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A growing number of studies have supported the use of unidimensional psychometric test instruments administered via the Internet; however, support for the use of multidimensional scales is weak. The present study compares paper and Internet administrations of the Multidimensional Health Locus of Control (MHLC) Scale (Wallston & Wallston, 1981). In terms of reliabilities and factor structures, the Internet data were found to be at least as good as the paper data. MHLC scores were comparable for paper and Internet administrations, although the Internet sample scored significantly lower on the Powerful Others subscale. Overall, the results show that administration of the MHLC Scale via the Internet can produce data comparable to that obtained by pen-and-paper methods. However, it is concluded that generalization of these findings beyond the psychometric test instrument and sampling procedures used here is not warranted.

Expressions of religious piety have been practiced in the Catholic Church as a response to plagues and pandemics. The faithful seek comfort in prayer and appeal to God and the saints for mercy and protection from illness and loss of life. In the Philippines, the veneration of sacred images and placing them outside the window of a house or a church is a religious expression known as "dungaw” (to look out). This paper discusses “dungaw” as a faith-response of Filipino Catholics during the COVID-19 pandemic. The study is an empirical phenomenology that consists of a literary review and interviews. This paper analyzed the significance of the religious expression “dungaw.” Four areas of inquiry were identified: (1) Views on the COVID-19 pandemic, (2) “Dungaw” and prayer life during the pandemic, (3) “Dungaw” as a religious expression, and (4) “Dungaw” and communal life. Results showed that Filipino Catholics utilized religion as a coping resource during turbulent times. Filipino Catholics also embodied traditional values to help repair the frayed social fabric during COVID-19.

Efforts to control and regulate alcohol has recently gained steam in Botswana. Inspired by a public health perspective, the government of Botswana has recently increased the alcohol tax levy, reduced the hours of operation for bars and increased penalties for alcohol-related offences to control alcohol-related harm. While these reforms have been central to policymaking, and caused some controversy, not much is known about the everyday experiences of alcohol consumers in Botswana. Drawing from semi-structured interviews (n = 40) collected amongst drinkers over a five-year period, this paper examines the everyday use of alcohol in Botswana. The analysis demonstrates that alcohol use constitutes an important part of leisure and night-time economy (NTE) activities in Botswana. It is a functional social activity that is used by people to take time away from the routines and pressures of daily life. More importantly, it is pleasurable to people, enhances sociability, and partaken as a form of transaction between men and women in bars. There is need for policy makers to consider the embodied experiences of alcohol use when designing alcohol interventions in Botswana.

There is ample evidence that exposure to Immigration and Customs Enforcement (ICE) activities could widen Latinas’ health disparities. Whether or not residing near an ICE detention center (IDC) further impacts their health is unknown. During nationwide increased ICE activities Latinas (N=45) attended an intervention at two separate sites: one near and another one far from an IDC. A focus group discussion and an interview were conducted using a grounded theory approach. Quantitative data were collected and analyzed. Participants residing near an IDC benefited less from the intervention and reported changes in anxiety levels and in mobility, and a sense of powerlessness. They also requested resources to respond to ICE overreach and broadcasting of their reality. Our results suggest that proximity to IDCs impacts immigrant communities and public health programming, which is inevitably embedded in political realities. These need to be addressed when providing much needed interventions. Supplementary Information The online version contains supplementary material available at 10.1007/s10903-021-01219-2.

Food contributes to an individual’s physical and mental well-being and expresses one’s cultural identity through preparation, sharing, and consumption (i.e., foodways). Inadequate access to cultural foods can create cultural stress and affect one’s identity and well-being. In particular, second-generation U.S. American student populations may have a higher risk for cultural stress due to being away from family, academic stress, environmental changes, and diminished financial stability to purchase cultural foods. Thus, an exploratory qualitative methodology was used to elicit information about second-generation U.S. Americans’ food experiences to identify how cultural foods play a role in individual identity and how individual well-being is influenced by the presence or lack of cultural foods. Sixteen semi-structured interviews were conducted with second-generation American students at the University of Nevada, Reno, who self-identified as a cultural or ethnic minority. A standard thematic analysis was conducted. The authors identified that cultural food security influenced the ability to practice foodways, which tied Second-generation American students to their cultural identities. The absence of foodways led to anxiety and depression among students, amplifying the feelings of identity degradation. Second-generation American students discussed that the ability to practice their foodways improved multiple well-being components and led to feelings of happiness, decreased stress, warmth, better digestion, and a sense of belonging, comfort, and safety. College populations continue to grow and become more diverse, and with the increasing Second-generation American students, it is essential to improve the access and availability of cultural foods to improve their overall well-being. (245/250 words). Supplementary Information The online version contains supplementary material available at 10.1007/s12571-020-01140-w.

Cultural background might influence knowledge and attitudes regarding autism, influencing willingness to interact. We studied whether beliefs, knowledge, contact, and attitude differed between the UK and Malaysia. With mediation analyses, we studied how these factors influenced willingness to interact. Autism was more often linked to food in the UK, and to upbringing in Malaysia. Knowledge, contact, and acceptance were greater in the UK. When excluding psychology students, Malaysian students were less willing to interact with autistic people. Knowledge and contact appeared to improve acceptance, but acceptance did not mediate the relation between country, beliefs, knowledge, and experience; and willingness to interact. Knowledge and contact regarding autism might improve acceptance in different cultures, but how acceptance could improve interaction is unclear.

This paper aims to clarify the role of culture as a public good that serves to preserve mental health. It tests the evolutionary hypothesis that cultural consumption triggers a microeconomic mechanism for the self-defense of mental health from uncertainty. The COVID-19 pandemic offers a natural experiment of cultural consumption under increased uncertainty. Using primary data from a pilot survey conducted online during the pandemic and applying Probit and Heckman selection models, the study analyzes levels of happiness and propensity to help others. The results suggest that past consumption of culture is associated with higher happiness levels during crises. Moreover, spontaneous cultural practices (such as group singing) during times of uncertainty are associated with an increase in the pro-social propensity to help others. These findings highlight culture as a tool for promoting mental health at the micro level and social capital resilience at the aggregate level.

There is a limited amount of empirical data available regarding the cultural and religious variation in perceptions about the age when young people should be regarded as competent to make decisions in health settings. A public survey of 400 adults from diverse religious and ethnic backgrounds was conducted in the UK and Spain. Attitudes were assessed using case vignettes. It was found that high religious practice was associated with recommending a higher age of consent for medical interventions. White British adults were more likely than Spanish adults to agree that younger adolescents should be allowed to consent to medical interventions. The study suggests that there is social, cultural and religious variation in adults' attitudes regarding the age when youngsters should consent to health interventions.

How animal communities arrive at homogeneous behavioural preferences is a central question for studies of cultural evolution. Here, we investigated whether chimpanzees (Pan troglodytes) would relinquish a pre-existing behaviour to adopt an alternative demonstrated by an overwhelming majority of group mates; in other words, whether chimpanzees behave in a conformist manner. In each of five groups of chimpanzees (N = 37), one individual was trained on one method of opening a two-action puzzle box to obtain food, while the remaining individuals learned the alternative method. Over 5 h of open access to the apparatus in a group context, it was found that 4/5 ‘minority’ individuals explored the majority method and three of these used this new method in the majority of trials. Those that switched did so after observing only a small subset of their group, thereby not matching conventional definitions of conformity. In a further ‘Dyad’ condition, six pairs of chimpanzees were trained on alternative methods and then given access to the task together. Only one of these individuals ever switched method. The number of observations that individuals in the minority and Dyad individuals made of their untrained method was not found to influence whether or not they themselves switched to use it. In a final ‘Asocial’ condition, individuals (N = 10) did not receive social information and did not deviate from their first-learned method. We argue that these results demonstrate an important influence of social context upon prioritisation of social information over pre-existing methods, which can result in group homogeneity of behaviour. Electronic supplementary material The online version of this article (10.1007/s10071-018-1178-y) contains supplementary material, which is available to authorized users.

Almost one in four women in Cambodia is a victim of physical, emotional or sexual violence. The study aims to provide a comprehensive understanding of the ways in which Cambodians see its causes and effects and to identify and analyse the cultural forces that underpin and shape its landscape. An ethnographic study was carried out with 102 perpetrators and survivors of emotional, physical and sexual violence against women and 228 key informants from the Buddhist and healing sectors. Their views and experiences of it were recorded-the popular idioms expressed and the symptoms of distress experienced by survivors and perpetrators. From these results, the eight cultural forces, or cultural attractors, that are seen to propel a person to violence were identified. Violence stemmed from blighted endowment, or 'bad building' (sɑmnaaŋ mɨn lʔɑɑ) determined by deeds in a previous life (kam). Children with a vicious character (kmeeŋ kaac or doṣa-carita) might grow to be abusers, and particular birthmarks on boys were thought to be portents. Krʊəh, or mishap, especially when a female's horoscope predicted a zodiac house on the descent (riesəy), explained vulnerability to violence and its timing. Astrological incompatibility (kuu kam) was a risk factor. Lust, anger and ignorance, the 'Triple Poison', fuelled it. 'Entering the road to ruin' (apāyamuk), including alcohol abuse, womanising and gambling, triggered it. Confusion and loss of judgement (mohā) led to moral blindness (mo baŋ). These were the eight cultural attractors that shaped the landscape of violence against women. The cultural epigenesis of violence against women in Cambodia is an insight which can be used to build culturally responsive interventions and strengthen the primary prevention of violence against women. An understanding of the epigenesis of violence could strengthen the primary prevention of violence against women.

This paper compares the biofilter capacity and cost-effectiveness of blue mussels (Mytilus edulis) and seaweed for use in integrated multi-trophic aquaculture (IMTA) based on experiences in Ireland and Denmark. This comparison shows that weight for weight, mussels are a better biofilter than seaweed with regard to the amount of nitrogen assimilated. Furthermore, in optimized systems, areal requirement for mussels is similar to the cultivation of the same tonnage (1,000 t) of seaweed (approximately 8 ha). The cost-effectiveness of a mussel biofilter is a,not sign11-30 kg(-1) nitrogen (N) removed based on various examples compared to production costs of a,not sign209-672 removed and a,not sign1,013 kg(-1) N removed, respectively, for Laminaria digitata and Alaria esculenta from extrapolated laboratory and field trials. However, commercial seaweed (Saccharina latissima) producers claim that production costs are less than a,not sign10-38 kg(-1) N removed. These up-scaled and commercial figures make the seaweed cost competitive to mussels for removal of nitrogen. Disadvantages such as predators (e.g. eider ducks) and biofouling should also be taken into account before choice of biofilter is made. These drawbacks can reduce overall biofilter capacity and biomass value as a consequence of biomass spoilage or loss. However, disadvantages may be mitigated by seasonal choice of cultivation and harvest times. Cultivation technologies and harvesting methods may be improved together with breeding to improve the cost-efficiency of the biofilter, especially in the newer European seaweed cultivation. Furthermore, upscaling of IMTA to commercial proportions, other than the Danish example, would allow more real data on production costs and revenues.

Spirit possession is a common, worldwide phenomenon with dissociative features. Studies in Europe and the United States have revealed associations among psychoform and somatoform dissociation and (reported) potential traumatic events. The aim of this study was to explore the relationships among spirit possession, dissociative symptoms and reported potentially traumatizing events in Uganda. One hundred nineteen persons with spirit possession, diagnosed by traditional healers, were compared to a matched control group of 71 nonpossessed persons. Assessments included demographic items and measures of dissociation and potentially traumatizing events. Compared to the nonpossessed group, the possessed group reported more severe psychoform dissociation and somatoform dissociation and more potentially traumatizing events. The associations between these events and both types of dissociation were significant. Yet, consistent with the cultural perception of dissociative symptoms, the participants subjectively did not associate dissociative symptoms with potentially traumatizing events. In conclusion, spirit possession deserves more interest as a possible idiom of distress and a culture-specific expression of dissociation related to potential traumatizing events.

Killer cell immunoglobulin-like receptors (KIR) gene frequencies vary between populations and contribute to functional variation in immune responses to viruses, autoimmunity and reproductive success. This study describes the frequency distribution of 12 variable KIR genes and their HLA-C ligands in two Iranian populations who have lived for many generations in different environments: the Azerbaijanis at high altitude and the Jonobi people at sea level. The results are compared with those published for other human populations and a large group of English Caucasians. Differences were seen in KIR and HLA-C group frequencies, in linkage disequilibrium and inhibitory/activating KIR ratios between the groups. Similarities with geographically close populations in the frequencies of the KIR A and B haplotypes and KIR AA genotype reflected their common ancestry. The extreme variability of the KIR gene family and their HLA-C ligands is highlighted and their importance in defining differences between geographically and culturally isolated communities subject to different environmental pressures who come from the same ethnic grouping.

Background Emerging data suggest that problem/pathological gambling may be highly prevalent among Asian-Pacific Islanders (APIs) and that can be a major concern to their communities. Methods This study surveyed problem/pathological gambling knowledge, attitudes, and perceived community impact of problem gambling among self-identified male and female APIs and non-APIs attending one of two API community events in Los Angeles County. Results Unexpectedly, our results indicated no effect for ethnicity with regards to ratings of problem/pathological gambling knowledge, community impact, or consequences. However, a gender effect with women reporting less problem/pathological-gambling-related knowledge than men, regardless of ethnicity was found. Over 40% of all respondents reported that problem/pathological gambling impacted their communities ‘a lot’, and the ratings for the impact of problem/pathological gambling was equal to ratings for other significant public health issues like diabetes, depression, drug abuse, and alcohol abuse. Discussion Based on these results, it is recommended that evidence-based legislation support the development of culturally-relevant prevention and intervention programs for problem/pathological gambling in Los Angeles County.

Establishing triage is necessary in mass casualty events. If the concept of triage itself is easy, its application in the field encounters many difficulties at times unforseen. MSF offers a list of the main obstacles encountered when establishing an efficient triage system.

HIV and AIDS have posed various medical, nutritional, social and economic problems, female-headed households being the most affected. Poor nutritional knowledge and dietary practices common among the most affected households significantly contribute to the rapid progression of HIV. However, very little data exist concerning these aspects of nutrition among women living with HIV and AIDS in resource-limited settings, such as Uganda. The aim of the study was to investigate the gaps in nutritional knowledge, attitudes, and practices and their relationship with sociodemographic characteristics in an urban population of women living with HIV and AIDS in Uganda. In total, 133 women living with HIV were interviewed using a pretested questionnaire. Most (89.5%) women reported being trained on the importance of nutrition for people living with HIV and AIDS (PLWHA) and believed that it is very important to consume a balanced diet (99.5%). On the contrary, only 21.8% consumed at least three meals per day and 39.8% at least six food-groups. They also reported higher dependency on starchy staples while foods of animal origin and fruits that play vital immunity and protective roles were inadequately consumed. Results of bivariate analysis indicated that consumption of a diversified diet was significantly associated with access to food-aid (p=0.006), possibly because access to food-aid reportedly enhances the ability of the household to access other food items. However, much is still needed to understand the drug-food interaction and dietary diversification and enhance proper dietary practices through sustainable projects that ensure increased access to food. Support groups of the PLWHA are a good vehicle for communication of nutrition information and implementation of nutrition-related projects.

This article reports the results of a qualitative study conducted in two villages of Matlab to explore the cultural dimensions of depression. Participants included adult men and women with and without a history of depressive episode (n=42), formal and informal healthcare providers (n=6), and caregivers (n=2). Adults (n=10) with a history of depressive episode were selected from a 2005 survey conducted by ICDDR,B. A case vignette was used for eliciting local terms for depression, perceived causes, impact, and treatments. Hardly anyone recognized the term bishonnota (literal translation of depression) used in the past survey. The participants thought that the vignette was about chinta rog (worry illness), and they spoke of somatic symptoms in relation to this condition. When explored further, they mentioned sadness and psychological complaints. Men felt that it affected them more while women felt the opposite. They associated chinta rog with poverty and social issues with impacts on marriage, work, and education. From their responses, it seemed that they preferred a psychosocial framework attributing the cause to thoughts and emotions, resulting from social causes. Commonly-suggested treatments were more income, better relationships, and tablets. Former health providers were often the first choice for help-seeking. The study hopes to 'culturally inform' the formal healthcare providers and programme planners.

Following the work of Hellman, this paper examines homosexism (the stigmatisation of non-penetrative sexual activities of men who have sex with men as non-sexual practices) in relation to hegemony, masculinity, and sexuality theories. In doing so, it discusses the function of sides, men who have sex with men but do not engage in penetrative sexual practices, in relation to the maintenance of established, normative, and damaging notions of masculinities. The central question this paper addresses is what the significance of the stigmatisation of sides is. In addressing this question, the potential of sides to facilitate and inhibit normative hegemonic structures is considered while more in-depth research is deemed necessary. The aim of this paper is to extend the discussion on homosexism, acknowledge non-penetrative sexual practices as legitimate forms of sexual expression, and encourage further scholarly research that focuses on the potential of sides to challenge and subvert established normative understandings of genders and sexualities, as well as the power structures that are involved in the construction of such understandings.

The literature suggests that a whole-institution culture of academic integrity is needed in order to prevent academic integrity breaches. It is also suggested that the national cultures and individual backgrounds of academic staff and students can impact on their propensity to breach academic integrity policies and on their uptake of initiatives aimed at enhancing academic culture. Much research has been conducted on academic integrity related to culture in the western world including the behaviours of international students, and some work has been conducted in various Asian contexts. However, little is known about how national culture and religion affect academic integrity in eastern countries with a Muslim majority. This paper presents a synthesis of the literature related to academic integrity and culture in regions where Muslims are the majority. An integrative literature review was carried out. Keywords were used to search and to collect academic integrity related research published from 2010 to 2020. The literature reviewed revealed that academics in countries with a Muslim majority faced challenges related to their local cultures, which included social and religious perceptions and practices. However, they were also able to draw upon some national and religious practices that supported and enhanced academic integrity. This paper concludes with recommendations for incorporating these positive cultural factors into an academic integrity framework for policy and practice appropriate for Muslim contexts.

In this paper, we provide an overview of our ongoing project in the Genetics and Human Agency Initiative sponsored by the John Templeton Foundation. Our project focuses on the ways that lay beliefs about the heritability of virtue influence reasoning about the nature of virtue, parenting behaviors, and the development of virtue in children. First, we provide philosophical perspectives on the nature of virtue and suggest that viewing virtue as a malleable skill may have important advantages. Next, we review theory and research that highlights the ways that lay heritability beliefs potentially undermine conceptualizations of virtue as a malleable skill. Finally, we discuss how lay heritability beliefs might ultimately affect parent-child interactions and child virtue development. The paper thus provides a brief description our project's theoretical foundation and a general look at the empirical questions it will tackle.

Built heritage faces increasing pressures and threats from development and change in the contemporary world, a situation that frequently results in compromise or loss of historic fabric and its associated values. This paper examines how Heritage Impact Assessment (HIA) methodology specifically addresses and mitigates threats to built heritage within an overall sustainable development framework. The methodology will be explained and examples will be given from across Asia of HIA applications to the urban and rural built environment to illustrate how this can be achieved. These case studies reflect a variety of ways in which development and heritage come into conflict and have been selected to show how versatile and adaptable HIA can be as a tool for finding balance and solutions. HIA is an approach rooted in a balanced and sustainable relationship between ‘the needs of the present and future generations and the legacy from the past’ (UNESCO 2011). The paper also illuminates some of the basic assumptions on which HIA functions and some of the contradictions that often arise when the methodology is applied to real world problems.

The purpose of this research is to investigate the relationship between innovation and human capital investment, and to show how the implementation of these two concepts leads to economic development. A case study was conducted in Jordan with one-to-one, in-depth expert interviews to obtain the information needed to answer the research questions; in addition, a focus group of ten final year undergraduate students (about to enter the educated workforce) experts offered their thoughts and ideas to identify how youth today relate to this research and its findings. The findings identified four main pillars required to support economic development and achieve a competitive advantage using the country’s human capital: Habilitation, Opportunity, Power Distance, and Entrepreneurship (HOPE). The findings also indicated that Jordanian culture is highly germane to all four pillars, which can encourage innovative human capital and ensure economic development. This paper is important to the Jordanian community and the Arab world in general, which lacks awareness of the importance of human capital in socio-economic development; the study helps understand innovation and economic development in the region. This paper explores the relationship between innovation and human capital investment, and shows how this combination will lead to the development of Jordanian culture and the economy.

This paper sets out to present a novel construal of one of the notions of Vygotskian cultural-historical theory viz., zone of proximal development (ZPD) drawing upon dynamic systems theory. The principal thesis maintains that ZDP is an emergent and dynamic system which is engendered by a dialectical concatenation of psychogenesic and sociogenesic facets of human development over time. It is reasoned that Vygotskian cultural-historical theory of human development, by invoking dialectical logic, has transcended Cartesian substance dualism and in turn has proffered a monistic and process-anchored ontology for emerging becoming of human consciousness. Likewise, it is contended that dynamic systems theory, having assumed fluent flux of reality with a capital R as its ontological axiom, entails a consilience of cognitive and contextual conceptual schemes to describe, explain, and optimize human development. The paper concludes by drawing some interpretive conclusions in regard to ZPD from dynamic systems theory perspective. peerReviewed

Christian Smith’s paper “The Incoherence of ‘Culture’ in American Sociology” is a valuable provocation that can prompt us to reflect on the role of concepts and on the role of agreement on the definition of concepts in scientific research. In this comment paper, I raise questions about Smith’s empirical expectation that sociologists should agree on a concept of culture based on debates in the sociology of science. I also suggest that in terms of the future agenda for the sociology of culture, we should distinguish between dialogue and clarification on the one hand, which I agree is needed, and standardization on the other hand, which seems incompatible with open-minded empirical research. Rather than work on agreement on what culture is, we might work on clarifying relevant distinctions among dimensions of culture.

Background This paper aims to examine the health care contexts shaping perinatal survival in remote mountain villages of Nepal. Health care is provided through health services to a primary health care level—comprising district hospital, village health facilities and community-based health services. The paper discusses the implications for future policies and practice to improve health access and outcomes related to perinatal health. The study was conducted in two remote mountain villages in one of the most remote and disadvantaged mountain districts of Nepal. The district is reported to rank as the country’s lowest on the Human Development Index and to have the worst child survival rates. The two villages provided a diversity of socio-cultural and health service contexts within a highly disadvantaged region. Methods The study findings are based on a qualitative study of 42 interviews with women and their families who had experienced perinatal deaths. These interviews were supplemented with 20 interviews with health service providers, female health volunteers, local stakeholders, traditional healers and other support staff. The data were analysed by employing an inductive thematic analysis technique. Results Three key themes emerged from the study related to health care delivery contexts: (1) Primary health care approach: low focus on engagement and empowerment; (2) Quality of care: poor acceptance, feeling unsafe and uncomfortable in health facilities; and (3) Health governance: failures in delivering health services during pregnancy and childbirth. Conclusions The continuing high perinatal mortality rates in the mountains of Nepal are not being addressed due to declining standards in the primary health care approach, health providers’ professional misbehaviour, local health governance failures, and the lack of cultural acceptance of formalised care by the local communities. In order to further accelerate perinatal survival in the region, policy makers and programme implementers need to immediately address these contextual factors at local health service delivery points. Electronic supplementary material The online version of this article (10.1186/s41043-018-0148-y) contains supplementary material, which is available to authorized users.

Background In recent years, Ireland has experienced a large-scale, outward migration of doctors. This presents a challenge for national policy makers and workforce planners seeking to build a self-sufficient medical workforce that trains and retains enough doctors to meet demand. Although, traditionally, medical migration has been considered beneficial to the Irish health system, austerity has brought a greater level of uncertainty to the health system and, with it, a need to reappraise the professional culture of migration and its impact on the Irish health system. Methods This paper illustrates how a culture of migration informs career and migration plans. It draws on quantitative data—registration and migration data from source and destination countries—and qualitative data—in-depth interviews with 50 doctors who had undertaken postgraduate medical training in Ireland. Results Of 50 respondents, 42 highlighted the importance of migration. The culture of medical migration rests on two assumptions—that international training/experience is beneficial to all doctors and that those who emigrate will return to Ireland with additional skills and experience. This assumption of return is challenged by a new generation of doctors whose professional lives have been shaped by globalisation and by austerity. Global comparisons reveal the comparatively poor working conditions, training and career opportunities in Ireland and the relative attractiveness of a permanent career abroad. Conclusion In light of these changes, there is a need to critically appraise the culture of medical migration to determine if and in what circumstances migration is appropriate to the needs of the Irish health system. The paper considers the need to reappraise the culture of medical migration and the widespread emigration that it promotes.

Background The World Health Organization recently made a recommendation supporting ‘culturally-appropriate’ maternity care services to improve maternal and newborn health. This recommendation results, in part, from a systematic review we conducted, which showed that interventions to provide culturally-appropriate maternity care have largely improved women’s use of skilled maternity care. Factors relating to the implementation of these interventions can have implications for their success. This paper examines stakeholders’ perspectives and experiences of these interventions, and facilitators and barriers to implementation; and concludes with how they relate to the effects of the interventions on care-seeking outcomes. Methods We based our analysis on 15 papers included in the systematic review. To extract, collate and organise data on the context and conditions from each paper, we adapted the SURE (Supporting the Use of Research Evidence) framework that lists categories of factors that could influence implementation. We considered information from the background and discussion sections of papers included in the systematic review, as well as cost data and qualitative data when included. Results Women’s and other stakeholders’ perspectives on the interventions were generally positive. Four key themes emerged in our analysis of facilitators and barriers to implementation. Firstly, interventions must consider broader economic, geographical and social factors that affect ethnic minority groups’ access to services, alongside providing culturally-appropriate care. Secondly, community participation is important in understanding problems with existing services and potential solutions from the community perspective, and in the development and implementation of interventions. Thirdly, respectful, person-centred care should be at the core of these interventions. Finally, cohesiveness is essential between the culturally-appropriate service and other health care providers encountered by women and their families along the continuum of care through pregnancy until after birth. Conclusion Several important factors should be considered and addressed when implementing interventions to provide culturally-appropriate care. These factors reflect more general goals on the international agenda of improving access to skilled maternity care; providing high-quality, respectful care; and community participation.

BACKGROUND: Open defecation is widely practiced in India. To improve sanitation and promote better health, the Government of India (GOI) has instituted large scale sanitation programmes supporting construction of public and institutional toilets and extending financial subsidies for poor families in rural areas for building individual household latrines. Nevertheless, many household latrines in rural India, built with government subsidies and the facilitation and support of non-government organizations (NGO), remain unused. Literature on social, cultural and behavioural aspects that constrain latrine adoption and use in rural India is limited. This paper examines defecation patterns of different groups of people in rural areas of Odisha state in India to identify causes and determinants of latrine non-use, with a special focus on government-subsidized latrine owners, and shortcomings in household sanitation infrastructure built with government subsidies. METHODS: An exploratory study using qualitative methods was conducted in rural communities in Odisha state. Methods used were focus group discussions (FGDs), and observations of latrines and interviews with their owners. FGDs were held with frontline NGO sanitation program staff, and with community members, separately by caste, gender, latrine type, and age group. Data were analysed using a thematic framework and approach. RESULTS: Government subsidized latrines were mostly found unfinished. Many counted as complete per government standards for disbursement of financial subsidies to contracted NGOs were not accepted by their owners and termed as 'incomplete'. These latrines lacked a roof, door, adequate walls and any provision for water supply in or near the cabin, whereas rural people had elaborate processes of cleansing with water post defecation, making presence of a nearby water source important. Habits, socialising, sanitation rituals and daily routines varying with caste, gender, marital status, age and lifestyle, also hindered the adoption of latrines. Interest in constructing latrines was observed among male heads for their female members especially a newlywed daughter-in-law, reflecting concerns for their privacy, security, and convenience. This paper elaborates on these different factors. CONCLUSIONS: Findings show that providing infrastructure does not ensure use when there are significant and culturally engrained behavioural barriers to using latrines. Future sanitation programmes in rural India need to focus on understanding and addressing these behavioural barriers.

The insignia worn by the British and Commonwealth Armed Services are rich in symbolism and meaning to the corps and regiments that wear them. Originally, before the adoption of national uniforms pre-1700s, there was little to distinguish friend from foe. To overcome that problem, certainly in battle, it was common practice to wear some sort of distinctive emblem, such as a sprig of a native plant. This then developed, in the reign of Charles II, to the custom of individual regiments or corps adopting devices and designs of their 'colours', through to modern cap and collar badges.On the centenary of the Royal Army Dental Corps, this paper gives some insight into those designs adopted by the Royal and Commonwealth Dental Corps, when a distinct service of dental care was recognised. They give a fascinating insight into the adoption and amalgamation of both national and dental symbols. The Dental Corps, separate from Army Medical Corps, went on to develop the vital provision of dental healthcare, both in the field and at home.

This paper analyses the nature of the relationship between risk and responsibility. Since neither the concept of risk nor the concept of responsibility has an unequivocal definition, it is obvious that there is no single interpretation of their relationship. After introducing the different meanings of responsibility used in this paper, we analyse four conceptions of risk. This allows us to make their link with responsibility explicit and to determine if a shift in the connection between risk and responsibility can be outlined. (1) In the engineer's paradigm, the quantitative conception of risk does not include any concept of responsibility. Their relationship is indirect, the locus of responsibility being risk management. (2) In Mary Douglas' cultural theory, risks are constructed through the responsibilities they engage. (3) Rayner and (4) Wolff go further by integrating forms of responsibility in the definition of risk itself. Analysis of these four frameworks shows that the concepts of risk and responsibility are increasingly intertwined. This tendency is reinforced by increasing public awareness and a call for the integration of a moral dimension in risk management. Therefore, we suggest that a form of virtue-responsibility should also be integrated in the concept of risk.

The purpose of this paper is to integrate the literature on family and social ties among older ethnic minority men and women with the literature on chronic illness self-care among elders in these groups, in order to increase understanding of social influences on self-care behavior, raise questions for future research, and inform culturally appropriate interventions to maximize the health-promoting potential of social relationships. The paper presents demographic and chronic illness prevalence information, and then summarizes literature about patterns of chronic illness self-care behaviors for older African-Americans, Latinos, Asian-Americans, and American Indians in the U.S. For each group, the sociological literature about residential, cultural, and socioeconomic patterns, family lives, and other social ties is then reviewed, and the self-care literature that has accounted for these patterns is discussed. Finally, six themes are outlined and related questions are identified to further illuminate the social context of older adults' chronic illness self-care.

This paper provides an analytical model representing four polar ethical approaches drawn from the main ethical positions suggested by the philosophical, psychological, and socio-economic literature. Moreover, it develops the model in order to obtain rankings of the four approaches in terms of happiness and, consequently, to provide insights into which ethical approach should best be adopted by each individual, according to his characteristics (income level, in developed countries (DCs) or in less developed countries (LDCs), aspiration level): some dynamics are also predicted, if the Golden and the Copper Rules are applied. Finally, this paper provides insights into which ethical approach should best be adopted by each society, according to its characteristics (DCs or LDCs, social distribution of aspiration levels), by predicting happiness levels in alternative countries, according to the prevailing ethics, and by comparing these predictions with the observed happiness levels, thus providing an empirical test of the analytical model: some dynamics are again predicted, with non-Protestant DCs moving to higher, and Protestant DCs towards lower, happiness levels (conditioned to the per capita income), due to the increasing and decreasing rejection of the Golden and Copper Rules, respectively, and with LDCs moving to lower (conditioned to the increasing per capita income) in the short-run and higher happiness levels in the long run, by establishing and entertaining conditions that set clear incentives for moral behaviour, in order to increase and decrease the adoption of the Golden and Copper Rules, respectively.

The papers in this special section of CMP explore new terrain in the cultural shaping of traumatic experience. The authors describe nightmares occurring in association with trauma across diverse settings. The innovative ethnographic work presented in these papers circles around basic questions about dreams and nightmares. What kind of experiences are nightmares? To what extent does their function, form and content follow from the neurobiology of dreaming? Put another way, what accounts for the admixture of biology, personal experience and cultural content in dreams? More specifically, in the case of nightmares related to trauma, how much of their content follows from the neurophenomenology of dreaming, how much reflects specific trauma memories and experiences and how much is a result of the dreamer’s imagination and interpretation operating either during the dream experience itself or on later recollection and recounting to others? Answers to these questions are crucial for any understanding of the potential links between dreams and trauma exposure and have clinical relevance for those seeking to understand and assist patients suffering from recurrent nightmares.

Background: The rise of genomic studies in Africa – not least due to projects funded under H3Africa – is associated with the development of a small number of biorepositories across Africa. For the ultimate success of these biorepositories, the creation of cell lines including those from selected H3Africa samples would be beneficial. In this paper, we map ethical challenges in the creation of cell lines. Discussion: The first challenge we identified relates to the moral status of cells living in culture. There is no doubt that cells in culture are alive, and the question is how this characteristic is relevant to ethical decision-making. The second challenge relates to the fact that cells in culture are a source of cell products and mitochondrial DNA. In combination with other technologies, cells in culture could also be used to grow human tissue. Whilst on the one hand, this feature increases the potential utility of the sample and promotes science, on the other it also enables further scientific work that may not have been specifically consented to or approved. The third challenge relates to ownership over samples, particularly in cases where cell lines are created by a biobank, and in a different country than where samples were collected. Relevant questions here concern the export of samples, approval of secondary use and the acceptability of commercialisation. A fourth challenge relates to perceptions of blood and bodily integrity, which may be particularly relevant for African research participants from certain cultures or backgrounds. Finally, we discuss challenges around informed consent and ethical review. Summary: In this paper, we sought to map the myriad of ethical challenges that need to be considered prior to making cell line creation a reality in the H3Africa project. Considering the relative novelty of this practice in Africa, such challenges will need to be considered, discussed and potentially be resolved before cell line creation in Africa becomes financially feasible and sustainable. We suggest that discussions need to be undertaken between stakeholders internationally, considering the international character of the H3Africa project. We also map out avenues for empirical research.

This paper analyses culture as a determinant of technology adoption in a developing country. While the literature discusses the influence of culture upon economic growth, little attention has been paid to the mechanisms at the micro level. Therefore, we postulate that culture plays a crucial role in hindering or fostering the diffusion of innovation, a key trigger of the engine of growth. This empirical study uses the Ethiopia Rural Household Survey to disentangle between individual cultural traits, namely, ethnicity and religion, and the cultural homogeneity of the environment as co-determinants of fertiliser adoption. To examine our hypotheses, we apply a multivariate survival model for clustered and correlated observations to account for time and location effects. The results reveal significant differences in the probability of adopting fertiliser among cultural groups. Moreover, habits and social norms, proxied by ethnicity, provide a better explanation for the role of culture, than religious beliefs, as usually posited in the literature. Also, the cultural environment turns out tobe a decisive trigger. The probability of adoption is higher in rural societies with a homogeneous ethnic environment but distinct religious variety.

Agrarian rural dwellers in Nigeria produce about 95% of locally grown food commodities. The low accessibility to and affordability of orthodox medicine by rural dwellers and their need to keep healthy to be economically productive, have led to their dependence on traditional medicine. This paper posits an increasing acceptance of traditional medicine country-wide and advanced reasons for this trend. The fact that traditional medicine practitioners' concept of disease is on a wider plane vis-à-vis orthodox medicine practitioners' has culminated in some socio-cultural and magico-religious practices observed in preparation and use of plant medicines for farmers' health management. Possible scientific reasons were advanced for some of these practices to show the nexus between traditional medicine and orthodox medicine. The paper concludes that the psychological aspect of traditional medicine are reflected in its socio-cultural and magico-religious practices and suggests that government should fund research into traditional medicine to identify components of it that can be integrated into the national health system.

Strong disciplinary academic fragmentation and sectoral division in policies lead to problems regarding the management of landscapes. As a result, there is a focus on the preservation and development of either cultural or natural landscapes. We argue that framing landscapes as “natural” or “cultural” will not help sustainable management. The goal of this paper is to show that even what is referred to as nature, virtually always features an intricate combination of physical geography, biology, and cultural history. It provides an analytical framework that visualizes the three forces at play in physical landscapes. Therefore, we introduce a diachronic triangular approach to study and manage landscapes from a holistic point of view, allowing an exchange of different perspectives. To test this approach, we have applied our model to a diachronic case study on Wadden Sea salt marshes. That area has been influenced by physical-geographical, biological, and cultural landscape forces, which are still visible in the landscape to a large extent. By placing different landscape zones in the triangular concept for different time periods, we can identify and visualize these driving forces through time for this specific landscape. These all play their specific roles in the appearance of the landscape over time in a close mutual interconnection. More importantly, we show that the diverse and complex interplay between these forces makes the current-day landscape what it is. We therefore conclude that the diachronic triangular approach provides a conceptual tool to define and operationalize landscape management in the Wadden Sea area. We welcome similar approaches in other landscapes to assess the usefulness of the diachronic triangular landscape approach.

Public Natural Resource Management (NRM) agencies operate in complex social-ecological domains. These complexities proliferate unpredictably therefore investigating and supporting the ability of public agencies to respond effectively is increasingly important. However, understanding how public NRM agencies innovate and restructure to negotiate the range of particular complexities they face is an under researched field. One particular conceptualisation of the social-ecological complexities facing NRM agencies that is of growing influence is the Water-Energy-Food (WEF) nexus. Yet, as a tool to frame and understand those complexities it has limitations. Specifically, it overlooks how NRMs respond institutionally to these social-ecological complexities in the context of economic and organisational challenges-thus creating a gap in the literature. Current debates in public administration can be brought to bear here. Using an organisational cultures approach, this paper reports on a case study with a national NRM agency to investigate how they are attempting to transform institutionally to respond to complexity in challenging times. The research involved 12 elite interviews with senior leaders from Natural Resources Wales, (NRW) and investigated how cultural narratives are being explicitly and implicitly constructed and mobilised to this end. The research identified four distinct and sequential cultural narratives: collaboration, communication, trust, and empowerment where each narrative supported the delivery of different dimensions of NRW's social-ecological complexity mandate. Counter to the current managerialist approaches in public administration, these results suggest that the empowerment of expert bureaucrats is important in responding effectively to complexity.

In the past 50 years, the original McMaster PBL model has been implemented, experimented, revised, and modified, and is still evolving. Yet, the development of PBL is not a series of success stories, but rather a journey of experiments, failures and lessons learned. In this paper, we analyzed the meta-analyses and systematic reviews on PBL from 1992 to present as they provide a focused lens on the PBL research in the past 5 decades. We identified three major waves in the PBL research development, analyzed their impact on PBL research and practice, and offered suggestions of research gaps and future directions for the field. The first wave of PBL research (polarization: 1990-mid 2000) focused on answering the question "Does PBL work?" and the outcomes. The results were conflicting. The researchers took polarizing positions and debated over the merits of PBL throughout this wave. However, the contradictory results and the debates in fact pushed the researchers to look harder for new directions to solve the puzzle. These efforts resulted in the second wave (from outcomes to process: mid 2000-mid 2010) that focused on the question "How does PBL work?" The second wave of PBL research targeted at investigating the effects of implementation constituents, such as assessment formats or single versus curriculum wide implementations. The third wave (specialization: mid 2010 and onward) of PBL research focused on "How does PBL work in different specific contexts?" These research widened our perspectives by expanding our understanding of how PBL manifests itself in different contexts. Given the diversification of PBL and more hybrid PBL models, we suggest "Why does PBL with particular implementation characteristics for specific outcomes work or not work in the condition where it is implemented?" to be the question to answer in the next wave of PBL research.

Introduction The practice of female genital mutilation (FGM/C) in traditional African societies is grounded in traditions of patriarchy that subjugate women. It is widely assumed that approaches to eradicating the practice must therefore focus on women’s empowerment and changing gender roles. Methods This paper presents findings from a qualitative study of the FGM/C beliefs and opinions of men and women in Kassena-Nankana District of northern Ghana. Data are analyzed from 22 focus group panels of young women, young men, reproductive age women, and male social leaders. Results The social systemic influences on FGM/C decision-making are complex. Men represent exogenous sources of social influence on FGM/C decisions through their gender roles in the patriarchal system. As such, their FGM/C decision influence is more prominent for uncircumcised brides at the time of marriage than for FGM/C decisions concerning unmarried adolescents. Women in extended family compounds are relatively prominent as immediate sources of influence on FGM/C decision-making for both brides and adolescents. Circumcised women are the main source of social support for the practice, which they exercise through peer pressure in concert with co-wives. Junior wives entering a polygynous marriage or a large extended family are particularly vulnerable to this pressure. Men are less influential and more open to suggestions of eliminating the practice of FGM/C than women. Conclusion Findings attest to the need for social research on ways to involve men in the promotion of FGM/C abandonment, building on their apparent openness to social change. Investigation is also needed on ways to marshal women’s social networks for offsetting their extended family familial roles in sustaining FGM/C practices.

Worldwide interest in the cultural landscape concept—covering rural and urban spheres—is now a major theme in considerations of the management of cultural heritage places. The roots of this interconnection lie in the social, political and economic relationships between people and landscape which, in turn, is related to how human attachment to landscape plays a major role in determining our sense of place. Notably the fundamental actuality of place attachment through landscape is cross cultural. Epistemologically it crosses the boundaries of differing values across diverse cultures underscoring the fundamental cross cultural significance of landscape. Co-incidentally the phenomenon of the ‘rise of cultural landscapes’ (Jacques 1995) has been intimately interconnected with the way in which thinking has changed— philosophically and professionally—on what heritage is. There is in effect a clear link between heritage and landscape. It is in this context that this paper addresses challenges of thinking and acting associated with China’s commitment to a rural revitalisation program.

Previous studies assessed cultural ecosystem services (CES) at the local scale but often ignored them in national assessments. This paper explores CES relationships in Switzerland using web-based participatory mapping. We identified the spatial relationships between CES, the drivers of negative change and solutions to mitigate it. Results indicated that CES tend to have positive spatial relationships, although not always significant. A proxy-based approach supported the findings that the provision of heritage and inspiration services decreased along the urban–rural gradient while others increased. Participants located more CES close to their residence, but acknowledged their presence in distant alpine regions. They reported that better planning and stricter implementation of policies were necessary to refrain CES loss. According to respondents, there might be a density threshold to ensure sustainable supply of CES. Although mitigation measures were specific enough at the national scale, they remained too broad to be applicable at the local scale.

The pace of urbanisation, with the increase in the number of metropolitan areas, has been paralleled with the heritage discourse of past generations that valorises monuments in isolation, and has pushed the appreciation of urban heritage to a grim corner in the face of development. Since the turn of the millennium there are international efforts to reverse this trend by placing culture and people-centred approaches into the heritage discourse in order to allow inclusive policies that see culture and cultural heritage as an asset and driving force for sustainable urban development. As one of such instruments, the UNESCO Recommendation on the Historic Urban Landscape, as an integrated management model, is considered in this article to have potentials to bridge existing divides to achieve sustainable urban development. With this belief, the paper looks into the future, with supporting arguments that come from discussions as a result of the WHITRAP International Expert Meeting on the Implementation of the HUL approach which took place in 2018, Shanghai, China.

According to a popular Dutch theory, water has shaped the Dutch national identity. The Dutch fight against the water would have stimulated perseverance, ingenuity, cooperation and an egalitarian and democratic society. Despite the long water management history of the Netherlands, water became an important part of the self-images of the nation only in the eighteenth Century. In the 1780s the idea that the Dutch had wrung their country from the sea became popular. Initially, this idea was especially popular among the (proto-)liberal opposition, who emphasised the importance of the nation and its achievements. By the end of the nineteenth Century, water had become a national symbol for orthodox Calvinists, Roman Catholics and Socialists too, despite their different views on the nation. Whenever there was fast social change, political turmoil or external threats, as in the late eighteenth Century, the 1930s and 1940s and since the 1990s, the link between water and the Netherlands was used to promote national pride and unity and stimulate action. This link has also been used to promote specific hydraulic works, but it is a topic for further research how widespread and effective this practice was. As this paper is part of a special issue, Water History in the time of COVID-19, it has undergone modified peer review.

The recent advancements in information and communication technologies have altered instructional contexts and re-shaped them into smart learning environments. One of the most common practices of these environments are learning management systems (LMS) where the learners and instructors utilize a software platform to fulfill, support and manage instructional activities around predefined objectives. Successful implementations of LMS have brought a variety on its usage from different cultures, genders, age groups or schooling levels. Hence, this study focuses on understanding the role of culture on LMS design, in along with the effects of gender, age and school year variables. The study participants were German (n = 83) and Spanish (n = 83) university students attending a fully online course offered by a South Korean university. At the end of the course, the students were asked to fulfill a survey on effective LMS design by pointing which features of LMS were more important for them. The survey included twenty questions on four major design factors; content management (six items), ease of use (five items), communication within LMS (four item) and screen design (five items). The dataset was analyzed by non-parametric statistical techniques around four variables on four dimensions (and their related survey questions). The most important result was insufficiency of one unique LMS design for all students which demonstrates the necessity of student demographics tailored smart systems. Additionally, age and gender variables were not making significant differences on LMS design as much as culture and school year variables. The study also revealed that while German students would appreciate goal-oriented individual learning, Spanish students would value process-oriented group learning with active communication. Furthermore, many features of LMS were highly valued by the freshman students more than other levels. The paper discusses these variables with possible explanations from the literature and depicts implementations for future design practices.

Background The role of global initiatives in catalyzing change within national contexts is complex and less understood. Addressing adolescent sexual and reproductive health in Kenya requires concerted efforts of both state and non-state actors and more importantly, a supportive environment. This paper deconstructs the moral and social narratives of adolescents’ and young people’s sexual and reproductive health (AYSRH) in Kenya as driven by the powerful discourse and ideologies pre- and within the Millennium Development Goal (MDG) era. Methods Literature was systematically searched in PubMed and Medline with policy documents obtained from government agencies from the pre-MDG period (2000 and earlier) and within the MDG period (2001–2015). Literature with a substantial focus on SRH were eligible if they captured the different facets of ASRH in Kenya and sub-Saharan Africa (SSA). The results were reviewed and synthesized to disentangle the moral and social narratives of AYSRH in Kenya with an MDG lens. Results The evolution of AYSRH policies and programmes in Kenya was gradual and largely shaped by prevailing development threats and moral and social narratives. Pre-MDG period was dominated by issue-based policies of population growth and high fertility rates, with a focus on married population with strong cultural and religious barriers to AYSRH; early to mid-MDG was mainly influenced by the threat of HIV/AIDS, culminating in the first Adolescent Reproductive Health and Development Policy in 2003. However, the policies and subsequent programmes focused on abstinence only and medical narratives, with persistent religious and cultural opposition to AYSRH. Late-MDG saw more progressive policies (these are policies that refer to those that tends towards acceptance of liberal social reforms and which sometimes are contrary to entrenched social norms, beliefs and practices), high government commitment and a refocus on SRH issues due to sustained early childbearing, culminating in the revised Adolescent Sexual and Reproductive Health Policy of 2015. Conclusion Debates in the translation of global goals and commitments to policy and practice at country level need to account for national level realities in AYSRH reforms. The findings contribute to critical evidence for strategic policy and programming approaches for AYSRH in Kenya and in SSA and for the realization of their rights within the context of sustainable development goals.

PURPOSE: There is a dearth of knowledge and limited research on the needs of Hispanic male cancer survivors (HMCSs). There is a clear need for the development of culturally and linguistically adapted needs assessment tools that are valid and reliable for use among the growing HMCS population. Thus, the purpose of this paper is to describe the field testing and psychometric evaluation of the translated and culturally adapted Spanish Cancer Survivor Unmet Needs Measure (S-CaSUN). METHODS: Hispanic male cancer survivors (n=84) completed the Spanish CaSUN (S-CaSUN), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Cancer Therapy-General Population (FACT-GP). Construct validity of the S-CaSUN was assessed by correlation analysis among aforesaid measures. A test-retest procedure with two-week delay was used to examine reproducibility with a participant subsample (n=50). Cronbach's alpha was computed to assess internal consistency of the S-CaSUN. RESULTS: Construct validity of the S-CaSUN was estimated by moderate correlation with the HADS anxiety (r = 0.55, P

Although a great deal of literature has looked at how individuals respond to stigma, far less has been written about how professional groups address challenges to their self-perception as abiding by clear moral standards. In this paper, we ask how professional group members maintain a positive self-perception in the face of moral stigma. Drawing on pragmatic and cultural sociology, we claim that professional communities hold narratives that link various aspects of the work their members perform with specific understanding of the common good. These narratives allow professionals to maintain a shared view of their work as benefitting society and to perceive themselves as moral individuals. As a case study, we focus on the advertising industry, which has long been stigmatized as complicit in exploitative capitalist mechanisms and cultural degradation. We draw on nine total months of fieldwork and seventy-four interviews across three US advertising agencies. We find that advertising practitioners use narratives to present their work as contributing to the common good, depicting themselves as moral individuals who care about others in the process. We analyze three prevalent narratives: the account-driven narrative, which links moral virtue to caring for clients; the creative-driven narrative, which ties caring to the production of meaningful advertisements; and the strategic-driven narrative, which sees caring in finding meaningful relationships for consumers and brands.

This paper examines the convergence of culture, myths, and taboos surrounding reproductive health issues African immigrant women, living in the United States, learned during childhood in their countries of origin. We also discuss how mothers' perceptions of reproductive health education (RHE) influenced the education of their own daughters aged 10-14 years. This was a qualitative descriptive study. Data were collected via interviews and demographic survey. The sample size was 20 African immigrant mothers living in a mid-sized city in the U.S. Interviews were transcribed verbatim. Qualitative data was analyzed using qualitative content analysis. Myths and taboos related to menstruation, sexual intercourse, pregnancy, and HIV/AIDS were reported by the women interviewed. Discussion of these issues was largely taboo, and most myths the mothers learned growing up pertained to sexual intercourse, pregnancy prevention, and pregnancy termination using non-hormonal ingested substances. Myths and taboos about sexual issues are widespread in Africa and are propagated to control sexual behavior, especially that of unmarried people, particularly women. By examining these myths and taboos, we are able to somewhat contextualize the mothers' immigrant experience regarding RHE. Although myths were reported, the majority of mothers did not appear to believe them. The most significant taboo reported was sexual intercourse. This in turn led to mothers' overemphasis on abstinence for their daughters. It is also noteworthy that this sample contained mainly African women who overall were highly educated, spoke English, and could adequately navigate life in the U.S. It is unclear what the results would be if we were to examine African immigrant women with less achievements in these areas.

Background Regulatory authorities in healthcare are authorised to develop and assess the cultural competence of their professionals. There remains significant diversity on approaches to cultural competency training and assessment. Little evidence exists about whether existing cultural competency training leads to improved patient health outcomes and reductions in health disparity. Discussion In this paper I frame cultural competency as analogous to the ocean and consisting of three zones: surface competency zone, bias twilight zone, and the confronting midnight zone. The surface competency zone focuses on deployment of culturally-specific knowledge: what people see, say, and do. The bias twilight zone is where people engage in critical reflection on their inherent/unconscious biases, and how such biases inform their thoughts and practices. The confronting midnight zone is where people engage in critical consciousness and self-awareness. Here they look beyond their biases to interrogate their power and positionality in society (their own privileges and centralisation). This attention is coupled with a commitment to social justice and to working within their means to reduce health disparities. Conclusions I suggest surface cultural competency is somewhat easier to see, teach and reach than the bias twilight or confronting midnight zones. But it is these deeper zones that cultural competency training needs to attend to if we are to see systemic cultural changes in healthcare provision. Research assessing the extent by which cultural competency training within each zone informs improved patient outcomes and reductions in health disparity is called for.