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“Canada is not a melting pot in which the individuality of each element is destroyed in order to produce a new and totally different element. It is rather a garden into which have been transplanted the hardiest and brightest flowers from many lands, each retaining in its new environment the best of the qualities for which it was loved and prized in its native land.”
– John Diefenbaker, prime minister of Canada (1957-1963). Canada is a country that is differentiated by a tradition of continued and changing settlement. There are the original inhabitants; the Aboriginal people, as well as the more socially dominant Anglo-Canadian population, descendants of the settlers who came here from countries in Europe during the colonial era and in more recent times, immigrants who have arrived from a range of countries across the globe. Today, Canada’s population represents citizens who originate from more than 150 different countries, who speak over 100 languages and practice over several religions.
Canada is recognized as a multicultural nation. Multiculturalism requires that each culture is considered equal to the other and cultural diversity is tolerated (Francis, 1999, Brannigan, 2000) FIND STATS.
Nursing is a vocation that engages at its most basic level with individuals, their families and communities (Allman, 1992). The delivery of nursing care is a significantly social activity. Nurses are in constant and close interaction with others and all aspects of nursing needs a high degree of interpersonal communication (Pallen, 2000). Nurses need to know how to effectively relate to and communicate with those patients in their care (Pallen, 2000). Nursing is associated with the physical, technical and social behavior: ‘nurses need to know what to do with clients, how to do it and know how to be while they are doing it” (Stein-Parbey, 2008, p.3) To accomplish optimistic outcomes when working with patients from diverse variety of cultural backgrounds, nurses must cultivate their understanding of that multifaceted cultural diversity and integrate it within their practice (Greenwood, 1996 FIND NON-AUSSIE).
The social environment within which nursing takes place in Canada is multicultural (no ref). This should motivate a need for nurses to develop cultivate and advance a deeper understanding of cultural diversity, due to its potential effect on the delivery of nursing care specifically and the consequences for healthcare (no ref). Historically, nursing care in Canada was provided by nurses of Anglo-Saxon origin and today nurses work in a healthcare system developed during the era of British Colonization which was has an enduring tradition in western values and ideology (no ref). It has become apparent in recent years that the growing cultural diversity has challenged much of these long-established assumptions about health, illness and health care provision. FIND INFO. Read more in this paragraph please.
It continues to be challenging for nurses in Canada and other Anglocentric counties, to find ways to accommodate the divergent and often unfamiliar social beliefs, values and life practices that have no become a part of the new social fabric of their communities. Nursing scholars and clinicians around the Western world identify and articulate a need to develop greater understanding about cultural care capacity, but they remain unsure about how to increase their knowledge of and ability to work with ethnically and socially diverse patient groups (Murphy & MacLeod, 1993; Bond, Kardong-Edgren & Jones, 2001; Grant & Letzring, 2003; Sergent, Sedlak & Martsolf, 2005; Allen, 2006). The capacity to provide appropriate cross-cultural care must be an essential attribute of contemporary nursing practice. If nurses are to be effective in meeting the needs of their patients, nursing practices must be better informed and modified to address a wider cultural range of patients. There is a growing need for suitable knowledge base that encompasses the requirements of education, research and practice and this paper seeks to offer nurses an examination and critique of Leininger’s transcultural nursing theory that underpins transcultural nursing. Someone and someone describe the gradual move toward a cross-cultural approach to nursing practice in Canada as a deep form of change and this paper will demonstrate the current position of nursing in Canada towards providing adequate and appropriate cultural care and explores the future of cross cultural nursing care.
Madeleine Leininger is broadly recognized as the founder of cultural theory in nursing. Leininger started writing in the 1960’s and her theory of transcultural nursing, also known as Culture Care Diversity and Universality, has turned out to be groundbreaking work in the nursing arena and been extensively implemented in western countries (Andrews & Boyle, 1995; Papadopoulos, 2004; Price & Cortis, 2000; Fawcett, 2002; Lister, 1999; Chinn, 1991; Cohen, 2000; Cooney, 1994; Narayanaswamy & White, 2005; Rajan, 1995; Chevannes, 2002; Coup, 1996; Culley, 1996). As Andrews (2008) proposes, “Transcultural nurses have taken action and are transforming nursing and healthcare in many places in the world” (p.13). Leininger’s theory has not only advanced her own philosophy but has founded the development of transcultural nursing and a number of later models that have contributed to transcultural nursing today. (Purnell & Paulanka, 2003; Geiger & Davidhizar, 2002; Papadopoulos, Tilki & Ayling, 2008; Andrews & Boyle, 2002; Spector, 2000; Camphina-Bacote, 1999).
Leininger was the first nurse to formally explore the relationship between patients and their different ethnic backgrounds. She recognized that a patient’s ethnicity had the potential to impact on health and illness. Leininger proposed that nurses might be more effective in their role if they developed a deeper understanding of the relationship between ethnicity and health. Leininger describes herself as an anthropologist and a nurse. She holds a PhD in Cultural Anthropology and wrote her theory while studying in that field. In 1969 Leininger established the first course in transcultural nursing in the United States and in 1977 initiated the first master’s and doctoral programs specific to that field. During her career, Leininger has written 27 books, published over 200 articles and authored 45 book chapters (Marriner-Tomey & Alligood, 2006).
Leininger originally worked as a children’s nurse in a psychiatric setting and noted that of” children who came from diverse cultural backgrounds such as Afro-American, Spanish-Americanâ€¦their overt behaviors clearly differed” (Leininger, 1978, p.21). These observations lead Leininger to develop an interest in anthropology. “I learnt that culture was a significant influence on behaviorsâ€¦and I began to understand the important links between nursing and anthropology” (p.23). Leininger’s goal was to investigate her belief that a patient’s ethnic background profoundly influenced their understanding of health and illness, which is turn determined the type of nursing care required by individuals. Leininger (1978) considered that “nurses tended to rely on uni-cultural professional values which are largely defined from our dominant Anglo-American caring values and therefore unsuited for use in the nursing of people from other cultures” (p.11).
Leininger came to consider that belief systems from other cultures needed to be described and understood in order for the predominately Anglo-American nurses to America to make predictions about the health beliefs, and so anticipate the care needs, of groups from cultures, other than their own (Leininger, 1978). From her studies in anthropology, Leininger’s theory of cultural care was published in 1967 and over a 40 year plan it has been further developed and refined. Subsequently, the theory of Culture Care Diversity and Universality emerged. As Daly and Jackson (2003) write, “the theory was to discover what in universal(commonalities) and what is diverse about human care values, beliefs and practices” (pxiii). This led to what is known as the transcultural nursing approach which Leininger considers ‘ethno-nursing’ and the design of a research methodology deemed ‘ethno-science’ was developed to collect cultural data. Ethno science provided a means “to obtain local or indigenous peoples’ viewpoints, beliefs and practices about nursing care or the modes of caring behaviors and processes of the designated cultural group” for use in providing nursing care (specifically ethno-nursing) to that particular group (Leininger, 1978, p.15). The ethno-science reach method involves the nurse researcher undertaking ethnographic study using direct observation and the interviewing of selected ‘culture bearing individuals’ from within a specific ethnic group, to gain data sets from the ’emic’ or insider perspective (Leininger, 1978). The nurse from the ‘etic’ or outside group can then understand the perpective of the ’emic’ group, combine it with the nursing philosophy of caring and use that to modify or vary nursing care and making it more appropriate. A body of knowledge is built up and maintained over time which contains the different cultural nuances, values and beliefs embedded in different ethnic groups and this is then used by nurses and can be relied upon to guide their practice. In 1992, Leininger claimed that more than 3000 international studies have been conducted, with over 300 ethnic groups having been researched and chronicled (Leininger, 1978).
Leininger later developed the ‘Sunrise Model; (1991). This is a cognitive map to support and guide nursing practice. Culture Care Diversity and Universality is illustrated in this model and it provides a framework for mapping and understanding a culture or subculture. As Omeri (2003) explains: “The model demonstrates the different domains of the theory and is designed to guide the discovery of new transcultural knowledge through the identification and examination of the culturally universal. The model is holistic and addresses worldview, cultural values, beliefs and lifeways, cultural and social structural factors, it focuses on individuals, groups and institutions. It allows for examining generic (folk) as well as professional care (the nurse)â€¦implementing the theory stimulates nurses, as carers and researchers to reflect upon their own cultural values and beliefs and how they might influence the provision of care.
In her early work, Leininger (1970) adopted an all-embracing definition of culture, in the tradition of anthropology, which comprised of “the total complex of material objects, tools, ideas, organizations, and material and non-material aspects related to man’s existence” (p.11). Leininger (1993) modified this original definition of culture to become more inclusive or the values and beliefs and she also began to refer to “the learned, shared and transmitted values, beliefs, norms and life ways of a particular group that guide their thinking, decisions and actions in patterned ways” and “the ways of life of the members of a society, or of groups within a society”(p.9). From its beginning, transcultural nursing has existed within a framework of race and ethnicity, with the fundamental promise that the term ‘culture’ refers primarily, if not exclusively to ethnicity. Labelling by ethnicity is a position fundamental to Leininger’s work (Leininger, 1988). In which she frequently referred to people of ‘different ethnic origins” (p.107), “people of color” and “ethnic groups of color” (Leininger, 1978, p.451).
The background to her work was derived in an essential way from, and in embedded in, anthropology and the concept of care is drawn from nursing. Leininger (1970) acknowledged the influence of anthropology on her work when she wrote, “nursing and anthropology are inified in a single specific and unitary whole” (p.2). Leininger felt that the anthropology’s most important contribution to nursing was to provide a foundation for the claim that health and illness states are primarily determined by the cultural background of the individual (Leininger, 1970, 1978) Her theory is in accord with the anthropological models that dominated in the 1960’s when Leininger first undertook fieldwork in Papua Guinea, a study which she still continues to reference some 40 years later (Leininger & McFarland, 2003).
The goal of transcultural nursing is to provide “culturally congruent, sensitive and competent nursing care” (Leininger, 1995, p.4). Culturally congruent care occurs when there is a meaningful and satisfactory match between the culture care beliefs, values and practices of the patient and the behavior of the nurse. The nurse must preserve, maintain or change nursing care behaviors with the goal of satisfying the needs of clients (Leininger, 1998, 2002) Leininger further defined such nursing action as: culture care preservation and maintenance, culture care accommodation or negotiation and culture care restructuring or re-patterning (Leininger, 1978, 1981, 1984, 1988). To become culturally competent nurses must require preparation and must undertake a course of theoretical study which gives them the ability to carry out etho-science research, culture based assessment and develop the cultural sensitivity required to design and implement culturally relevant nursing interventions (Leininger, 1978, 1981, 1984, 1988, 1995, 1998, 2002).
Social Constructionism of the theory
In the 1950’s, nurses in the United States of America began to develop and use structured theory. These theories offered nurses a new approach to knowledge and provided a means to systematically order, analyze and interpret information and buy, doing so, develop ‘nursing’ knowledge through which nurses might evaluate their thinking and reflect on their actions during patient care ( Pearson, 2007; Nancy Edgecombe) Culture Care diversity and Universality was written in the style of an American mid-range theory of the time and Leininger employed the concepts of ‘person’, ‘environment’, ‘nursing’ and ‘health’ which were popular with American theorists. (Fawcett,2002). I believe, Leininger’s theory was developed in a particular cultural context. According to Nancy Edgecombe, thinking and writing take places in a certain social location that echoes the culture and context of the theorist and this context will inspire the style of ideas development. The USA has a modern history of settlement by immigrants from Europe, Britain and Ireland (Ward, 2003). As a result, Anglo-Celtic customs, beliefs, and values came to underpin the American social structure and control its social institutions, as well as healthcare (Ward, 2003). The American Civil rights movement was just starting to find its footing when Leininger began her work in the 1950’s. Social segregation of the African-American community had just ended in 1954 and the black communities of previous African slaves that were taken from Africa to America 200 years earlier were becoming increasingly expressive about their human rights and were no longer pleased to hold a submissive social position in American society (Ward, 2003). This black community arose to assert its voice as American citizens born in America and entitled to all the rights and benefits as promised by the American Constitution for the citizens of America (Ward, 2003). During the 1960’s and 1970’s, immigrants from less traditional countries such as the Hispanic and Asian communities were settling down in the USA in larger numbers (Gabbacia, 2002). The previous ideal of the ‘melting pot’ culture, where immigrants settling in America were expected to forgo their values and traditions and assimilate into the American way of life, was coming under inquiry (Gleason, 2002). These minority groups were to become substantial and ever increasing groups, thus contributing to the social heterogeneity of America (Gabbacia, 2002). Joining them were the Native American peoples, formally socially dislocated and disempowered during those eras of colonization and immigration. The Native people also wanted to be represented in the new human rights movement and assert equality with the mainstream Americans (Gabbacia, 2002; Price and Cordell, 1994; Naylor, 1997). This rapidly changing social environment and increased awareness of human rights and freedoms was the environment in which Leininger was originally writing. This is also analogous with the swift social change that the nursing world is facing today, on a worldwide scale.
Assumptions of knowledge and truth
Leininger’s point of views and theory resulted from both a nursing and an anthropological background (Leininger, 1995). As her knowledge is derived from two different disciplines it can be considered as being unique. With regards to the ‘type’ of Leininger’s knowledge I assume it to be conceptual knowledge (Schultz & Meleis, 1988). “Conceptual knowledge is abstracted and generalized beyond personal experiences; it explicates the patterns revealed in multiple experiences in multiple situations and articulates them as models or theories.” (Schultz & Meleis, 1988, p. 220). Furthermore, Schultz & Meleis (1988) suggest that a person who uses conceptual knowledge uses knowledge from disciplines other than nursing. Leininger used her anthropological knowledge to develop the cultural knowledge of nurses. Leininger (1995) also discusses the use of her ethnonursing method enabled her (1995) to “obtain the people’s ideas, values, beliefs, and practices of care and contrast them later with nurses’ knowledge “(p. 99), and thereby enrich the cultural knowledge of nursing and nurses.
As described by Andrews and Boyle (2007), numerous authors have identified transcultural nursing as the blending of anthropology and nursing in both theory and practice. However the field of anthropology has undergone a radical transformation of idea and has changes its position significantly over the last 20 yeas regarding patient representation (Marcus and Fischer, 1989). Yet this progression in knowledge seems largely to be unacknowledged within transcultural nursing theory, which has continued to rely on the anthropological constructs originally penned by Leininger. During the 1980’s, anthropology underwent what has been deemed a ‘crisis of representation’ (Clifford & Marcus, 1986; Geertz, 1988; Marcus and Fischer, 1986). Research and writing became more reflexive and researchers sought new methods. Denzin and Lincoln (2008) explain how critical reflections on race, gender, class, power relations and claims to truth inspired these new forms of representation and led to a re-examination of the way in which anthropologists described their own and other people’s experiences. Critical theory, feminist theory, and epistemologies of color now had influence and challenged many long held beliefs about the validity, reliability and objectivity of interpretations previously believed to be accurate, “Many critical ethnographers have replaced the grand positivist vision of speaking from a historically and culturally situated standpointâ€¦because all standpoints represent particular interests and positions and are partial (Foley & Valenzuela, 2005, p.218)
Furthermore, Leininger discusses emic and etic knowledge (Leininger, 2010). Leininger describes them as, “emic knowledge was the natural, local, indigenous root care values. In contrast, etic care knowledge was derived from outsider views of non-local or non-indigenous care values and beliefsâ€¦” (2010, p. 10). What is worrying about this emic knowledge is that this knowledge of the indigenous person is obtained through the researcher’s reinterpretation of narrative and written into the text by the author. So how accurate can the ‘lived experience’ of individuals be clearly understood by a researcher and then extrapolated to represent the ‘lived experience’ of an entire cultural group? Denzin and Lincoln (2008) challenge ethnographers to reconceptualize their approach using new strategies and hew methods of analysis that are cognizant of the contemporary concerns around race, gender, ethnicity and class. The world of the ethnographer today, they claim “is a politically charged space” (p.21) and as a consequence the act of researcher can no longer be viewed from a neutral or ostensibly objective perspective. Given this crisis, which changed the approaches taken to both methodology and method in anthropology, the original ethnographical approach utilized by Leininger and still employed for the methodology of ethno-science and data collection in transcultural nursing, may not be relevant or as able to claim truths as it was once believed.
Leininger (2010) articulates that her knowledge was based on both similarities and differences of one culture to another culture and is supported in her statement, “the most important feature of the theory was to conceptualize culture care by searching for diversities and universalities” (p. 10). She believes that this particular blending of knowledge is not only unique to transcultural nursing but vital to study transcultural nursing (Leininger, 2010). It seems to me that she is comparing the ‘other’ culture to her own. Though this can prove effective in contributing knowledge by comparisons of subjective experiences it could also run into the risk of being biased and possibly not accurate to apply it generally to transcultural nursing knowledge as it is just one person’s, the theorist’s subjective experiences. This again questions the reliability of the results similar to the outdated anthropological approach to ethno-science in nursing.
The way in which people perceive different cultures may be considered true to them and not true to someone else. White (2004) states, “what is count as the truth is constantly contested, but what is not usually contested is that there is truth to be found” (p.10). This applies to Leininger’s theory as there are unknown truths about cultures to be discovered. However, it is the manner in which the information is obtained that brings forth the question of whether or not it is actually true. White (2004) discusses that the study of epistemology is “to figure out what can be recognized as true and not necessarily to present facts” I tried to delve into how Leininger’s assumptions about truth by looking into how she obtained and interpreted her knowledge. Although Leininger claims to not be of the positivism perspective with regard to her theory (Leininger, 1995), I believe that her assumptions of truth could be viewed from a positivism perspective. I think that her assumptions of truth could be viewed from a positivism perspective due to her need for scientific proof to underpin her thinking as she was concerned with the cataloging of the beliefs and practices of various minority ethnic groups as per her research, her articles and her books. Pfeffer (1998) explains this positivist approach to ethnicity in which “facts are observed and boxes are ticked off” (p.1382). Classifications of ethnicity employ mechanisms such as skin color, religion, name, nationality, anything which allows a marker to be developed and people assigned to it in the interests of determining ‘who they are’ and how we must respond to them and their needs. The danger with this approach, she maintains, is that it suggests that everyone designated to a particular group will be believed to experience and understand the world in the same way and it doesn’t take into regard the person’s individuality, only the community/culture the person belongs too. Therefore, Leininger seems to express that one truth or reality may be revealed when examining cultures (Hair & Donoghue, 2009 and Leininger, 1995). The difficulty with truth from a positivism approach is that what is determined to be true is done so from another’s standpoint (Hair & Donoghue, 2009). Hair and Donoghue (2009) support this when they state, “â€¦’root causes’ for behaviors, thoughts, and feelings can be discovered, generalized, and predicted. Moreover, the truth is determined according to knowledge that has been sanctioned by Euro-Western standards and claimed by ‘experts’â€¦” (p. 73).
That is, as Leininger (1995) discusses the importance of understanding the ‘others’ perspective Rajan (1995) contends that, Leininger demonstrates a phenomenological approach (p.452). Moreover, “within the existential -phenomenological philosophy, human beings are viewed as subjects rather than objects” (Rajan, 1995, pg. 452). Leininger (1995) also communicates the importance of being aware of not providing care from an ethnocentric perspective, which is also supported by this philosophy (Rajan, 1995). In addition, the existential perspective acknowledges that culture is derived from values and meanings that contribute to the total being (Rajan, 1995). Rajan (1995) explains that existentialism “gives an account of how an individual consciousness apprehends existence” (p. 452). I believe this particular philosophy is reflective of Leininger’s perspective, especially in the 1960s and 1970s. Leininger acknowledges that the reason she met opposition regarding her theory was as a result of nursing adhering to the medical model which only valued the biophysical and the psychological aspects of humans (Leininger, 1995). However, Leininger realized that there was more to consider, as Crowell supports by acknowledging that although existentialism does not disregard the medical model, it recognizes that it does not completely account for all human existence (2010).
In addition, I think that Leininger’s theory may also be perceived as liberal, humanist perspective (Campesino, 2008). “A humanist perspective emphasizes notions of equality and individual freedom, and operates on an assumption of human commonality among people” (Campesino, 2008, p. 299). This is true of Leininger’s work, for she conveys the importance of culturally appropriate caring in order to meet the needs of other cultures (Leininger, 1995). Leininger (1995) also discusses not only differences between cultures but the need to discover the similarities as well. The liberal humanistic perspective is also perceived as potentially creating problems (Campesino, 2008). That is, if one fails to examine the power differences within the social categories or cultures then it is possible to potentate these differences. This power imbalance is discussed in depth within critical theory (Campesino, 2008). Critical theory recognizes that, “nursing science and practice involves examining ways in which categories of social difference are constructed and operate in structural systems of privilege and power” (Campesino, 2009, p. 300). I question whether Leininger did this, for I could not find any discussion regarding the potential for power difference (Leininger, 1995 & Leininger, 2010 *******ADD MORE REFERENCES HERE). Even with regard to Leininger’s visit to the Gadsup peoples I did not perceive any discussion regarding the possibility of Leininger’s own influence of the visit. Campesino, 2009, contends that privilege, even regarding skin colour, white privilege, can significantly alter relationships. As such, I wonder to what extent Leininger compensated or thought about this influence.
Domains of Nursing
Leininger found the four concepts of person, health, environment and nursing which are the definitive metaparadigm of nursing “questionable, limited, inappropriate, and inadequate to explain or fully discover nursing especially ideas bearing on transcultural nursing” (Leininger & MacFarland, 2006, p.6). The absence of care and culture in the metaparadigm demonstrated to Leininger, the nurses’ limited interest in these concepts or value in studying the aspect of care as a nursing concept. And therefore Leininger’s Culture Care theory focused on the missing phenomena of culture and care as these concepts needed to be discovered in order to comprehend the full nature of nursing (Leininger et al, 2006).
Leininger had some concern with the use of ‘person’ which is one of the four metaparadigms from a transcultural knowledge perspective. In nonwestern cultures, using the term ‘person’ or ‘individual’ may be culturally taboo as it does not agree with the ‘collectivism’ concept of the culture and are too egocentric whereas in western cultures, person and individualism are the dominating concepts. Leininger suggests that the use of ‘person’ in the metaparadigm is questionable as it could lead to “cultural clashes, biases and cultural imposition practices or to serious ethical-moral conflicts” (Leininger et al, 2006, p.9). She suggests the use of the term human being as it is more accepted transculturally and carries respect and dignity for people and I agree with her (Leininger et al, 2006).
The concept of environment is complex and is a multifaceted dimension in all cultures. It requires a very extensive geophysical and social knowledge. The environmental context also includes the ecological, spiritual, sociopolitical, kinship, environmental symbols, and technological dimensions and gives clues about its influences on culture, care expressions, ways of life, health, wellbeing and patterns of living for individuals, families and communities. The environment has to be viewed from a holistic perspective that goes beyond the traditional focus of nurses on the biophysical and emotional environment (Leininger et al, 2006).
The concept of health has great importance in Leininger’s Culture Care theory but has been viewed by Leininger in a different perspective than traditionally implied. In the Culture Care theory health is predicted “as an outcome of using and knowing culturally based care, rather than biophysical or medical procedures and treatments” (Leininger et al, 2006, p.10). Leininger has defined health as “a state of wellbeing that is culturally defined and constituted. Health is a state of being to maintain and the ability to help individuals or groups to perform their daily role activities in culturally expressed beneficial care and patterned ways” (Leininger et al, 2006, p.10). All cultures have their ways of maintaining health which have similarities and differences to other cultures and understanding these components of health such as the particular culture’s rules for wellness, how cultures know, transmit and practice healthcare, intergenerational practices and so on have to be discovered, understood and respected in order to provide health and well-being to that particular culture. Through this manner an appreciation for the similarities and differences of the culturally varied approaches to health can occur. Many nurse theorists have focused only on health as an outcome without knowledge of culture care influences and have also failed to understand the importance, power or major influences of care to explain health or wellbeing. . Leininger stands firm and believes it is “care and caring knowledge and actions that can explain and head to the health or wellbeing of people in different or similar cultures (Leininger et al, 2006, p. 11).
Nursing as a concept of the metaparadigm is not agreeable to Leininger as it “it is not logical to use nursing to explain nursing. It is a theoretical and logical contraindication to use the same term to explain or predict the same phenomenon.” (Leininger et al, 2006, p. 7). She does not believe that ‘nursing’ should be a metaparadigm of nursing and I concur for the simple fact it seems illogical to me as well.
It is very clear that Leininger’s Culture Care Theory has shed light on the weaknesses of this metaparadigm of nursing. With regards to this metaparadigm of nursing, Leininger finds them to be limited and inadequate as it has neglected two importance concepts, care and culture, to explain nursing despite the linguistic use of care in the daily language of nurses. And her theory has given rise and weight to these neglected concepts of nursing; care and culture (Leininger et al, 2006). I do agree with Leininger that these concepts have an essential role in nursing in providing culturally appropriate state of wellbeing and satisfaction.
Utilization in North America
There has been
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