Deleting Default Culture: Simple Steps for Accessing Your Cultural Humility
By Kassidy Sharpe, PhD, Diversify Dietetics Intern
If you had to summarize your culture in one paragraph what would it say? It seems daunting to distill 28 years of fish fries on my birthday in June, holidays celebrations, Sunday dinners, and so much more into one paragraph. Furthermore, food and culture are so deeply intertwined. I learned about meals and cooking from snapping peas and peeling potatoes for my grandmother, and laughing over poundcakes with my sisters.
Imagine if someone summarized your culture into one paragraph or one page and stopped there. They would miss so much. Similarly, cultural humility goes beyond summarizing the core tenets of culture and instead invites us to be open to always learning about others with the goal of deeper connection and greater understanding for all.
In pursuing a career in dietetics, you are pursuing a commitment to seeking and applying new information to benefit your community. Cultural humility is yet another way to take in and actively apply new information. Our culture is so unique in shaping our food landscape - understanding how to harness that information can enrich our lives and create deeper and more effective nutrition education.
What is cultural humility?
Systemic racism is ever present in our modern healthcare system. Two ways, among others, that racism shows up is through a lack of access to care, and through poor treatment due to biases of healthcare professionals. One way that we can commit to equity in care is through committing to a personal practice of cultural humility.
Brief history of cultural humility
The concept of cultural humility represents a lifelong process of self critique and identifying your own biases. This includes being aware of historical realities, identifying and educating on gaps in knowledge, fixing power imbalances, and centering your patient’s experience.
Additionally, cultural humility includes developing lasting partnerships with people and groups that advocate for marginalized and underrepresented groups. The term cultural humility was coined by researchers Tervalon & Garcia in 1988 to train doctors with the skills to effectively work with the ever increasing diversity of their patient population.
Cultural Competence vs cultural humility
Cultural competence and cultural humility are often used interchangeably, but there is a distinct difference between the two! Let’s discuss:
The concept of cultural competence came out of social and political activism in the 1960s when demands were made regarding cultural diversity in social work and healthcare spaces. The root of cultural competence posits that with greater understanding of cultures beyond your own increases the ability of community practitioners to communicate effectively and efficiently across cultures. There have been numerous definitions of cultural competence and the resulting teachings have garnered pushback for decades.
One critique of cultural competence is that the primary focus is knowledge acquisition which results in several undesirable outcomes. Namely, that it creates a view that you can learn everything about a culture and creates a mentality of checking off a checkbox instead of one of continually learning and reexamining cultural differences.
Additionally, equity advocates critique that cultural competence can reinforce negative stereotypes and the view that whiteness is the norm and that any other culture is tangential in comparison. For these reasons, nutrition equity curricula for both students and practitioners is evolving to incorporate greater tenets of cultural humility, and we couldn’t be more thrilled.
New developments in cultural humility for dietetic students
As health and nutrition equity become a national priority, dietetic programs are finding interesting ways to incorporate cultural humility into their nutrition and dietetics curricula:
One method used at the University of Hawai’i was to adapt medical nutrition therapy (MNT) case studies to be culturally appropriate to the populations, disease states, usual dietary intake, social, and cultural histories that are most commonly seen in Hawai’i. Students were asked to examine how the place-based case studies impacted their confidence for delivering nutrition education to diverse populations and identifying how personal bias can interfere with delivering adequate care to their clients.
All of the students stated that they had more confidence in delivering nutrition education to diverse populations but a lower number of students reported that they could identify how their personal biases impact the care that they provide. This is where we come in.
This highlights one key difference between cultural competence and humility. Learning information about other cultures can be easy to accomplish in a brief training but understanding the importance of continually self evaluating for personal bias takes greater effort and an individual commitment to equity in care.
New developments in cultural humility for dietetic practitioners
Another innovative approach being used to train nutrition and dietetic practitioners in cultural humility is anti-racism training. One anti-racism training for Philadelphia Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) practitioners included definitions of key concepts, identity reflections, case studies with time to debrief, and an action plan for addressing bias before, immediately after, and 6-months after the training.
After the training, employees reported greater awareness of the influences of racism in healthcare, and greater confidence in identifying and addressing interactions that promote racism, although the percentage of employees that still agreed with this statement after 6-months was decreased.
Although these new approaches are introducing concepts of cultural humility in brief interventions, for cultural humility to be the standard of the nutrition field, each practitioner must be able to draw on their own skills of cultural humility prior to interacting with diverse populations, during the client interaction, and especially the ability to self reflect and change behavior that may be based on personal bias frequently. So, what does this mean? Ask yourself the following questions to understand how to access your cultural humility.
Accessing your cultural humility
Understanding what cultural humility is is the first step, but now let’s take a step further and reflect on how cultural bias can show up in our counseling and education sessions. For each question below, try taking a moment to reflect and answer on your own first.
Have I developed any false biases or stereotypes concerning cultural foods?
Stereotypes surrounding cultural foods can be dangerous and impede equitable care in nutrition spaces. Begin to think about the populations of people you serve the most often. What beliefs do you have about the kinds of foods that they eat or behaviors they practice? What information helped you to shape those beliefs?
Does my social position or privilege impact my understanding of how to help clients navigate their food environment?
Is your priority for your clients care the same as their priority? What perceptions do you have about the types of support systems available to your client? How did you come to those perceptions?
What barriers exist that are outside of the clients control?
Can you offer services or resources that can benefit the client without adding additional burdens?
Where do I require more knowledge to better advocate for the patient’s needs?
What resources can you have on hand to better address the needs of the populations you serve? Do you know where to find culturally appropriate resources? How do you know if a situation regarding personal bias is taking place?
Case Studies from the Field: Cultural Humility in Action
Let’s practice cultural humility in action with some specific examples in several dietetics practice areas. I am a WIC nutritionist and my clinic serves a diverse community in North Georgia. Every client on the schedule showed up for their appointment and there were numerous walk in appointments as well. Now I have a break before lunch - let’s assess my practice.
Example 1:
Reflection: What did I learn from each person I encountered?
I learned that although certain grocery stores have reputation for having a smooth check out experience for WIC participants including correctly labeling WIC products, many families go to other stores because that is where they commonly do the rest of their shopping or where the person who shops for their household usually shops, highlighting some of the nuances of accessibility in grocery shopping. I also learned that although translation services are available to all participants, many bring a family member or friend to translate for them because they are not aware of the service or have more trust in their own interpreter. How can these lessons help to grow my cultural humility? They can help me to keep an open mind and to collaborate with clients to address their needs in the most helpful way
Respect: Did I treat everyone involved in that encounter respectfully?
There are several ways I made sure to show respect to every family I meet. I always greet everyone and introduce myself to everyone present for the visit. I am also sure to thoroughly address all parent concerns, being sure to address nonverbal cues as well. Also, a smile never hurts
Regard: Did unconscious bias drive the interaction?
In what ways could unconscious bias have driven your interactions this morning? Perhaps you are given statistics stating that certain age or ethnic groups have lower rates of breastfeeding initiation- this could cause you to offer information about breastfeeding more or less often than to other groups. Bias can cause us to group individuals together when each case has its own individual goals and characteristics. Cultural humility helps us to see each person as an individual that we can learn from.
Relevance: How was cultural humility relevant in this interaction?
There are some cases where cultural humility is not relevant to the clients needs and goals and times where it is not. That is why it is important to reflect on client interactions so that you can more accurately assess when cultural humility is at play. For example, a family that is used to giving toddler formula to children instead of plain milk because they believe it is nutritious and necessary for growth may call on cultural humility while a family that believes that kids should not eat pork is not culturally relevant to the families ongoing healthcare goal. An important question to consider is what opportunity did you take to learn more about how culture impacts the client's decisions regarding their nutrition care.
Resiliency: How was my personal resiliency affected by this interaction?
And lastly, how open was I to learn new information from my clients? This is the most important reflective question to ask because open communication and collaboration across cultures is how you can grow as a clinician and provide more equitable and effective care.
Example 2:
Now you are a nutrition researcher. You are leading a series of focus groups with Black families to understand their perceptions of sugary drinks for an upcoming nutrition education campaign - let’s assess your practice.
Reflection: What did I learn from each person I encounter?
Your research participants stated that they felt the harm done by negative stereotypes about Black families. They also stated that they did not feel fully represented by current interventions that target Black families but are not open to the many shapes and forms that they come in or do not consider how collectivist they can be, with aunts keeping multiple cousins or grandmothers doing the shopping for the family while parents are working. They also felt that their life priorities were not being adequately considered. For example, how important does 4 oz of juice seem when you are worried about whether your child will make it home alive? And lastly, they reported that they emphasized the heterogeneity within Black communities, even small ones. Do these statements challenge any previous assumptions that you had?
Respect: Did I treat everyone involved in that encounter respectfully?
How can you show respect while conducting research? You can personally address anyone that is not speaking very much or not allowing participants to speak over one another so that every participant's voice is heard. You can also validate each response, especially the vulnerable ones that may have been difficult to share in a group of strangers.
Regard: Did unconscious bias drive the interaction?
In what ways could unconscious bias have driven this interaction? One way to check is by examining what surprised you about an interaction. Did it challenge a biased belief you did not know you held? I was surprised that popular cultural references that are often used in conversation were sometimes disliked by parents when used in messaging campaigns because they felt disingenuous and pandering instead of familiar as was intended.
Relevance: How was cultural humility relevant in this interaction?
Cultural humility is especially important when aiming to create culturally appropriate nutrition educational material. As a researcher your role is to listen to what the audience is telling you that they need and how it could best be delivered in a way that they can absorb and effectively utilize the information. For these reasons you must take every opportunity to learn about how culture impacts the clients decisions regarding their nutrition care.
Resiliency: How was my personal resiliency affected by this interaction?
Because of the nature and structure of focus groups, I was very willing to accept new information, and even open disagreement from the research participants. But it is important to remember that every client interaction is an opportunity to learn from your client and expand your skills in cultural humility.
Impact of cultural humility on dietetic practice for both clients & practitioners
Cultural humility impacts every practitioner and every client. You and me both. It extends beyond the field of dietetics to every field that includes diverse populations. In the short term, cultural humility training results in you being more competent nutrition professionals. It can also result in you achieving greater levels of trust and connection with your clients. One way to personally commit to equitable nutrition care is to regularly and thoughtfully assess your nutrition practice and access your cultural humility.
Resources for Further Learning on Cultural Humility for Nutrition Professionals
University of Oregon Cultural Humility Toolkit
Cultural Humility in Food & Nutrition
Tailoring Nutrition Advice to Maintain Cultural Relevance & Humility
Embracing Cultural Humility in Community Engagement
Improving Cultural Humility in Diabetes Care
Practicing Cultural Competence & Cultural Humility in the Care of Diverse Patients
References
Santoro, C. M., Farmer, M. C., Lobato, G., James, M., & Herring, S. J. (2023). Antiracism training for nutrition professionals in the special supplemental nutrition program for women, infants, and children (WIC): a promising strategy to improve attitudes, awareness, and actions. Journal of Racial and Ethnic Health Disparities, 10(6), 2882-2889.
Esquivel, M. (2023). Innovating Clinical Dietetics Instructional Methods: Placed-Based Case Studies for Teaching Clinical Nutrition. Journal of Nutrition Education and Behavior, 55(7), 82.
Babatunde, O., & Wall-Bassett, E. (2023). Foundation Nutrition Course Promotes Diversity, Encourages Cultural Humility, and Empowers Students as Food Citizens. Journal of Nutrition Education and Behavior, 55(7), 21-22.
Tervalon, M., & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of health care for the poor and underserved, 9(2), 117-125.
Fisher-Borne, M., Cain, J. M., & Martin, S. L. (2015). From mastery to accountability: Cultural humility as an alternative to cultural competence. Social Work Education, 34(2), 165-181.