Framing the impact of culture on health: a systematic review of the PEN-3 cultural model and its application in public health research and interventions.

OBJECTIVE: This paper reviews available studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors. METHODS: We search electronic databases and conducted a thematic analysis of empirical studies that applied the PEN-3 cultural model to address the impact of culture on health behaviors. Studies were mapped to describe their methods, target population and the health behaviors or health outcomes studied. Forty-five studies met the inclusion criteria. RESULTS: The studies reviewed used the PEN-3 model as a theoretical framework to centralize culture in the study of health behaviors and to integrate culturally relevant factors in the development of interventions. The model was also used as an analysis tool, to sift through text and data in order to separate, define and delineate emerging themes. PEN-3 model was also significant with exploring not only how cultural context shapes health beliefs and practices, but also how family systems play a critical role in enabling or nurturing positive health behaviors and health outcomes. Finally, the studies reviewed highlighted the utility of the model with examining cultural practices that are critical to positive health behaviors, unique practices that have a neutral impact on health and the negative factors that are likely to have an adverse influence on health. DISCUSSION: The limitations of model and the role for future studies are discussed relative to the importance of using PEN-3 cultural model to explore the influence of culture in promoting positive health behaviors, eliminating health disparities and designing and implementing sustainable public health interventions.