 58.1% women, mean age = 26.3 years) and structural equation modeling to test the relationships between enculturation, cultural efficacy, and mental health. The direct effect of enculturation on anxiety was positive. The indirect effect of enculturation via cultural efficacy was negatively associated with anxiety and positively associated with positive mental health. Cultural efficacy is an important linking variable through which the protective effects of culture manifest. The complex nature of culture must be met with innovative measures and deep understanding of Indigenous peoples to fully capture the protective role of culture.

Does community cultural connectedness reduce the influence of area disadvantage on Aboriginal & Torres Strait Islander young peoples' suicide?

OBJECTIVE

The study aimed to examine associations of community cultural connectedness with Aboriginal and Torres Strait Islander young peoples' suicide rates in areas with elevated risk factors.

METHODS

Age-specific suicide rates (ASSRs) were calculated using suicides recorded by the Queensland Suicide Register (QSR) of Aboriginal and Torres Strait Islander young people (aged 15-24 years) in Queensland from 2001-2015. Rate Ratios (RRs) compared young peoples' suicide rates in areas with high and low levels of cultural connectedness indicators (cultural social capital and Indigenous language use) within areas with elevated risk factors (high rates of discrimination, low socioeconomic resources, and remoteness).

RESULTS

Within low socioeconomically resourced areas and where Aboriginal and Torres Strait Islander people experienced more discrimination, greater engagement and involvement with cultural events, ceremonies and organisations was associated with 36% and 47% lower young peoples' suicide rates respectively (RR=1.57, 95%CI=1.13-2.21, p=<0.01; RR=1.88, 95%CI=1.25-2.89, p=<0.01). Within remote and regional areas, higher levels of community language use was associated with 26% lower suicide rates (RR=1.35, 95%CI=1-1.93, p=0.04), and in communities experiencing more discrimination, language use was associated with 34% lower rates (RR=1.53, 95%CI=1.01-2.37, p=0.04).

CONCLUSION

Cultural connectedness indicators were associated with lower Aboriginal and Torres Strait Islander young peoples' suicide rates in communities experiencing the most disadvantage. Implications for public health: This provides initial evidence for trialling and evaluating interventions using cultural practices and engagement to mitigate against the impacts of community risk factors on Aboriginal and Torres Islander suicide.

First, Do No Harm: From Diversity and Inclusion to Equity and Anti-racism in Interpersonal Violence Research and Scholarship

This article aims to support interpersonal violence (IPV) researchers in promoting diversity and inclusion in their research and scholarship and urges the IPV field to advance a racial equity, anti-oppressive, and justice-driven research agenda. The article discusses a range of factors to consider at each stage of the research process as researchers seek to be inclusive, responsive to diversity concerns, and seek equity. The researcher's perspective and positionality are discussed and the importance of critical self-examination of one's position in relation to the research is emphasized. Participatory and collaborative research processes are recommended, to engage with community partners, strengthen the validity of the findings, and help ensure that the research benefits the participants. Examples illustrate ways researchers might support diversity and inclusion with respect to sampling and measurement, cultural validity, and the conceptualization and operationalization of race. Recommendations are offered to promote diversity, equity, and inclusion when analyzing data, interpreting results, and writing up the study. The importance of a strengths-based approach and structural level analysis is emphasized. This article goes beyond discussion of the minimum, "do no harm" standard that researchers should meet in attending to diversity and inclusion in research and urges the pursuit of equity, anti-racism, and justice toward dismantling those structures that perpetuate violence in its many forms. Researchers are encouraged to ask themselves: Where would I situate my research? Is it racist, not racist, or anti-racist? Not all IPV research has the goal of dismantling inequities, but we should aspire that it do so.

Family as the Conduit to Promote Indigenous Women and Men's Enculturation and Wellness: "I wish I had learned earlier"

The purpose of this article is to explore how food and other cultural traditions promote wellness, cultural continuity, enculturation, and family resilience within tribal communities in the U.S. Using the Framework of Historical Oppression, Resilience, and Transcendence (FHORT), this critical ethnography examines Indigenous peoples' perspectives on and experiences with food and cultural traditions. Thematic analysis of data from 436 participants (approximately 2/3rds of which were women) across two Southeastern tribes revealed a theme of "fostering the transmission of tribal knowledge and intergenerational family bonding." Traditions such as dancing, food, sewing, beadwork, basket-weaving, music, and tribal sports were some important facets of tribal culture that participants described. Food and cultural practices promoted wellness, pro-social values, and health by fostering physical activity, traditional food practices, enculturation, and social support. Cultural practices offset historical oppression and health disparities. Programs that utilize the strengths of experiential learning through family and cultural practices are highly recommended.

Healing of the canoe: preliminary results of a culturally tailored intervention to prevent substance abuse and promote tribal identity for Native youth in two Pacific Northwest tribes

Using Community-based and Tribal Participatory Research (CBPR/TPR) approaches, an academic-tribal partnership between the University of Washington Alcohol and Drug Abuse Institute and the Suquamish and Port Gamble S'Klallam Tribes developed a culturally grounded social skills intervention to promote increased cultural belonging and prevent substance abuse among tribal youth. Participation in the intervention, which used the Canoe Journey as a metaphor for life, was associated with increased hope, optimism, and self-efficacy and with reduced substance use, as well as with higher levels of cultural identity and knowledge about alcohol and drugs among high school-age tribal youth. These results provide preliminary support for the intervention curricula in promoting positive youth development, an optimistic future orientation, and the reduction of substance use among Native youth.

Narrative descriptions of miyo-mahcihoyān (physical, emotional, mental, and spiritual well-being) from a contemporary néhiyawak (Plains Cree) perspective

Background

There are unequivocal health disparities, both physical and mental, between the Indigenous and non-Indigenous peoples of Canada.

Methods

Utilizing narrative inquiry, 15 néhiyawak (Plains Cree people) between 18 and 71 years of age from Thunderchild First Nation were interviewed to explore what improved their mental health and well-being and what they needed to attain optimal mental health and well-being. By posing questions that focused on the positive, the strengths and resilience of the néhiyawak came to the forefront.

Results

Narrative thematic analysis of interview data consistently revealed four overarching themes that highlighted what positively impacted néhiyawak mental health and well-being and their perceived needs to attain optimal mental health and well-being: relationships; spiritual beliefs and cultural practices; tānisīsi wāpahtaman pimātisiwin (worldview); and ēkwa ōhi kikwaya piko ka-ispayiki kīspin ka-nohtē-miyo-mahcihoyān (these are the things that need to happen if I want to be healthy). The néhiyawak in this study described holistic health determinants that correlate with the medicine wheel and the determinants of health, and described these holistic health determinants as making a positive difference to their mental health and as necessary for them to obtain optimal mental health and well-being.

Conclusions

These results suggest that mental health programming and interventions should be harmonious with Indigenous culture; utilize a holistic approach that takes physical, emotional, mental, and spiritual well-being into consideration; and address the existing mental health disparities using the determinants of health as a framework, with an increased focus on the current socio-economic status of Indigenous peoples in Canada.

Indigenous Approaches to Health Promotion: Challenges for Education Support in South Africa

This article explores whether and how an integrated approach to health promotion, which draws on indigenous and other worldviews and approaches, can be developed to address more effectively biopsychosocial challenges that constitute barriers to learning and development in education contexts. More specifically, the article aims to investigate whether and how indigenous perspectives to health promotion have been incorporated into support services in Native American contexts and what lessons can be learnt from this for the South African context. An analysis of relevant literature and interviews with 25 key informants in Native American contexts in the United States highlighted the following key challenges relating to incorporating different views of and approaches to health promotion in education in South Africa: facilitating ‘paradigm shifting’ or mindset change; addressing power dynamics relating to ongoing colonialism; developing culturally responsive education support services and life skills education curricula; and developing strong school–community partnerships. The article argues that these challenges could be successfully pursued within a South African health promoting schools framework that reflects the different perspectives of role players in this context.

Problem-gambling severity and psychiatric disorders among American-Indian/Alaska native adults

INTRODUCTION

Little is known about the association between problem-gambling severity and psychiatric disorders among American-Indian/Alaska-Native (AI/AN) individuals. Thus, we examined these factors among a nationally representative sample of AI/AN and other American adults in the USA.

METHOD

Using the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) data, we conducted separate Wald tests and multinomial logistic regression analyses comparing AI/AN to black/African American, white/Caucasian, and all other racial/ethnic groups, respectively.

RESULTS

Relative to other American adults, AI/AN adults were least likely to report non-/low-frequency gambling (NG: AI/AN 66.5%, white/Caucasian 70.5%, black/African American 72.8%, other racial/ethnic group 72.3%) and most likely to report low-risk gambling (LRG: AI/AN 30.1%, white/Caucasian 26.5%, black/African American 23.4%, other racial/ethnic group 24.7%). The association between at-risk/problem-gambling (ARPG) and any past-year Axis-I disorder was stronger among AI/AN versus other American adults. Although ARPG and LRG were associated with multiple past-year Axis-I and lifetime Axis-II psychiatric disorders in both AI/AN and other American adults, LRG was more strongly associated with both Axis-I disorders (particularly major depression, generalized anxiety disorder and nicotine dependence) and Cluster-B Axis-II (particularly antisocial personality disorder) disorders in AI/AN versus other American adults.

DISCUSSION

A stronger association between problem-gambling severity and past-year psychiatric disorders among AI/AN relative to other American adults suggests the importance of enhancing mental health and problem-gambling prevention and treatment strategies that may help AI/AN individuals.

Sociocultural Influences on Gambling and Alcohol Use Among Native Americans in the United States

Gambling opportunities on and near Native American lands have increased in recent decades; yet there is a lack of research examining the patterns of problem gambling and alcohol abuse among Native Americans in the US. Traditional Native American cultural identity may be a protective factor for problem gambling and alcohol abuse among Native Americans. Telephone interviews were conducted with 415 Native American adults aged 18 years and older across the US. The past-year prevalence of gambling among Native Americans is similar to the rate for non-Native Americans in the US (80 vs. 77%). However, Native Americans have over twice the rate of problem gambling as the US sample (18 vs. 8%). Although Native Americans have a lower rate of past-year alcohol use than the US population (47 vs. 68%), they have a somewhat higher rate of alcohol abuse than their US counterparts (5.5 vs. 4.3%). Logistic regression analysis, with problem gambling as the dependent variable, revealed that lower socioeconomic status is significantly associated with an increased odds of problem gambling for Native Americans. Counter to the hypothesis, the higher the score on the Native American orientation, the higher the odds of being a problem gambler. Further, living by the "White way of life" was associated with a decreased odds of being a problem gambler; and perceived gambling convenience was associated with an increased odds of being a problem gambler. None of the Native American factors was significant in predicting alcohol abuse. These findings highlight the need for further investigation into the influence of cultural factors on Native American gambling.

Intergenerational patterns of substance abuse among urban American Indian families

Substance abuse continues to be a family problem in American Indian (AI) families. This article highlights findings from a two generation study on substance abuse among nine AI families. Five common themes shared by the parent and adult child groups included early onset of substance abuse, minimization of substance abuse (and a subtheme of efforts to control use), taking accountability for substance abuse (and a subtheme about perpetuated stereotypes), turning point moments in use (and a subtheme of negotiating and exploring sobriety), and perceptions of the abstinence only approach. Clinical implications are discussed in light of the findings.

Ethnic Identity and Orientation to White American Culture Are Linked to Well-Being Among American Indians – But in Different Ways

This study examined the relationship between ethnic identity, orientation toward the White mainstream culture, and psychological well-being among American Indians. In the light of the unique history of American Indians, we investigated the relationship between identification with the American Indian ingroup, orientation toward the dominant White American culture (in terms of showing behavior typical for White mainstream culture as well as positive attitudes and feelings of belonging to White American culture), and self-efficacy and learned helplessness as indicators of psychological well-being. Structural equation analyses with an adolescent and an adult sample revealed a positive relationship between ethnic identity and self-efficacy but no link with learned helplessness. The tendency to show behavior typical for White mainstream culture was associated with higher self-efficacy in both samples and with lower helplessness in the adult subsample. White American orientation in the form of positive attitudes and sense of belonging were associated with higher helplessness in both samples and with lower self-efficacy among adults. The findings are discussed in terms of the role of both ethnic identity and the orientation toward the mainstream culture for well-being among American Indians, focusing on the distinct relations of White American behavior versus White American affiliation with well-being in American Indians.

The Healthy Children, Strong Families intervention: design and community participation

Healthy Children, Strong Families (HCSF) is a 2-year, community-driven, family-based randomized controlled trial of a healthy lifestyles intervention conducted in partnership with four Wisconsin American Indian tribes. HCSF is composed of 1 year of targeted home visits to deliver nutritional and physical activity curricula. During Year 1, trained community mentors work with 2-5-year-old American Indian children and their primary caregivers to promote goal-based behavior change. During Year 2, intervention families receive monthly newsletters and attend monthly group meetings to participate in activities designed to reinforce and sustain changes made in Year 1. Control families receive only curricula materials during Year 1 and monthly newsletters during Year 2. Each of the two arms of the study comprises 60 families. Primary outcomes are decreased child body mass index (BMI) z-score and decreased primary caregiver BMI. Secondary outcomes include: increased fruit/vegetable consumption, decreased TV viewing, increased physical activity, decreased soda/sweetened drink consumption, improved primary caregiver biochemical indices, and increased primary caregiver self-efficacy to adopt healthy behaviors. Using community-based participatory research and our history of university-tribal partnerships, the community and academic researchers jointly designed this randomized trial. This article describes the study design and data collection strategies, including outcome measures, with emphasis on the communities' input in all aspects of the research.

Feasibility, Acceptability, and Initial Findings from a Community-Based Cultural Mental Health Intervention for American Indian Youth and Their Families

Through a CBPR partnership, university and American Indian (AI) tribal members developed and tested Our Life intervention to promote mental health of AI youth and their families by addressing root causes of violence, trauma, and substance abuse. Based on premises that well-being is built on a foundation of traditional cultural beliefs and practices, and that it requires a process of healing and understanding, the 6-month intervention had four components: 1) recognizing/healing historical trauma; 2) reconnecting to traditional culture; 3) parenting/social skill-building; and 4) strengthening family relationships through equine-assisted activities. Feasibility, acceptability, appropriateness, and preliminary outcomes were examined in a mixed-method within-group design. Engagement and retention were challenging, suggesting that families faced numerous barriers to participation. Youth who completed the program experienced significant increases in cultural identity, self-esteem, positive coping strategies, quality of life, and social adjustment. Qualitative data supported these findings and suggested additional positive effects.

The relationship between internalizing and externalizing symptoms and cultural resilience factors in Indigenous Sami youth from Arctic Norway

OBJECTIVES

To examine whether enculturation factors, like cultural activities, ethnic pride and native language competence, are related to decreased internalizing and externalizing symptoms in Indigenous Sami youth from Arctic Norway. The impact of self-efficacy on the relationship between enculturation factors and mental health problems was also examined.

STUDY DESIGN

Population-based, cross-sectional questionnaire study.

METHODS

The Norwegian Arctic Adolescent Health Study was conducted among 10th graders in junior high schools in north Norway during 2003-2005. The study sample consisted of 450 Indigenous Sami youth, aged 15-16 years. Internalizing symptoms were measured with the Hopkins Symptom Check List-10 (HSCL-10), while externalizing symptoms were measured by two subscales of the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

For boys, self-efficacy and participation in cultural activities were associated with decreased internalizing symptoms. Additionally, self-efficacy interacted with Sami language competence and cultural activities: when self-efficacy increased, these enculturation factors were related to symptom reduction. For girls, self-efficacy had an independent effect on internalizing symptoms and also strengthened the relationship between participation in cultural activities and reduced externalizing symptoms. Sami language competence was related to the reduction of both internalizing and externalizing symptoms in girls.

CONCLUSIONS

In the present study, several enculturation factors as well as self-efficacy were identified as potential protective factors against mental health problems. In order to develop theoretical models that explain the mechanisms between cultural resilience and mental health, there is a need for both qualitative studies and longitudinal studies.

The impact of scientific information on ecosystem management: making sense of the contextual gap between information providers and decision makers

Scientific information is not always effectively incorporated into decision-making processes. This phenomenon seems to hold even when the information is aligned with an articulated need, is generated according to sound scientific procedures, and is packaged with end-user preferences in mind. We propose that contextual or cultural differences contribute significantly to the misalignment in communication between those who generate information and those who seek information for improved management of natural resources. The solution is to cultivate shared understanding, which in turn relies on acknowledgment and sharing of diverse values and attitudes. This constitutes a difficult challenge in a culturally diverse environment. Whereas cultural diversity represents wealth in experiences, knowledge and perspectives it can constrain the potential to develop the shared understandings necessary for effective integration of new information. This article illustrates how a lack of shared understanding among participants engaged in a resource-management process can produce and perpetuate divergent views of the world, to the extent that information and knowledge flows are ineffective and scientific information, even when requested, cannot be used effectively. Four themes were distilled from interviews with management and scientific staff of a natural resource-management agency in South Africa. The themes are used to illustrate how divergent views embedded in different cultures can discourage alignment of effort toward a common purpose. The article then presents a sense-making framework to illustrate the potential for developing shared understandings in a culturally diverse world.

Parents' ethnic-racial socialization practices: a review of research and directions for future study

Recently, there has been an emergence of literature on the mechanisms through which parents transmit information, values, and perspectives about ethnicity and race to their children, commonly referred to as racial or ethnic socialization. This literature has sought to document the nature of such socialization, its antecedents in parents' and children's characteristics and experiences, and its consequences for children's well-being and development. In this article, the authors integrate and synthesize what is known about racial and ethnic socialization on the basis of current empirical research, examining studies concerning its nature and frequency; its child, parent, and ecological predictors; and its consequences for children's development, including ethnic identity, self-esteem, coping with discrimination, academic achievement, and psychosocial well-being. The authors also discuss conceptual and methodological limitations of the literature and suggest directions for future research.

Traumatic events and alcohol use disorders among American Indian adolescents and young adults

This study examined the relationship between severe traumatic events and alcohol use disorders in American Indian adolescents and young adults. Interviews of 432 adolescents and young adults who were enrolled tribal members living on or near two closely related American Indian reservations were used. Results indicated that severe trauma increased the odds of alcohol use disorders (p <.001), with the number of traumas having a dose-dependent effect. The authors conclude that trauma is associated with alcohol use disorders in this population. This study's findings yield important insights into the risks in American Indian adolescents and young adults that may result from early trauma, as well as implications for the timing and possible settings for intervention.

Measures of psychological acculturation: a review

This article reviews conceptual and methodological issues in the measurement of psychological acculturation. The major issues involve the question of dimensionality and the assessment of specific domains of cultural change. Bidimensional scales that cover both overt and internal domains are more informative for the assessment of general levels of psychological acculturation. The validity of such scales must be examined in terms of the actual exposure of individuals to and involvement in each culture, and the influence of sociocultural factors on the course of acculturation. The parallel application of qualitative and quantitative methods may be useful for validity studies. The complementary use of emic and etic approaches will enhance the psychometric soundness of acculturation scales.

The implications of ecologically based assessment for primary prevention with indigenous youth populations

This paper describes a five-stage approach toward conducting an ecologically based assessment with Indigenous youth populations, and the implications of this approach for the development and implementation of culturally grounded prevention interventions. A description of a pilot study funded by the National Institutes of Health/National Institute on Drug Abuse (NIH/NIDA) focused on drug use and American Indian youth is presented as one model for operationalizing ecologically based assessment with Indigenous youth populations, and issues related to translating the pilot study into a prevention intervention are discussed. This paper suggests that ecologically based assessment can serve as a foundation for culturally grounded prevention interventions, promoting the social and ecological validity of those interventions.

Ego development and ethnic identity formation in rural American Indian adolescents

Ethnic identity development was assessed in the context of ego development in 12- to 15-year-old students from a Southeastern American Indian community. Self-protective was the modal level and was characterized by awareness of ethnic group membership but little exploration or self-reflection. Impulsive adolescents had the least developed ethnic identities and highest levels of interpersonal vulnerability. Conformist adolescents expressed positive feelings about ethnic group affiliation, described relationships as harmonious, but demonstrated moderate social anxiety. Postconformist adolescents had the highest levels of agency, social competence, and identity achievement, but also had high levels of psychological distress and family conflict. Adolescent identity strivings may be understood in context with the level and timing of psychosocial maturity, for which ego development appears a useful marker.

HIV/AIDS prevention in "Indian country": current practice, indigenist etiology models, and postcolonial approaches to change

Many tribal and urban American Indians and Alaska Native communities have initiated HIV/AIDS prevention and treatment services. The richness, depth, and scope of these efforts, however, are not well known and have not been sufficiently documented in the academic literature. In this article we assess the strengths and weakness of the published literature using the constructs of the socioecological framework. We discuss the need to apply an "indigenist" etiology paradigm to HIV/AIDS risk and protection. Finally, we define and discuss the varied postcolonial approaches to HIV/AIDS prevention, treatment, and healing.

Sense of Belonging in School as a Protective Factor Against Drug Abuse Among Native American Urban Adolescents

This article presents the results of a study conducted with 243 Native American students who were part of a multi-ethnic sample of adolescents attending middle school in a large urban center in the Southwest region of the United States. Native adolescents who felt a stronger sense of belonging in their school were found to report a lower lifetime use of alcohol and cigarettes, lower cigarette and marijuana use in the previous month, lower frequency of current use of these substances, fewer substances ever used, and a later age of initiation into drug use than other Native students. Research implications are discussed in relationship to school environment, culturally-grounded prevention curricula, and school social work practice.

Reconceptualizing native women's health: an "indigenist" stress-coping model

This commentary presents an "indigenist" model of Native women's health, a stress-coping paradigm that situates Native women's health within the larger context of their status as a colonized people. The model is grounded in empirical evidence that traumas such as the "soul wound" of historical and contemporary discrimination among Native women influence health and mental health outcomes. The preliminary model also incorporates cultural resilience, including as moderators identity, enculturation, spiritual coping, and traditional healing practices. Current epidemiological data on Native women's general health and mental health are reconsidered within the framework of this model.

Assessing mental capacity in Canadian Aboriginal seniors

In recent years, researchers and practitioners have begun to modify existing cognitive assessment instruments and develop new tools in order to increase the accuracy of mental capacity evaluations among seniors in cross-cultural settings. Based on a review of the literature and consultations with members of the Aboriginal capacity assessment committee at the Royal Alexandra Hospital in Edmonton, Canada, during the summer of 1998, the authors argue that both the process by which capacity assessments are conducted and the content of the assessment instruments are problematic. The article summarizes the difficulties that differing degrees of acculturation within and between Aboriginal groups create for cognitive evaluations. It recommends steps that mental health professionals can follow to develop meaningful assessment strategies for Aboriginal seniors that reflect both the content and the interactional processes that characterize their traditional cultural orientations.

Culturally competent care

OBJECTIVES

To define key concepts and summarize available guidelines that are important resources to assist nurses to provide culturally competent care.

DATA SOURCES

Medline, anthropologic and epidemiologic literature, and National Institutes of Health documents.

CONCLUSIONS

Controversy remains about the most appropriate language to use to describe features of diverse populations.

IMPLICATIONS FOR NURSING PRACTICE

Becoming culturally competent begins by understanding terms and concepts that are essential in developing cultural awareness, knowledge, and skills. Sensitivity to language and the history of the development of some labels are important.