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Health Education Theoretical Models and Multicultural Populations 117

that explains illness, disease, and course of treatment from a cultural point of view
(Nakamura, 1999). For example, some racial and ethnic groups perceive and explain
the cause of illness and disease in terms of “ soul loss, ” “ spirit possession, ” and “ spells ”
(Spector, 2004). Similarly, some groups describe diseases as the consequences of an
individual ’ s personal actions or interrelationship with family and community or as
related to supernatural agents (Huff, 1999); thus members of these groups would be
more likely to follow a nontraditional treatment modality to deal with the disease than
they would be to visit a health care provider. In addition the perceptions an ethnic
group has of the Western health care system will affect access to health care and pro-
motion services. “ If target group members perceive the Western health care facility as
a ‘ death house ’ where family or friends go in alive and come out dead, . . . then they
will be more likely to avoid contact with this type of facility except under the most dire
situation ” (Huff & Kline, 1999, p. 495). Health educators must be aware of racial and
ethnic groups ’ understanding of health and illness, their health practices, and ways that
group views can be incorporated into health promotion interventions.
Finally, this model proposes an assessment of the Western health care organiza-
tion and the service delivery system that provide services to multicultural groups.
Although some may consider this area a separate assessment, Huff and Kline (1999)
argue that the way the health care and promotion organization perceives and works
with the target group plays a key role in the overall assessment process. This process
must include assessment of the cultural competence and sensitivity of the agency and
its staff, assessment of the extent to which organizational mission and policies enhance
the process of cultural competence, and assessment of the evaluation processes in
place to measure organizational efforts in this area. Although this process might be
cumbersome, it is important for health promoters to understand the agency if they are
to develop appropriate and effective health promotion programs.

The PEN - 3 Model
The PEN - 3 model was developed by Airhihenbuwa (1995) as a conceptual model for

health promotion and disease prevention in African countries, specifically to guide a cul-
tural approach to HIV/AIDS, and then it was adapted for use with African Americans.
The PEN - 3 model provides a functional method of addressing culture in the develop-
ment, implementation, and evaluation of health education and promotion programs.
Although this model draws on theories and applications in cultural studies, it incorpo-
rates existing health education models, theories, and frameworks. Initially, the PEN - 3
model included three dimensions of health beliefs and behaviors: health education, edu-
cational diagnosis of health behavior, and cultural appropriateness of health behavior.
The revised PEN - 3 model, presented in Figure 6.2 , consists of three primary domains —
cultural identity, relationships and expectations, and cultural empowerment — and three
components (whose initial letters spell PEN) within each domain (Airhihenbuwa &

DeWitt Webster, 2004). Once health educators and practitioners have identified a health
issue, they can frame relevant sociocultural issues into the nine categories displayed
in Figure 6.2 .

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