Culture-Based Health Practices in Tribal Communities and Challenges of the Nurses; Basis for Health Education

This research explored the culture-based healthcare practices of Bangsamoro residents and how their culture-based healthcare practices address their health needs. Also, these have enumerated the numerous challenges nurses experience during health education and how they address the challenges encountered. The research was conducted based on firsthand interviews and observations as well as unstructured observation, semi-structured interviews, and focused group discussions considered to find the research outcomes. Utilizing narrative-thematic analysis as its methodology, results determined that there are similarities and differences in their culture-based practices among the different Bangsamoro tribes which mainly affect their health-seeking behavior. The different challenges identified were linked to the influences of the practices of the Bangsamoro Tribes. The research shall be a framework for more culturally sensitive healthcare activities to benefit the respondents.


INTRODUCTION
Health Education is a vital component of the health care workers in addressing health care issues, not only in the hospital setting but as well in the community setting. In the past decades, as the health care system improved, health education has been in the hands of healthcare professionals as tools for teaching their patients to achieve the optimum dynamic balance between physical, emotional, social, and cultural aspects of health. It has been agreed among health care practitioners, academicians, policymakers, and researchers that they recognize the role of health education in improving the overall status of public health. Despite the continued efforts of the different health organizations, the World Health Organization in improving the health care agenda of the population and there has always been a challenge and a spectrum of problems that persist to be a hindrance to achieving the safest possible health care service that the people do truly deserve. Lack of sufficient budget for health care facilities challenges the manpower services for both local and private health institutions; technological deficits and cultural barriers strongly affect the health literacy and health-seeking behavior of the community residents. Health education is the primary medium between a health care personnel and its client to produce health-related interaction to achieve its primary goal, which is to improve health through language. It can also be concluded that since health education has been the key point medium to improve health, the interaction between two or more individuals with various cultural affiliations may create an opportunity for miscommunication. The message of health education to its respondents cannot be truly effective unless the health educators truly understand the meaning of transcultural health education bridging the gap between the two thus the conceptualization of this research study. This study's primary purpose was to explore the culture-based healthcare practices among the selected Bangsamoro Communities in Zamboanga City. Specifically, it aims to answer the following.
2. What are the challenges of the nurses during the conduct of health education in the community?
3. How do the nurses address the challenges encountered during the conduct of health education? The outcome of the study would play an important role to the following groups; the residents of the selected Bangsamoro Communities will pave the way for the realization of more culturally sensitive health activities, and the Community Nurses shall be able to gather a comprehensive assessment of various culture-based practices of the Bangsamoro residents which can be used as baseline data to formulate an effective health education framework for the residents that will address health issues and concerns in more culturally sensitive health activities, the policymakers specifically the Department of Health and City Health Office create health programs that are appropriate and acceptable for the Bangsamoro residents, the Higher Educational Institutions and Colleges of Nursing Education to include it in the community health nursing exposure, and lastly to the future researchers as a reference whose study is deemed similar to this research. Therefore, the primary purpose of the research is to explore the different cultural practices of the selected Bangsamoro residents and how it affects their health literacy. Also, the research has identified the different challenges of the nurses in the conduct of health education on the same respondents, and how the practices of the Bangsamoro residents would contribute to the challenges of the nurses. The research also has utilized Madeleine Leninger's concepts on transcultural nursing, how the culture care sunrise model would support the data that have been gathered as the product of this research would serve as a basis for a more culturally sensitive framework of health care activities.

LITERATURE REVIEW
Culture has a variety of definitions guided by multiple principles and phenomena. In a group or a subgroup, it can be said that it may exist whether in a total or partial relationship among human behavior, influenced and redirected by different organizations and the byproducts of its behavior. It is a shared pattern of interactions, cognitive constructs, and understanding that are developed by socialization. According to the study, knowledge, institutions, beliefs, traditions, religion, and governance, including all activities on behavior change are affected by different factors of culture. (Huff, 2014). Especially for the special subgroup or indigenous people, health is not merely on the aspect of physical, mental, and spiritual concepts, but as well it deals with how we interpret health issues, concerns on the internal welfare of the community, and the traditional, spiritual connection between land owners and its ancestors which should not be underestimated. (McLennan & Khavarpour, 2004). The complexity of culture in different settings has led to the complicated formulation of a universally, unbiased definition of culture. (Kreuter, et.al.,2003) It must be emphasized that there is no exact definition of culture but there is a general agreement that it is a shared and learned transmission of knowledge and practice from the past to the present generation which comprises the existing norms, practices, values, and ways of life and other societal activities. Additionally, a study conducted by Spenos (2005), regarding the effects of health literacy over cultural experience, states that individuals with adequate health literacy skills must have a health-related experience where they were exposed to the language of health care. Rachel and Annis (2007) have emphasized that nurses should remove their cultural biases and carefully identify barriers among culturally diverse people. All cultures are built with diverse systems of health beliefs to explain what causes illnesses, how it is addressed, and who is involved in the healthcare delivery. The extent to which patients perceive health education to its cultural relevance can have a ripple effect on their reception of the information provided and their willingness to use it. According to Betancourt (2013), the goal of having a standard on cultural care is "to improve the ability of health care providers and the health care system to effectively communicate and care for patients with diverse social and cultural backgrounds." Almost all professional healthcare workers try to address cultural and linguistic differences in the healthcare system. Many views that cultural competencies and health literacy as separate and individual fields of concepts. However, some, have approached it from a more holistic view.

Theoretical Framework
The Leininger Sunrise Model represents the structure of culture care theory by describing the relationship between anthropological and nursing beliefs and principles. Nurses use this model when making cultural evaluations of patients. The model connects the concepts of the theory with actual clinical practices while offering a systemic approach to identifying values, beliefs, behaviors, and community customs. The model encompasses numerous aspects of culture: religious, financial, social, technological, educational, legal, political, and philosophical dimensions. These factors, along with language and social environment, significantly affect the services delivered by systems, whether traditional or professional. Traditional healthcare systems are based on conventional beliefs related to health, whereas professional systems rely on learned knowledge, evidence-based practice, and research. The nursing profession considers patients' physical, spiritual, and cultural needs. A thorough understanding of these needs facilitates the achievement of desired clinical outcomes. Moreover, Leininger's model helps healthcare professionals to avoid the stereotyping of patients. To accomplish such goals, the model utilizes three concepts: culture care maintenance/preservation, culture care negotiation/accommodation, and culture care restructuring/patterning. Cultural preservation refers to nurses' provision of support for cultural practices, such as employing acupressure or acupuncture for anxiety and pain relief prior to medical interventions. Similarly, cultural negotiation refers to the support provided to the patients and their family members in carrying out cultural activities that do not pose threats to the health of the patients or any other individual in the healthcare setting. Finally, cultural restructuring refers to nurses' efforts to deliver patient-centered care by helping patients modify or change their cultural activities. Cultural restructuring is suggested only when certain cultural practices may cause harm to the patient or those in the surrounding environment. These concepts can inform nurses in achieving their ultimate goals to have more culturally sensitive care. (Albougami et. al, 2016)

MATERIALS AND METHODS Research Design
This qualitative research identified culture-based health care practices based on firsthand interviews and observations. This type of research design tends to emphasize the dynamic, holistic, and individual aspects of the nurse's experiences as well as of the Bangsamoro residents specifically Yakan, Maranao, Maguindanaon, Tausug, and Sinama which attempts to capture those aspects in their entirety within the context of those who are experiencing them. Data collection and analysis are used based on a research design that progresses concurrently as the study shifts through information, insights are gained, new questions emerge, and further evidence is sought to confirm the insights. Thematic respondents. It was noted that the community has embodied residents who are included in the Bangsamoro entity (specifically Tausug, Yakan, Maranao, and Sinama) in the communities of Rio Hondo, Mariki, Tumaga Taluksangay, and Upper Calarian.

Analysis of Data
The data gathered from the participants was consolidated and analyzed through narrative thematic analysis. According to Miles, Huberman & Saldana (2014), there are three phases to analyzing qualitative research through this process. The following are the processes employed in this study.
1. Data Condensation is the process of reducing a large amount of data into some condensed meaningful units that can help us understand and address our research problem.
2. Data Display is the process that refers to ways we use tables and other graphic representations of the data to synthesize it and make it even much more understandable to the readers of this study.
3. Conclusion drawing or verification, which helps the researcher draw conclusions and make interpretation of the data. It helps address the research problem and the research questions and propose solutions to the problem. In general, after the consolidation of data from the interview and focus group discussion, coding was essential to fuse concepts similar thus reducing saturation with the available data on hand. Coding more concepts from the gathered data filtered the recurring ideas making it easier to categorize the ideas. When categorization occurs, interpretation comes in followed by synthetization which arrived at your conclusion that answered your research questions.

RESULTS AND DISCUSSION
Based on the approach of Miles and Huberman's thematic analysis, there were two themes identified, and the 1st theme has been categorized further into two on the aspect of Bangsamoro's cultural practices.

First Theme-Cultural Health Traditions Similar Cultural Health Practices
There were seven (7) identified similar cultural health traditions that have been identified during the interview. The following are as follows.

Practice of "Pagduwa'a"
This is a common practice among all Bangsamoro entities that have been interviewed in this study. Pagduwa'a is a practice of the residents since they have a strong relationship with Islam as their religion. It has been said that when somebody is sick, elders shall perform a prayer asking for help from God to alleviate the sickness of the individual, then the offering of the slaughtered animal shall be done. A major theme that has been explained during the interview is that pagduwaa can be done at home every Friday or may be done by the elders of the analysis was the data analysis center to further inline the study's research design.

Sampling Design
The study was conducted at the selected Bangsamoro Community in Zamboanga City. The research sample was composed of 10 community deployed nurses in the selected Bangsamoro community and 10 community residents of the selected community. The sampling technique used was purposive sampling. Throughout the entire research process, snowballing was also utilized as referrals occurred during the data gathering process.

Research Instrument
Unstructured observation, semi-structured interview, and focus group discussion was utilized, which were approved and thoroughly scrutinized by the College Technical and Ethics Committee to ensure the accurateness and sensitivity of the research questions to be used. A camera/ recorder was used with the consent of the respondents during the duration of the interview and focus group discussion.

Research Locale
The research locale was selected based on the necessity of the researcher and the presence/ availability of the sick individual in their hometowns such as Jolo which is done in the mountains. This has been a tradition and has been passed on generation and generation that serves as a cure when medicine cannot answer the problems of the sick accordingly. Verbalization supported the practice.
• "…3rd we must have a strong sense of faith with our Lord, praying that we will always be in good health. For example our daily prayers, we should not forget on praying to our ancestors, like climbing mountains and offering sacrifice for them." (P1-Tausug) • "…all praises to God! Pray only because this will help us and always ask for help that we will be in good shape; our sicknesses will be healed.". (P2-Maguindanaon) • "pray to the almighty one, pray 5x in a day and ask for help that our sicknesses will be healed." (BR 3-Sinama) • "..when you were young, you will be brought to the mountains in Jolo and will perform prayers there, the soil coming from the grave of your ancestors will be wiped on your forehead for protection ad yes it will help us." (P4-Tausug)

Practice of "Tubig-Tawal"
This is a concept widely practiced by the respondents of this study. In this concept, the individual takes "prayed" water or blessed water wherein Qur'anic prayers were done. There is even one respondent named it "ruqyah" wherein you need to read specific verses of the Quran into the water before giving it to the sick individual. They also used this holy/ blessed water imbued with prayers in wiping parts that are inflamed or in pain by the sick person. It is believed that this holy water can alleviate the pain/inflammation by wiping it directly to the affected area.
• The first thing we do is that we let the sick person drink a glass of water which was prayed on." (BR 3-Sinama) • "get a glass of water and pray over it and ask for help to God if he can alleviate the sickness. We always do this practice especially if the sickness does not recover. " (P4-Tausug) • "..a glaff of water is prayed on, that will be drunk by the person who is sick or wiped over with the part that is painful. When we have Zam-zam water then better." (P5-Tausug) • "..another practice we do is that we let our sick family members drink water prayed with Quranic prayers, the same water will be used to wipe over the part that is painful." (P6-Sinama)

Use of Amulets
This is another concept that is common among all the respondents. Based on the interview, the concept of the use of amulet/s can protect them from sickness or can cure them from sickness. One respondent said that it is common in the Tausug culture wherein a piece of stone or a piece of Qur'anic text can be placed in a pouch and used as a necklace. It can be noted that the use of amulets has been widely used not only by the Bangsamoro tribes but by many ancient Filipinos which has been carried on until the present.
• "…prayers only, I remember we have ancestors that place Quranic text in our necks to serve as amulets." (P5-Tausug) • "Another practice is by using "habay-habay" or amulets placed in the abdomen. The amulet contains a special stone that has been prayed or stone coming from the graves of our elders that will serve as a protection or lucky charm for the bearer." (P6-Sinama) • "..You know it is a trend to use amulets wherein Quranic text is in it and create it into necklaces to protect us from sickness and misfortunes." (P8-Maguindanaon)

Concept of "Paghagtuh"
This concept is common among Bangsamoro tribes wherein an elder performs this by massaging the scalp of the individual and pulling hair by area wherein they believe that this releases the stress and sickness in the individual. The elder also wipes her hair to the sick individual after massaging it because they believe wiping it over the sick person's body will cleanse the individual's impurities and will remove all its suffering. They believe that the sickness of the individual has been caused by an evil spirit and by doing this practice, the spirit may be removed from the body.
• But sometimes, we have our grandparents who perform "hagtuh" when we have headaches. (P2-Maguindaoan) • Another practice that we do is we let our grandparents perform "hagtuh" to remove evil spirits that may cause sickness from us. (P3-Sinama) • Sometimes, my grandmother performs "hagtuh" to us, wherein they pull hair and wipe it over us. (P4-Tausug) • ".. those are the things we do, we also have paghagtuh wherein the one performing it will massage the head portio and pray over on it and seek for the reason for the headache." (P6-Sinama)

Use of Herbal Medicine
The use of herbal medicine has been evident not only with the interviewed individuals but as a universal alternative practice for healing by a lot of indigenous groups. As stated by the respondents of this study, traditional herbal medicines have been used to treat toothaches, body pain, post-labor bleeding, and other ailments per se. Some herbal medicines that have been stated were guava leaves concoction, pitawali, pigi bangkal, jiddam seeds, and garlic.
• "Another thing that we have inherited from our elders is the practice of drinking herbal medicines to treat hypertension and diabetes. Having a healthy diet by eating vegetables is also another practice we do" (P4-Tausug) • "Another practice that we strongly believe is by drinking herbal medicines from herbal extracts such as from "pigih bangkal", "pitawali" and "panaktakan" which has medicinal properties that have not yet been studied by science." (P5-Tausug) • "We also take lagundi or papaya extracts to treat us." (P9-Maranao) "Hilot" as Remedy This is another common practice that has been continuously mentioned by the respondents during the interview. As verbalized by the respondents, a hilot massages the inflamed or painful part of a sick individual with the use of herbal oil. They believed that doing this, can hasten the healing or remove the source of pain and Am. J. Interdiscip. Res. Innov. 1(2) [34][35][36][37][38][39][40][41][42]2022 sickness. This is usually done by a "mangungubat" locally known as hilot in Filipino terms.
• "Massage when there is something painful, at times Efficascent oil is applied, which can cure body pains" (P1-Tausug) • "Massage is a good treatment especially when someone has fever accompanied with prayed water. But when the patient is already severe then he must be brought to the hospital." (P3-Sinama) • "Apu Aliya knows how to perform hilot and hagtuh that's why we really go to her." (P7-Yakan)

Concept of "Pagliguh"
This is a concept introduced by some of the respondents that can be categorized culturally or religiously depending on they define it. On the cultural aspect, according to the respondent, they believe that this concept cleanses and purifies the individual who is sick by letting the individual take a bath in water poured by the faith healer while uttering prayers which is derived from Quranic verses. They also believe that doing, this removes the "jin" of spirits residing in the body of the sick individual that causes the sickness of the person. • "We do "pagliguh" to remove spirits that are attached to the sick people. We let them take a bath and pray over them" (P2-Maguindanaon) • "When a person comes back to Islam, we perform "pagliguh" over him. Also during Ramadan we perform "pagliguh" to cleanse ourselves from our sins. (P3-Sinama) • "..pagliguh is important for Muslims because it is way to cleanse its sins. We bath the person who is sick, and we pray over them" (P4-Tausug) • "..those who are knowledgeable in performing this are the Imams or shamans. They bath the person to remove spirits with you that causes the sickness." (P 5-Tausug)

Unique Cultural Health Practices
There were six (6) identified unique cultural health practices identified during the interview. The following are as follows.

Use of Sea Water as Treatment
This is practice verbalized by Bangsamoro resident 3. According to her, taking a bath in sea/salt water can remove and purify the sickness and stress of an individual. According to Bangsamoro resident 3, further explained that usually it is done during the month before Ramadan wherein an event called "Panulak Bato" is practiced by their tribe wherein an Imam or the head of the family prays over the members of the family while they are taking a bath in the seawater. They throw stones behind them indicating that they are throwing away their bad luck and sickness cleansing and preparing them for the upcoming year. Also, Bangsamoro 10 expressed that seawater is also a treatment for those who have skin diseases and joint paints.

Exotic Treatments
These are some exotic animal parts used as treatment as verbalized by the respondents during the interview. It has also been noted that during the focus-group discussion this was filtered and was not agreed upon by the twosimilar tribe respondents.
• Use of Stingray Skin-This is a practice verbalized by participant 10 who believes that using this exotic animal part can cure skin diseases and can aid in the healing of a wound. This is a unique practice solely presented by this respondent.
• Use of "Tabil" Extract. This is a practice mentioned by Participants 3 and 8 wherein local green tree lizard is being captured and used as the main ingredient for concoction used to treat asthma. Accordingly, as stated in the interview, the lizards being captured are fried and pulverized to be mixed in boiled water to serve as a treatment regimen. Both respondents have reinstated the purpose of this practice.
• Use of Whale Bones. This is a practice verbalized by Bangsamoro resident 6 reinstating that they use whale bones as a treatment regimen for wound healing. According to the respondent, old whale bones provided by the shamans of their community are pulverized and mixed with water and applied directly to open wounds. They believe that they have antiseptic/antibacterial properties that can aid wound healing.
• Use of Kamanyan Stones-Frankincense in English term as mentioned by participant 8 to drive evil spirits accordingly. The respondent narrated that "kamanyan" stones are being lit up to smoke the sick person as this will drive the evil spirit away with the aromatic smell released by the stone.
• Gas as Tetanus Remedy-According to participant 7, natural gas is used to avoid tetanus in wounded persons. As narrated, after washing the wound, the gas shall be applied thoroughly to the affected part. This shall be mixed with vinegar accordingly to destroy tetanus bacteria on the wound.

Second Theme-Religious Health Traditions
Concept of Pagduaa "We also do "Ruqyas" wherein we pray on the water with Quranic supplications to remove spirits on the person who is sick in case. So far that's the only practice we do, we don't perform prayers in the mountain, etc",(P9-Maranao) Concept of "Pagligguh" "..when somebody dies, pagliguh is done to the body then is wrapped by a white cloth. We also perform pagliguh during Fridays before we go to Masjid for prayers, because it is a way to cleanse oneself." (P9-Maranao)

Use of Herbal Medicines
We also use black seed oil which we use for different skin diseases, stomachaches, at times diarrhea, which our stocks come from my sibling in Saudi Arabia. Even the Zamzam water from Saudi, we use it because of its healing properties" (P9-Maranao) "For us, we also utilize Honey to treat different wounds. We also drink it because it serves as a vitamin supplement for us. This is based on the Quran" (P 9-Maranao) Inherently, it can be inferred that culture and religion play a significant role in the health-seeking behavior of the Bangsamoro residents. The study presented that despite the differences in the tribal affiliations of the Bangsamoro residents, there were a lot of similarities present in how they address their health needs. The participants also emphasized that beliefs and practices whether it was deemed cultural or religious, made an impact on the regularity of the individuals in seeking consultation from medical practitioners. Concepts on the practice of "pagduwa'a", "tubig-tawal" and "paghagtuh" is the common denominator among all. Evidence of the practices was verbalized and thoroughly explained. This can lead to the idea that culture revolves around the faith of the Bangsamoro residents which is Islam. In a study done by Domain (2001), on the cultural practices of a pregnant woman in northern New Mexico, the researcher's findings on the study have shown that the participants expressed their beliefs as strength comes from God and their religion. Just like in this study, all of the similar practices centered on the strong ties and beliefs in their religion which is Islam.
Another study that will support the findings is a study presented by Rogers (2010), exploring the different health beliefs and care-seeking behaviors of the participants. The findings o her study showed that using traditional care was a long cultural tradition of the individuals, which were familiar to them, knew how to it, and were comfortable using them The culture-based health care practices evolved a sense of familiarity to them. In comparison with the findings of this study, most of the Bangsamoro residents would reiterate that culture-based health practices are proven and tested through time and have been passed down generation by generation which will explain their efficiency in treating the sick for them. Furthermore, all the similar practices identified in this study played on putting a solution to the different concerns of the residents, financially as well as spiritually. Subsequently, the unique practices identified in this study have contributed to the healthcare management of certain Bangsamoro entities, depending on which tribe explains it. Based on the discussions with the participants, it was understood that individuals do have unique practices that can solely be found in a certain individual, depending on how they define and practice it, but the commonality is that it revolves around the faith that is being practiced by the respondents. Lastly, religious practices were categorized separately and were classified as a separate theme for their definition and explanation are different depending on the respondents that were asked. As one respondent has quoted, "Nowadays, we thought that our practices are Islamic in nature, but if we are going to study the Qur'an, it will tell us that those practices are not Islamic but cultural in nature, we just got it from our ancestors which have many influences way back then." On the other hand, the following are the concepts and themes presented during the interview and focus group discussion done to the community nurses who are mainly involved in handling the different Bangsamoro residents on what are their difficulties and strategies to counter them.

Lack of Knowledge of the practices of the Residents
Based on the interview, the nurses would emphasize that sometimes they do not understand the rationale behind the culture-based health practices of the residents, and they sometimes invalidate as the practices that are being stated by the residents are not scientifically proven. Another contributing factor that gives them less interest in understanding the said practices is due to the difference in religion, set of values, and culture that exists between the nurse and the Bangsamoro resident.

Financial Capability of the Residents
It has been clearly stated that one of the challenges experienced by the community nurses is that the residents do not have enough financial capability to continue medical treatment or neither to avail of the medical treatment that is necessary for the management of the sick. It has been emphasized that due to the low financial capability of the residents, even the nurses teach them to take the medicines needed or to avail the medical services they need, the financial status of the patients hinders it, especially for treatment modalities that do not have any other treatment alternatives.

Dialect Difficulties
Based on the interview and has been agreed by the respondents that another challenge that greatly affects the deliverance of health services/health education is the dialect difficulties that they meet with the different clienteles they have in the community. Due to diverse dialects present in a single community present and sometimes limited vocabulary by the nurse assigned, understanding is established at a superficial level which hinders full understanding of the concepts being taught to the clientele in the community.

Lack of LGU Support
It has also been noted based on the interview and focused group discussion done, that LGU support is inefficient due to the lack of funding for available health services and deliverance for community residences. It has been noted, that community nurses complain lack of resources to be used for teaching a different type of clientele encountered in the community.

Limited Contact Time
Lack of time available for the clients to be taught especially since most of them are working and child caregivers. Sometimes health activities take time which is not appreciated by the clienteles because they need to attend to a lot of other things. Am. J. Interdiscip. Res. Innov. 1(2) 34-42, 2022 Attitude Lastly, the community nurses emphasize that a challenge that is common for them is the stubbornness and dishonesty of the clients they have. Stubbornness in the sense that whatever they teach the clients; they will not still apply the new learning they have. Retention is not evident. Dishonesty also in the sense that the clients do not divulge the true status of their health statuses. The themes are the consolidated concepts extracted from the interview and FGD done by the researcher during the data gathering procedure. The challenges mostly involve interpersonal difficulties between the community nurses and the clients in the community. Logistics comes next as a problem. According to Rogers (2010), people's perceptions of health and illness and how these perceptions interact with cultural context impact how people think about, access, and utilize care. She has discussed that a great deal of the research on health disparities has been fragmented, focusing on just a few of the factors or barriers thought to be related to the different challenges presented, excluding the context in which these factors exist. In comparison with the result of this paper, health literacy among Bangsamoro respondents surfaces as one of the challenges of the nurses that makes it difficult for them to implement different approaches to health activities. Rogers (2010), presented the responses from participants in her study reflected a need for a better connection with the healthcare community (e.g., knowing that resources exist, trusting that they would be met with respect and understanding should they access care) not a need for more clarification of technical healthcare jargon. Further, participants' responses indicated that beliefs about illness and whether family members would support care-seeking behaviors were influential on whether participants would attempt to access conventional care. Understanding the nature of these beliefs and their impact on careseeking behaviors could contribute a great deal to our understanding and implementation of healthcare improvement efforts such as literacy campaigns. This implication can now be derived as to what strategies should be utilized based on the findings from the community nurses that have been interviewed in this study. The following now are the summarized concepts that have been presented during the data analysis.
Alternative Teaching System the community nurses make the most out of it by utilizing different teaching strategies available in the community to make health teaching/ implementation of health activities more efficient. Some that were mentioned were the use of infographics such as videos, use of flyers, or house to house approach wherein the community nurses directly go to the houses of the clients to perform an information drive.

Strengthening Linkages
It has been mentioned during the data gathering process with the respondents that they coordinate with other institutions and private companies with the help of the LGU to conduct different health activities within the community. Due to inadequate funding as narrated, external linkages shall be sought by the community nurses as narrated.

Efficient Teamplay
This is an essential strategy that the community nurses have emphasized wherein they ensure that they help each other to make a health activity successful. Designation and coordination are done whenever an assigned health activity is conducted in the community. About the theory of Madeleine Leininger's Transcultural Nursing, it can be concluded that several factors such as language barrier, community customs, and trust among the Bangsamoro residents in healthcare professionals affect the healthcare services being delivered causing a gap between the two variables. Thus, the model emphasizes that nurses must offer a systematic approach to identifying the values, beliefs, behaviors, and customs of the Bangsamoro residents to produce a more culturally sensitive health care agenda. The data has also presented the different influences specifically the different culturebased practices that affect the health-seeking behavior of the Bangsamoro residents. In summary, nurses who understand and value the practice of culturally competent care can effect positive changes in healthcare practices for clients of designated cultures. Sharing a cultural identity requires knowledge of transcultural nursing concepts and principles, along with an awareness of current research findings. Culturally competent nursing care can only occur when client beliefs and values are thoughtfully and skillfully incorporated into nursing care plans. Caring is the core of nursing. Culturally competent nursing guides the nurse to provide optimal holistic, culturally based care. These practices also help the client to care for himself and others within a familiar, supportive, and meaningful cultural context. Continual improvement and expansion of modern technologies and other nursing and general science knowledge are integrated into practice if they are appropriate. Today nurses are faced daily with unprecedented cultural diversity because of the increasing number of immigrants and refugees. Commitment to learning and practicing culturally competent care offers great satisfaction and many other rewards to those who can provide holistic supportive care to all patients (Leininger 2002).

CONCLUSION
The research has identified the different culture-based healthcare practices, and their differences from one tribe to another, in general, there are commonalities among their practices since the practices mainly revolve around the Islamic point of view of living. Based on the interview and focus discussion that has been done, it can be inferred that culture-based practices mainly affect their ability to seek consultation since their strong relationship Am. J. Interdiscip. Res. Innov. 1(2) 34-42, 2022 with their faith and belief is being considered. Another concept that was raised and pointed out during the discussion with respondents was their financial capability to undergo medical treatment versus the traditional way of healing which is cost-efficient and accessible to the residents. It was derived from the following findings, that despite the community nurses' efforts to bridge the gap between evidence-based health practices with the Bangsamoro residents, religion and culture play a vital role in the healthseeking behavior of the Bangsamoro residents. Based on the data presented, the Bangsamoro respondents presented diverse culture-based practices that affect their health-seeking behavior to medical practitioners, this is because the belief is rooted in their religion which is Islam, which is their way of life. There are also several factors aside from those culture-based practices presented which hinder effective implementation of health-driven activities by the community nurses such as financial incapacity of the residents to be consistent with their treatment modalities, language barrier also exists, lack of LGU support for the health sector in the local level, transient contact time with the residents during health activities and various personality problems among the residents in the community. Thus, it should be emphasized that this paper shall be utilized as a baseline knowledge to develop a framework or teaching modality to effectively implement more culturally accepted health activities for the Bangsamoro residents The researcher recommends for continuity of these studies to further generate knowledge and understanding of the different culture-based practices and challenges of the nurses in the community to further develop existing health programs and create new programs that will be acceptable for the Bangsamoro residents. Also, Islamic scholars in the city may be included in creating these programs to further educate these Bangsamoro residents on the practices that should be done. Furthermore, it is recommended to consider exploring the cultural practices as there are practices that have been practiced for centuries but are only later considered by science.