The PEN-3 Model, was initially developed for use in African countries. It is a conceptual model that is aimed at targeting relevant cultural factors in order to allow for the development of culturally sensitive health outreach and education programming. In the United States, it has been used with the African American population to address health issues, such as HIV prevention, diabetes management, and influenza and HPV vaccine education and outreach programs. The model has three dimensions of health, which are both interrelated and interdependent. These three dimensions are: cultural identity, relationships and expectations, and cultural empowerment. In turn, each dimension has three components (Iwelunmor, Newsome, & Airhihenbuwa, 2014).

The cultural identity, dimension is critical in the development of culturally appropriate interventions targeted to racial and ethnic minorities. This dimension has positive, existential, and negative  components that refer to perceptions, enablers, and nurturers that lead the target population to engage in particular health related behaviors. Positive factors promote engagement in healthy behaviors or promote avoidance of harmful behaviors. There are many positive factors in this dimension in relation to vaccine use. First, African-American culture focuses heavily on inner strength and motivation (Cowdery, Parker, & Thompson, 2010). This strength can be used to promote healthy behaviors, such as getting vaccinations and overcoming any larger systemic issues that arise as barriers. African-Americans also have large extended families and are culturally very family focused. William et al., (2015) found in their study that African-Americans cited wanting to live in order to take of their family and loved ones as an incentive to participate in screening and vaccinations (Williams, Moneyham, Kempf, Chamot, & Scarinci, 2015).

The “existential” factors in this realm refer to culturally based perceptions and practices that may be not align with traditional medical views, such as high rates of faith in the Black community. These factors are typically harmless and should be incorporated into culturally sensitive interventions. Negative factors include perceptions, enablers, and nurturers that inhibit the target population from engaging in healthy behaviors or that cause them to have harmful behaviors (Williams et al., 2015). There are many negative components associated with African-American utilization of health services including vaccines.

Many of these negatives are rooted in a history of medical discrimination and ethical violations. Specific to vaccines, many African-Americans are aware of the incident with denying African-American men the syphilis vaccine in order to study disease progression. There is also historical evidence of medical experimentation in the African-American community. Research indicates that this has resulted in a fear or distrust of the medical community (Tanner, Kim, Friedman, Foster, & Bergeron, 2015). Williams et al. (2015) found that African-Americans feared further discrimination and stigmatization due to new diagnosis when accessing screenings and vaccinations. A culturally relevant program would have to focus heavily on providing information, building trust, and gaining informed consent. Low health literacy and lack of knowledge are also barriers that could be addressed through a dedicated focus on education (Tanner et al., 2015).

The second dimension includes relationships and expectations. This realm focuses on determining the components that impact the person, family, and communit. Positive enablers and nurturers include strong social support networks, such as churches and community organizations. These networks can be used to disseminate information, provide safe places to host outreach and education activities, and house resource and referral information (Williams et al., 2015; Tanner et al., 2015). Perceptions are the attitudes, beliefs, and knowledge that drive or prevent engagement in a specific health behavior. Enablers are community or structural factors like resources and referrals. Nurturers are the components that reinforce the target population and derive from the social network (Williams et al., 2015; Tanner et al., 2015; Iwelunmor et al., 2014).

There are negative enablers including limited African-American medical professionals and medical professionals with insufficient cultural training in relation to the African-American community. Additionally, many public service announcements and outreach materials are not geared towards this community and do not prominently feature African-Americans. This reality can lead to negative perceptions that health interventions and prevention strategies are not relevant to the Black community. Therefore, health education should be culturally sensitive by incorporating respected community leaders and visual materials familiar to the community. Another negative enabler is the fact that many poorer communities of color may be located away from resources and the health management program would need to provide transportation or come into the community (Williams et al., 2015; Taner et al., 2015).

The final dimension deals with cultural empowerment. There are many positive factors related to cultural empowerment. There is a positive perception related to education and an overall willingness to learn. And, there are increasing positive enablers in cultural organizations that focus on health promotion and education. These resources can be used to encourage education and awareness and promote participation in vaccination programs. Negative enabling factors include systemic social economic policies that result in many African-Americans having lower incomes than their White counterparts. And, poorer clients may not be able to afford preventive medicine and vaccinations (Williams et al., 2015; Tanner et al., 2015). Therefore, low cost or free options should be offered. Existential enabler include a reliance on home and family based rumors, which, when appropriate, can be incorporated into education, prevention, and management programs (Tanner et al., 2015).