Giger and Davidhizar’s Transcultural Assessment Model: Complete Guide and Case Study
13 min read Question
Using Giger and Davidhizar’s Transcultural Assessment Model, create a case study for one cultural group and perform a comprehensive assessment of how your selected cultural group’s beliefs and practices might affect healthcare decision-making, treatment adherence, your communication, your interventions, and your education to align with the patient’s cultural values and preferences.
Introduction
Patients bring their culture, language, beliefs, family roles and life experience into every healthcare encounter. When nurses overlook culture, misunderstandings, mistrust, poor adherence and worse outcomes can follow. Giger and Davidhizar’s Transcultural Assessment Model gives nurses a practical, structured way to assess these influences and plan culturally congruent care (Giger & Davidhizar, 2002; Giger & Haddad, 2021).
This article first gives a comprehensive guide to the model. It then applies the model to a case study of a Somali-American Muslim woman with newly diagnosed type 2 diabetes who plans to fast during Ramadan.
Part 1: A comprehensive guide to the Giger and Davidhizar Transcultural Assessment Model
Background
Joyce Newman Giger and Ruth Davidhizar developed the model in 1988 to help nursing students assess and care for patients from diverse cultures. It has since been used in nursing education, practice and research, and in other health professions (Giger & Davidhizar, 2002). The model is explained in the textbook Transcultural Nursing: Assessment and Intervention, now in its 8th edition (Giger & Haddad, 2021).
Key assumptions
- Every person is culturally unique. Individuals are shaped by their culture, but they are not defined by it. Variation within any group is large.
- Culture influences health beliefs, behaviors and responses to illness.
- Culturally competent care is a dynamic, fluid process of finding meaningful and useful care-delivery strategies based on knowledge of the patient’s cultural heritage.
- Assessment comes before intervention. Nurses should assess, not assume.
Structure of the model
At the center is the culturally unique individual. Around this person are six cultural phenomena that vary across and within cultural groups. Each one must be assessed to plan individualized care.
1. Communication
- Language, dialect, voice tone, touch, nonverbal cues, silence
2. Space
- Personal distance, comfort with touch, modesty, body movement
3. Social organization
- Family, religion, roles, decision-making, community
4. Time
- Past/present/future orientation, punctuality, social vs clock time
5. Environmental control
- Health beliefs, locus of control, folk and religious healing
6. Biological variations
- Genetics, disease risk, skin, drug metabolism, nutrition
The six cultural phenomena and assessment questions
| Phenomenon | What it covers | Sample assessment questions |
|---|---|---|
| 1. Communication | Language and dialect; literacy; voice volume and tone; use of silence, touch, eye contact and gestures; preferred interpreter | “What language do you prefer to speak and read?” “Would you like a professional interpreter?” “How do you prefer to be addressed?” |
| 2. Space | Comfort with personal and intimate distance; touch; modesty; body movement; preferences about the gender of the caregiver | “Are you comfortable with me sitting this close?” “Do you prefer a female or male nurse or provider for examinations?” |
| 3. Social organization | Family structure and roles; who makes decisions; religion; community and social networks; work and leisure | “Who would you like involved in decisions about your care?” “How does your faith influence your health?” “Who helps you at home?” |
| 4. Time | Orientation to past, present or future; perception of clock time vs. social time; punctuality; schedules shaped by work, prayer or family | “What does your usual day look like?” “Are there times of day when taking medicine or coming to appointments is difficult?” |
| 5. Environmental control | The person’s ability to plan activities that control nature or their environment; health beliefs; internal vs. external locus of control; folk, traditional and religious healing practices | “What do you think caused your illness?” “What remedies or practices do you use to stay well?” “What do you hope treatment will do?” |
| 6. Biological variations | Body structure, skin color, genetic and disease susceptibility, enzyme and drug metabolism differences, nutritional preferences and deficiencies | “What foods do you usually eat?” “Are there illnesses that run in your family?” plus physical assessment adapted to the patient (for example, skin tone) |
Combining the model with Kleinman’s explanatory-model questions, such as “What do you call your problem?”, “What do you think caused it?” and “What do you fear most about it?”, helps nurses understand the patient’s own view of the illness (Kleinman et al., 1978).
Strengths and limitations
| Strengths | Limitations |
|---|---|
| Simple, organized framework with six clear domains | Can encourage stereotyping if group “facts” replace individual assessment |
| Applicable to any cultural group and any setting | Comprehensive assessment can be time-consuming |
| Includes biological variations, which many cultural models omit | Less focus on structural factors such as racism, poverty and immigration policy |
| Supported by a comprehensive textbook and widely taught | Needs to be combined with cultural humility and self-reflection |
Other well-known frameworks include Leininger’s Culture Care Theory (Sunrise Model), the Purnell Model for Cultural Competence and Campinha-Bacote’s Process of Cultural Competence in the Delivery of Healthcare Services. Giger and Davidhizar’s model is often preferred for bedside and student assessments because of its concise six-phenomenon structure.
Part 2: Case study
Case study: Mrs. Amina H. (fictional)
Mrs. Amina H. is a 52-year-old Somali-American Muslim woman who moved to Minneapolis, Minnesota, 12 years ago. She lives with her husband, three of her five children and her elderly mother-in-law. She speaks Somali and some Arabic, has limited English proficiency and limited formal schooling, and works part-time in a childcare center. At a primary care visit, she is diagnosed with type 2 diabetes (HbA1c 9.2%, BMI 33). The provider prescribes metformin and lifestyle changes. Ramadan begins in three weeks, and Mrs. H. says she plans to fast “as I always do.” Her husband accompanies her and answers many questions for her. She asks for a female provider, keeps her hijab on during the visit, and avoids direct eye contact with the male medical assistant. She mentions that she takes black seed (habbat al-sawda) oil and that “everything is in God’s hands.”
This case is fictional and is used to illustrate the model. Individuals within any cultural group vary widely. Every assessment must be confirmed with the patient rather than assumed.
Part 3: Comprehensive assessment of Mrs. H. using the six cultural phenomena
1. Communication
Assessment: Mrs. H. prefers Somali and has limited English and limited literacy. Somali culture has a strong oral tradition. Her husband speaks for her, which may reflect respect, protectiveness or her language limits. She avoids direct eye contact with men, which is a sign of modesty and respect, not evasiveness. Phrases such as “Inshallah” (God willing) are common and do not mean that she lacks motivation.
Implications: Using family members as interpreters risks errors and may filter information. Written materials alone may not be understood.
Plan: Use a trained Somali medical interpreter, preferably female, in person or by video. Speak directly to Mrs. H., not to the interpreter. Use plain language, pictures and demonstration, and confirm understanding with teach-back. Ask her privately and respectfully how much she would like her husband involved.
2. Space
Assessment: Islamic modesty norms shape her preferences. She asked for a female provider, keeps her hijab on, and may be uncomfortable with touch or exposure from male staff.
Implications: Ignoring these preferences may cause distress, refusal of examinations or missed follow-up visits.
Plan: Schedule female clinicians where possible, explain each step before touching, expose only the area being examined, offer a gown that maintains coverage, and offer a chaperone. For foot examinations and glucose monitoring teaching, ask permission first.
3. Social organization
Assessment: Family is central, and decisions are often made collectively. The husband and older relatives, such as her mother-in-law, may carry significant influence. Islam guides daily life: five daily prayers, halal diet, and fasting during Ramadan. The local Somali community and mosque are important sources of support and information.
Implications: Health decisions may be made with the family, not individually. Religious leaders can strongly influence acceptance of treatment.
Plan: With her consent, include her husband and family in education, especially the family members who cook. Respect religious practice, and consider partnering with a mosque-based or community health worker program for diabetes education. Ask whether she would like to discuss fasting with her imam. Islamic teaching exempts people from fasting when it would harm their health, and an imam’s guidance can support safe decisions.
4. Time
Assessment: Her day is organized around prayer times, work and family responsibilities, and during Ramadan, around the pre-dawn meal (suhoor) and the meal that breaks the fast at sunset (iftar). Some immigrants may also have experienced healthcare systems where preventive appointments were uncommon.
Implications: Standard medication schedules, such as “three times a day with meals,” may not fit Ramadan. Appointment times that conflict with prayer or work may be missed.
Plan: Schedule appointments around prayer and work. Adapt medication timing to suhoor and iftar during Ramadan. Use reminders through phone calls in Somali or text messages read aloud.
5. Environmental control
Assessment: She expresses a belief that health is in God’s hands, an external locus of control combined with personal faith. This does not necessarily mean fatalism or refusal of treatment. Many Somali patients see medical care as compatible with faith. She uses black seed oil, a traditional remedy, and may use Qur’anic recitation and prayer for healing.
Implications: If her beliefs are dismissed, she may hide traditional practices or disengage from care. Some herbal remedies may interact with medications or affect glucose.
Plan: Use her explanatory model to ask what she believes caused her diabetes and what she hopes treatment will do. Frame treatment as working together with faith, for example: “Taking care of your body is part of caring for the gift God has given you.” Ask about all remedies without judgment, accept harmless practices, and discuss any that could be risky with the provider or pharmacist.
6. Biological variations
Assessment: African immigrants to the United States may develop type 2 diabetes at lower BMIs, and diet changes after migration can raise risk. Darker skin and full body covering, combined with Minnesota’s northern latitude, increase the risk of vitamin D deficiency. Lactose intolerance is common in many East African populations. Physical assessment in darker skin requires care: pallor and cyanosis are best assessed in the conjunctivae, oral mucosa and nail beds.
Implications: Standard dietary advice, for example to drink low-fat milk, may not fit. Fasting-related hypoglycemia and dehydration are risks during Ramadan.
Plan: Consider checking vitamin D, and adapt physical assessment for skin tone. Build the meal plan around traditional Somali foods: smaller portions of rice and canjeero (a pancake-like flatbread), more vegetables and legumes, lean halal meats, and limiting sugary tea and sweetened drinks. Refer to a dietitian who understands Somali cuisine.
Part 4: Impact on decision-making, adherence, communication, interventions and education
| Area | How Mrs. H.’s beliefs and practices may affect it | Culturally congruent nursing response |
|---|---|---|
| Healthcare decision-making | Shared family decisions; husband’s and elders’ influence; faith and imam guidance; desire to fast | Ask her preferred decision-makers; include family with consent; offer imam involvement; use shared decision-making about fasting safety |
| Treatment adherence | Ramadan fasting changes meal and medication timing; preference for natural remedies; limited literacy; competing work and family demands | Simplify the regimen; align doses with suhoor and iftar; acknowledge remedies; use pictorial medication schedules; follow up by phone in Somali |
| Communication | Somali-language preference; oral learning style; indirect eye contact; modesty with men | Use a professional female interpreter; speak to the patient directly; use teach-back; respect nonverbal norms |
| Interventions | Preference for female clinicians; modesty; fasting; halal diet | Assign female staff where possible; maintain coverage; work with the provider on a pre-Ramadan risk assessment and medication adjustment; give halal meal planning |
| Education | Oral tradition; family-based food preparation; faith-based motivation | Group or family education; mosque-based sessions; picture-based materials; culturally tailored food plates; faith-aligned messages |
Safe Ramadan fasting: a key intervention
Mrs. H. wants to fast, so the most important culturally congruent intervention is a pre-Ramadan assessment and education session 6–8 weeks before Ramadan, or as early as possible. International guidance recommends that people with diabetes who wish to fast receive individualized risk stratification, medication adjustment and education (International Diabetes Federation [IDF] & DAR International Alliance, 2021). Key points include:
- The provider assesses her fasting risk and adjusts medications. Metformin is generally considered lower risk for hypoglycemia, and doses are typically shifted to suhoor and iftar.
- Teach self-monitoring of blood glucose. Checking glucose does not break the fast.
- Teach when to break the fast: blood glucose below 70 mg/dL, above 300 mg/dL, or symptoms of hypoglycemia, dehydration or acute illness.
- Encourage a balanced suhoor taken as late as possible, plenty of fluids between iftar and suhoor, limits on sweets and fried foods at iftar, and moderate activity.
- Plan a follow-up visit after Ramadan.
Cultural humility: The goal is not to talk Mrs. H. out of fasting, but to help her fast as safely as possible, or to make an informed choice not to fast, within her own values. Respect for her faith builds trust, and trust improves adherence.
Expected outcomes
- Mrs. H. demonstrates correct glucose monitoring and states when to break her fast, through teach-back with an interpreter, before Ramadan.
- She takes her medication as scheduled during Ramadan with no severe hypoglycemic episodes.
- She and her family identify three changes to traditional meals that lower carbohydrate and sugar intake.
- Her HbA1c decreases toward her individualized target within 3–6 months.
- She reports feeling respected and understood by the care team.
Conclusion
Giger and Davidhizar’s Transcultural Assessment Model guides nurses to assess six cultural phenomena (communication, space, social organization, time, environmental control and biological variations) while treating each person as culturally unique. Applied to Mrs. H., the model shows how language, modesty, family decision-making, prayer and fasting schedules, faith-based health beliefs and biological risk factors all shape her diabetes care. Using a professional interpreter, respecting modesty, involving family and faith leaders, adapting medication and meals to Ramadan, and teaching with culturally tailored methods turns these influences from barriers into strengths. The result is care that is safe, respectful and aligned with her values, which supports trust, adherence and better outcomes.
References
Giger, J. N., & Davidhizar, R. (2002). The Giger and Davidhizar transcultural assessment model. Journal of Transcultural Nursing, 13(3), 185–188. https://doi.org/10.1177/10459602013003004
Giger, J. N., & Haddad, L. G. (2021). Transcultural nursing: Assessment and intervention (8th ed.). Elsevier.
International Diabetes Federation & DAR International Alliance. (2021). Diabetes and Ramadan: Practical guidelines 2021. https://www.idf.org/guidelines/diabetes-in-ramadan
Kleinman, A., Eisenberg, L., & Good, B. (1978). Culture, illness, and care: Clinical lessons from anthropologic and cross-cultural research. Annals of Internal Medicine, 88(2), 251–258. https://doi.org/10.7326/0003-4819-88-2-251
