Use the information below to fill in the blanks for the Unit 1 Preparations section II Cultural Influences on Nutrition and Cultural Competency.

Some of the commonly cited reasons for needing culturally competent health care individuals includes the following:
 Merriam-Webster Dictionary defines culture as "... the integrated pattern of human knowledge, belief, and behavior that depends upon man's capacity for learning and transmitting knowledge to succeeding generations." Therefore, culture is not something we are born with, but rather it is learned and passed on from one generation to the next. Culture encompasses more than simply race or ethnicity because it is a shared system of values, beliefs, attitudes, and learned behaviors. For example, dress, family structure, language, and food habits often indicate one's culture.

Below are a few pictures that were taken while my husband lived in Japan. The first picture shows the traditional attire that is worn for kyudo, or Japanese archery. The second picture was taken at the end of a tea ceremony, or chakai, and the women are all adored in kimonos. The next picture is of me taking shodo or calligraphy lessons in Japan, and the last picture is of dango, which are Japanese dumpling made from rice flour and is often served with green tea.
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Every decade a census of the United States is conducted. According to the U.S. Census 2000, 284 million people live in the United States. The categories used in the most recent census included white, black or African American, American Indian and Alaska Native, Asian, Native Hawaiian and other Pacific Islander, and "some other 'race.'" Note: Clearly, there are many subgroups within each of these categories.

The expected changes in the nation's demographic makeup in race and age categories have been cited numerous times as reason enough for health professionals to pursue personal competence in cultural knowledge. It is projected that by 2050 Latinos will triple to become the largest minority group and the percentage of Asians will nearly double. By 2065 Non-Hispanic whites will most likely be a minority group.

The U.S. Census Bureau website, 2005-2007 American Community Survey includes a breakdown of the demographic characteristics of Lane County, Oregon:

POPULATION OF Lane County: From 2005-2007, Lane County had a total population of 340,000 - 172,000 (51 percent) females and 167,000 (49 percent) males. The median age was 38.1 years. Twenty-one percent of the population was under 18 years and 14 percent was 65 years and older.

Please go to the following link (http://factfinder2.census.gov) and enter Lane County, Oregon. Under "Quick Start" enter Lane County, Oregon and then click on "Go". In the "Search for" box enter "demographics" and a file titled "ACS DEMOGRAPHIC AND HOUSING ESTIMATES" should be one of the first files listed. Click on that file and answer the demographic questions and Lane County below:
 Using the maps below, what do you find to be most surprising or interesting? (Map 1 on the left or top shows the percent of the total population who are American Indian and Alaska Native alone in 2007 and Map 2 on the right or bottom shows the percentage of the total population who are Asian alone in 2007.)

Map 1: Percentage of the total U.S. population who are American Indian and Alaska Native (click here for map legend). (Note: As of 3/29/2012 the link is no longer intact, but the darker the area on the map, the more concentrated the population group that resides in that area.)
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Map 2: Percentage of the total U.S. population who are Asian alone (click here for map legend). (Note: As of 3/29/2012 the link is no longer intact, but the darker the area on the map, the more concentrated the population group that resides in that area.)
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Many agree that the US population is currently more like a "salad bowl" rather than a "melting pot." A salad may contain many ingredients, and blend into a harmonious whole, but each ingredient retains its unique taste and texture.

However, it is not enough to simply recognize and accept that our culture continues to diversify. Cultural competency, especially in healthcare, is the ability to understand and respond effectively to the cultural and linguistic needs of patients or clients. Implied is the acceptance and tolerance of different backgrounds and their associated traits, beliefs, etc., and absence of prejudice against unfamiliar cultures. Learning to value diversity and being open-minded about other cultures are key characteristics of cultural competency. A culturally competent professional recognizes and understands the differences in his or her culture and the culture of the patient or client. Therefore, it is no wonder that cultural competency is a current buzzword in health care.

Cultural competency is a process that occurs along a continuum. At one end of the continuum is cultural destructiveness and at the other end is cultural proficiency. The chart below was developed by the National Center for Cultural Competence in 1999.
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According to the University of Michigan Health System, the steps involved in developing personal cultural competency are as follows:
 Considering self-assessment is an essential element of cultural competence, the following activity will allow you to assess your cultural competence:

Cultural Competence Health Practitioner Assessment

 Along this journey to attain cultural proficiency, it is important to understand the difference between stereotyping and generalizations. Stereotyping is an assumption that ALL people in a particular group think and behave alike. Stereotypes are often judgmental and do not allow for individual differences--for this reason, a stereotype is an ending point. For example, a stereotype could be that "All white southerners eat pork, have buttered grits for breakfast, and drink sugared tea." In contrast, generalizations refer to the trends or behaviors within a group, but with the knowledge that further information is needed to determine if the generalization applies to this particular person.  Therefore, a generalization is a starting point. An example of a generalization-based questions is asking a Jewish client "Do you follow traditional Jewish dietary laws?" This question provides a starting point to work from rather than stereotyping that all Jewish clients follow traditional dietary laws.

Keep in mind that just as individuals within a cultural group are unique, so are their diets. For example, not all Japanese-Americans like wasabi. Thus the emphasis should be on seeing the patient or client as an individual, which is also known as patient-centered care. Providing patient-centered care can prevent bias, prejudice, and stereotyping on the part of healthcare providers from contributing to differences or disparities in care. After all, the connection with the patient or client is the most important component.

According to the National Center for Cultural Competence, cultural competency in healthcare is paramount for fostering more favorable clinical outcomes, results in positive and rewarding interpersonal experiences, and promotes patient or client satisfaction. In order for health care to be successful, services must be received and accepted. The real benefit of cultural competency is improved outcomes. Cultural competency is NOT an optional skill to learn, but rather a necessity. In order to deliver culturally competent care, health care providers should understand: beliefs, values, traditions and practices of a person's culture, family structure and the roles within the family in making decisions, health-related needs of individuals, families, and communities, cultural beliefs about health and etiology of diseases, cultural beliefs about healing and disease treatments, and attitudes about seeking help from health care providers.

The dominant American cultural paradigm is largely derived from Anglo-American heritage and places high value on individualism, privacy, personal responsibility and control. The "culture" of healthcare in the U.S. reflects Anglo-American values, many of which include being time oriented, focused on disease management and treatment, and dedicated to preserving life at any cost. These values are often in direct opposition of the values of many traditional cultures, which often believe that fate, God or other supernatural factors determines a person's destiny and directly influences their health and family almost always includes extended family, who commonly participate in the decision-making, especially regarding health care.

When I was a dietetic intern, which means I had completed my Bachelor's degree in nutrition but I was required to complete a one-year internship and pass a national exam before I could use the title of Registered Dietitian, I interned at a hospital where about 70% of the patients were Vietnamese. I covered the cardiac unit and the first nutrition education that I provided was with a patient who primarily spoke Vietnamese and the nurse was our translator as she was from Vietnam. The nurse was kind enough to let me know that when giving dietary instructions it would be perceived as disrespectful to give the instructions without the family present. I agreed to return when the family was present, which was a challenge as I felt I needed to "stay on schedule".

Like language, food distinguishes one culture from another. A culture is strongly identified with its foods, and it's food preferences will out last nearly any other cultural practice. Afterall, what could be more culturally defining and also unifying than diet? Persons of all cultures today expect space to be made for their cultural norms, and individuals who accept the United States as their new home, although they may adopt U.S. portion sizes and fast-food culture, typically maintain many of their own cultural food practices. In order to positively impact the diet and health of a person or family from another culture, one must understand their culture, their communication style, values, and health beliefs. By understanding these cultural aspects institutional food services can work on including a variety of ethnic foods that are reflective of their client base and nutrition counseling interactions can incorporate familiar cultural foods.

The images below were taken when I recently visited Papa's Soul Food Kitchen BBQ in Eugene, OR. The menu included foods most Americans would consider to be unique or strange, such as jerk chicken, southern fried snapper, collard greens, black-eyed peas, and sweet tea.
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A good starting point for learning about cultural, ethnic and religious food customs is to be able to access the nutritional composition of many traditional foods.

A handy resource is the Oldways website. The mission of Oldways is an internationally-respected non-profit, changing the way people eat through practical and positive programs grounded in science, traditions, and delicious foods and drinks. It is best known for developing consumer-friendly health-promotion tools, including the well-known Mediterranean Diet Pyramid.

The Asian Diet Pyramid, Mediterranean Diet Pyramid, Vegetarian Pyramid, and the Native American Food Pyramid can be found at the Food and Nutrition Information Center website (www.nal.usda.gov/fnic).

The packet will ask you a few questions that will require to check out the Ethnic/Cultural Food Guide Pyramids.
 Starting next week, Week 2, you will work in groups to analyze the nutritional status of an individual of a different racial, ethnic, and/or religious group and life cycle stage. The cuisines that will be discussed for each racial, ethnic, and/or religious group will include the following:
Based on what we've discussed about the importance of cultural competence we all must continually seek out opportunities to develop culturally competent skills. Some of the ways in which you can do this are listed below:
Below are a few images we took when we attended a Japanese-American Lantern Festival in Eugene, Oregon.

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One consequence of not attaining cultural competency can be seen in the multitude of healthcare disparities that exist in the United States. A healthcare disparity occurs when a segment of the population bears a disproportionate incidence of a health condition or illness. A segment of the population can include gender, race, ethnicity, education or income, disability, living in rural localities, or sexual orientation.

In the U.S. there are four historically under-represented people groups, African Americans, Native Americans/American Indians, Latinos, and Asian Americans/Pacific Islanders. (Sound familiar to the categories used in the most recent census?) In general, there is a higher incidence of certain cancers, cardiovascular disease, diabetes, obesity, and mortality in these population groups compared to non-Hispanic whites.

The following list includes some of the most common causes of healthcare disparities in the U.S.
 The following is an example of a healthcare disparity:
 Unfortunately, in today's fast paced life the health care system is not immune to time pressures. The Institute of Medicine, in its report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, cast a spotlight on time pressure in the clinical setting to eliminate stereotyping and other uncertainties that could have a negative effect on quality of care. “In the process of care, health professionals must come to judgments about patients’ conditions and make decisions about treatment, often without complete and accurate information. In most cases, they must do so under severe time pressure and resource constraints... [leading to] those factors identified by social psychologists as likely to produce negative outcomes due to lack of information, to stereotypes, and to biases.”

The Office of Minority Health of the US Department of Health and Human Services (HHS), in conjunction with the Agency for Healthcare Research and Quality, established National Standards on Culturally and Linguistically Appropriate Services (CLAS), a collection of 14 mandates, guidelines, and recommendations designed to eliminate racial and ethnic health disparities. The idea behind the CLAS system is that better communication leads to better adherence to medications and lifestyle changes, which leads to improved health status, which leads to less use of emergent care services and less frequent hospitalizations.

Click on the CLAS link above to review the 14 mandates, guidelines, and recommendations. Which one do you think will be most helpful in eliminating racial and ethnic health disparities and why?