Cultural
Competency — Values, Traditions, and Effective Practice
Today’s Dietitan
By Carol Brannon, MS, RD, LD
Vol. 6, No. 11, p. 14
In the midst of a seemingly homogenous world culture
created by mass media, global commerce, and easy travel, many find
life increasingly complex. The more choices we have, the more separated
we are from our cultural roots. We eat meals that great-grandfather
wouldn’t have even known about. Yet paradoxically, we seek
new experiences while trying to find “comfort zones”
of familiar places and things. The lure of a new “ethnic”
restaurant and a yen for traditional or “heirloom” foods
combine to make the American diet evermore diverse.
The trouble is that these meals may not be particularly
healthful or at least compatible with modern dietary goals. While
tradition may hamper dietitians’ efforts to provide sound
nutritional counseling and dietary modification, more often it is
lack of knowledge about unusual foods that makes providing effective
nutrition education and counseling difficult. To your professional
goal of “core competency”— understanding and applying
nutrition science and dietetic standards of practice—add “cultural
competency.” In this article, we’ll explore what that
means and how to achieve it.
The 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.”1
Culture is not something one inherits biologically.
It encompasses more than simple race or ethnicity—a word used
to describe large groups of people classed according to common racial,
national, tribal, religious, linguistic, or cultural origin or background.1
Culture is learned and passed on from one generation
to the next through enculturation, the repetitious and systematic
inculcation of a shared system of values, beliefs, attitudes, and
learned behaviors.2,3 These include dress, family structure, language,
and food habits.
Diversity—today’s fashionable term—means
dissimilarity and variance between things or people. Cultural diversity
is the recognition that people come from a variety of ethnic, geographic,
economic, and religious backgrounds.1,2,3
Currently, approximately 25% of the U.S. population
consists of ethnic subpopulations. According to the Census 2000,
284 million people live in the United States; 75% are white alone
or in combination with another race and non-Latino; 13% are Latino
or Hispanic; and 12% are African American.4
The census data on race and ethnic origins were
more detailed for 2000 than for 1990. The categories used in 2000
included white, black or African American, American Indian and Alaska
Native, Asian, Native Hawaiian and other Pacific Islander, and “some
other race.” Within each of these categories were many subgroups.4
This reflects the increased diversity of the U.S.
population. The percentage of ethnic subpopulation groups is expected
to increase to approximately 47.5% by 2050; Latinos will be the
largest minority group by 2050. Non-Hispanic whites will most likely
be a minority group by 2065.5,6 There is a great diversity within
these ethnic subpopulations7 as well as a “melting pot”
effect, wherein younger generations move away from some, but not
all, defining characteristics of their ancestral cultures.
Developing Cultural Competency
It is not enough to simply recognize and accept cultural diversity.
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 and beliefs
and absence of prejudice against unfamiliar cultures. Multicultural
is a term often used to describe an organization that promotes an
environment free of discrimination and promotes policies, processes,
and procedures that recognize and value cultural diversity.7
The development of cultural competency is a process
that occurs along a continuum. At one end of the continuum is cultural
destructiveness, and cultural proficiency is at the other end.7
Chart 1 illustrates and briefly explains the six proposed “stages”
along this continuum.8,9
Cultural competency is about learning to value diversity
and being open-minded about other cultures. Culturally competent
professionals recognize and understand the differences in their
culture and the culture of their patients or clients. Cultural competency
is reflected in a professional’s attitude and communication
style. Are you enthusiastic, cooperative, creative, and flexible
in working with people from different cultures?5,10 The steps involved
in developing personal cultural competency are as follows:11
• recognize your own personal cultural biases
and preconceived ideas or opinions;
• desire to learn about and become involved
with people from diverse cultures;
• seek out and increase your knowledge about
other cultures; and
• learn and develop multicultural communication
and counseling skills.
Melting Pot or Salad Bowl?
Developing cultural sensitivity is essential to developing cultural
competency. Cultural sensitivity means recognizing subtle but important
facets of another person’s culture and accepting his or her
expression of the culture. People in minority population groups
no longer feel compelled to emulate middle-class Anglo-American
culture12; many desire to maintain their cultural uniqueness and
individuality. In this way, the U.S. population is currently more
like a “salad bowl” 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.2,12
K. R. Curry, professor emeritus of dietetics and
nutrition at Florida International University, has written: “In
nutrition counseling, where many therapeutic interventions are on
a personal level, sensitivity to the strong influence of culture
on an individual’s food intake, attitudes, and behaviors is
especially imperative.”12
Stereotypes and Generalizations
However, every person has a unique worldview—how they look
at the universe and their place in it to form values, beliefs, and
opinions about themselves and others.3
Cultural sensitivity has a pitfall: stereotyping.
A stereotype is an assumption that all people in a particular group
behave and think alike. Stereotypes are often judgmental and do
not allow for individual differences. For this reason, a stereotype
is an ending point.13 An example of a dietetic stereotype is: “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 whether or not the generalization
applies to a particular person. A generalization is a starting point.13
An example of a generalization-based question is asking a Jewish
client, “Do you follow traditional Jewish dietary laws?”
This question would provide a starting point from which to work
with this client as opposed to assuming that all Jewish clients
follow traditional dietary laws.
Individuals within each culture are unique and have
distinctive characteristics. “Intra-ethnic variation”
refers to the individuality, racial, regional, and economic differences
or diversity within each culture.2,14 As dietary options proliferate,
there will be more such variations.
Outcome Orientation
Culturally competent healthcare fosters more favorable clinical
outcome, results in positive and rewarding interpersonal experiences,
and promotes patient or client satisfaction. For healthcare to be
successful, services must be received and accepted.7 While fairness
and civility are laudable, the real benefit of cultural competency
is improved outcomes. Cultural competency helps ensure delivery
of quality of health and nutrition services, effective communication,
rewarding interpersonal experience, client or patient satisfaction,
and better compliance with treatment plan, all of which lead to
improved health outcomes.7,15
Cultural competency is not an optional skill to
learn; it is a necessity for all dietitians and healthcare professionals,
regardless of their specialty.12,15 There is a need to effectively
communicate and bring about desirable behavior changes in patients
and clients regardless of their cultural background. The goal of
dietitians and other healthcare professionals is to promote positive
behavior changes in their patients or clients.12,16
Effectiveness is determined by evidence of behavior
change in clients and patients. Indeed, healthcare providers are
beginning to recognize that addressing the cultural uniqueness of
their patients is essential to positive health outcomes.17 To ensure
positive outcomes in working with patients or clients, it is necessary
to understand their culture, including their language, dietary habits,
lifestyle, beliefs, and attitudes and values about health.18 Likewise,
health professionals must be culturally competent in working with
fellow health professionals from different cultures. Administrative
dietitians and foodservice managers must be culturally competent
in working with culturally diverse foodservice staff.7
Common and Uncommon Ground
We all share some fundamental needs regarding our health. These
fundamental needs include the need to tell about our illness or
express our health concerns, the need to receive competent care,
and, perhaps most important of all, the need to be understood, acknowledged,
and valued20—we all need a social support system. To deliver
culturally competent care, healthcare 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 the etiology of diseases; cultural
beliefs about healing and disease treatments; and attitudes about
seeking help from healthcare providers.21
It is important to recognize and understand the
dominant American cultural paradigm, which is derived largely from
an Anglo-American heritage that shaped our laws and administrative
organization. Anglo-American culture places a high value on individualism,
privacy, and personal responsibility and control. Emphasis is placed
on the nuclear family, but what is best for an individual often
takes priority over what may be best for the family as a whole:
the family will sacrifice its economic well-being to finance care
for a member. Extended family usually does not play a role in major
decision making.2,18
Though a “right to privacy” and confidentiality
is prioritized, we value direct, open, and honest communication.
Hiding unpleasant news about a health condition is unacceptable—we
have a “right to know.” Informality is considered synonymous
with friendliness. For example, it is common and acceptable to call
people by their first name even upon first meeting them2,18—a
practice that is considered rude in many cultures.
Anglo-Americans are future-oriented, setting and
working toward long-range goals. Immediate gratification is a low
priority; there is a desire to work hard to provide a better future
for children. We are a task-oriented society, with a near-compulsion
to always be doing something. Value is placed on promptness and
“staying on schedule.”2,18 Self-worth in American culture
is often determined by a person’s accomplishments.2,18 Self-esteem
is often associated with physical appearance. Dietitians know that
despite widespread obesity, there is an obsession with thinness.22
Though overwhelmingly religious, we are largely self-determiners—“fate”
is not an overwhelming force but an opportunity.
The values of many traditional cultures are very
different. Many traditional cultures believe, for instance, that
fate, God, or other supernatural factors determine a person’s
destiny and directly influence his or her health. Personal relationships
determine self-worth and take priority over time schedules—promptness
is not a priority. Family almost always includes extended family,
and the extended family participates in decision making, especially
regarding healthcare. There is a family hierarchy in many traditional
cultures in which men are the head of the household, make decisions,
and speak for the women. The welfare of the family takes precedence
over the individual’s welfare.2,18
Informality is associated with rudeness in certain
cultures. For example, it is better to call a client named Juan
Garcia “Mr. Garcia” than “Juan.”2,18 Formality
also equals respect and politeness to Japanese people.
Many traditional cultures are polychronistic, which
means people are comfortable doing many things at once—“multitasking”—but
not at the expense of personal relationships. It is more important
to be kind and courteous than to be punctual. For example, a Brazilian
may be late for a doctor’s appointment because he does not
want to cut a visit with his aunt short. While talking with his
aunt, he may also repair her stove and at the same time watch a
soccer game on TV. In contrast, most Anglo-Americans are monochronistic,
which means they prefer to focus on and perform tasks in a sequential
manner.2,18 There is no pressure to constantly be busy doing something
because value is placed on just being. In Latin countries, siesta
time follows lunch; in America, people eat lunch at their desks.2,18
Other differences of note: traditional cultures
give more power to one gender or another (women may be “the
power behind the throne” or control finances); thinness is
considered unattractive; cooperation is preferred to competition;
tradition and continuity are valued over change (a reverence for
the past takes precedence over efficiency of striving); and idealism
is stressed over practicality or expedience.22,23
Healthcare Culture
The culture of healthcare in the United States reflects Anglo-American
values. The U.S. healthcare system is complex, time-oriented, focused
on disease management and treatment, and dedicated to preserving
life at any cost. Conventional medical care is standard practice
in the United States,2,18 although personal responsibility for prevention
and direct participation in treatment may include alternative care.
People from traditional cultures, in contrast, often believe the
provider should determine and direct their care. Beliefs about disease
prevention, causes, and treatment vary from culture to culture.
Folk, spiritual, or psychic healing may be preferred.2
Health professionals should not assume the superiority
of one set of values over another. It is important to know and understand
the implications of these differences, particularly when it comes
to decision making. While we would normally address family dietary
instructions to American women, we might be showing disrespect if
we do that to a Vietnamese family, and the results might be less
than ideal.
In the United States, there are four historically
underrepresented people groups: African Americans, Native American/American
Indians, Latinos, and Asian Americans/Pacific Islanders. In general,
there is a higher incidence of certain cancers, cardiovascular disease,
diabetes, obesity, and mortality in these population groups compared
with non-Hispanic whites. African Americans and Latin Americans
have a higher incidence of HIV. In addition, the immunization and
vaccination rates for childhood diseases are lower in these population
groups.3,7
Racial and ethnic groups often receive lower-quality
healthcare regardless of their insurance coverage and socioeconomic
status.3,24 The reasons are not completely understood, but a contributing
factor is failure to deliver culturally competent care. The Asian
father whose power and status have been eroded by a dietitian giving
his wife instructions on cooking might forbid compliance or follow-up
to avoid losing more “face.” Meeting with aunts, uncles,
and cousins of a Middle Eastern family may be more effective than
giving one-on-one instruction. Shoving a handout with hurried instructions
to “call if you have questions” might offend a Japanese
client and make compliance tenuous.
A culturally competent and eclectic healthcare system
would incorporate or accommodate all nuances of culture, including
nonconventional healing practices. However, universal cultural competency
is impossible due to the major intracultural differences and the
need to provide uniform modern care. Attempts to rationalize care
in a diverse world pose great challenges.
Regulatory Dilemmas
Healthcare organizations and food and nutrition programs must comply
with legislative, regulatory, and accreditation requirements or
standards, including those designed to ensure the delivery of culturally
competent services. The Joint Commission on Accreditation of Healthcare
Organizations and the National Committee for Quality Assurance,
which accredits managed care organizations and behavioral health
managed care organizations, advocate standards that require cultural
and linguistic competence in healthcare7— and therein lies
a challenge. Older Americans Act Nutrition Programs are being challenged
to meet the needs of a variety of cultural groups, including African
Americans, Asian or Pacific Islanders, Hispanics or Latinos, American
Indians, and Eskimos.
At a minimum, institutional foodservices should
include a variety of ethnic foods reflective of their client base,
with flexibility for the unusual request. Offering familiar foods
increases satisfaction and enjoyment; older clients especially are
more likely to eat culturally familiar foods. Foodservice staff
should be culturally sensitive and competent to deliver quality
food and nutrition services.19
Nutrition counseling poses a greater challenge.
The good news is that almost all cultures believe a healthful diet
plays a major role in maintaining good health and recognize that
certain foods have functional medicinal purposes.2
Before recommending dietary or lifestyle changes,
you must first have a clear understanding of the person’s
dietary habits within the context of a person’s culture. Dietary
changes or recommendations, if they are to be effective, should
incorporate familiar cultural foods.12 The use of universal dietary
recommendations is not practical or effective.
Fortunately, new information on the nutritional
composition of many traditional foods is becoming available. A variety
of tools, including the Asian Diet Pyramid, Mediterranean Diet Pyramid,
Vegetarian Diet Pyramid, and the Native American Food Pyramid, have
been developed. They can be found at the Food and Nutrition Information
Center Web site (www.nal.usda.gov/fnic) and the Georgia State University
Nutrition for New Americans Project Web site (http://monarch.gsu.edu/multiculturalhealth).
Food restrictions based on ideational, moral, or
religious precepts are hardest to work with, whether those restrictions
are based on inherited culture or received information. Teenaged
vegetarians and Hindus believe animal flesh is forbidden—the
teenager may abandon that belief, but the Hindu cannot without extreme
anxiety and guilt. Islam forbids pork, as does orthodox Judaism.
Certain cultures would rather eat snakes than sausage—and
objectively, who could fault them?
Like language, food distinguishes one culture from
another. A culture is strongly identified with its foods, and its
food preferences will outlast nearly any other cultural practice.25
The meal size, meal composition, social setting, and rules vary
from culture to culture.2,26 The culturally competent dietitian
will learn from each client, keep a mental “book” of
cultural characteristics, and always treat individuals with respect
and understanding.
— Carol Brannon, MS, RD, LD, is a consulting
dietitian at Fowler YMCA and in private practice in Georgia.
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