An Examination of Culturally Safe Dietetics Practice in the Pacific Island Region

1. An Examination of Culturally Safe Dietetics Practice in the Pacific Island Region Cyndy Endrizal, PhD, MPH, RDN, LD, FAND Chief Quality Officer Wahiawā Center for Community Health Adjunct Junior Specialist Complementary and Integrative Medicine, John A. Burns School of Medicine, University of Hawaiʻi at Mānoa Marie Kainoa Fialkowski Revilla, PhD, RDN, LD Assistant Professor in Human Nutrition Human Nutrition, Food and Animal Science, University of Hawaiʻi at Mānoa HAND Spring Conference 2019

2. Outline • Learning Objectives • Acronyms / Definitions • Brief History of the Pacific • Indigenous vs. Western worldviews and values • Cultural Safety • Origination • Compared to Cultural Competency • Why study this in the Pacific? • An example of Cultural Safety (Foley article) • What we learned • Implications for our practice • How can we continue to provide more culturally relevant care? HAND Spring Conference 2019

3. Distinguish between Indigenous and Western worldviews and values in relation to nutrition and health care services • Explain the eight dimensions of Cultural Safety • Identify dimensions of culturally safe practice in Western-trained dietitians Learning Objectives No conflicts of interest are reported for purposes of this presentation HAND Spring Conference 2019

4. Acronyms Saipan crab AI/AN American Indian/Alaskan Native AND Academy of Nutrition and Dietetics CDR Commission on Dietetic Registration CNMI Commonwealth of the Northern Mariana Islands FSM Federated States of Micronesia HAND Hawai‘i Academy of Nutrition and Dietetics MNT Medical Nutrition Therapy NCD Non-Communicable Disease NH/PI Native Hawaiian/Pacific Islander NIH National Institutes of Health OI Outer Island RDN Registered Dietitian Nutritionist RD Registered Dietitian RMI Republic of the Marshall Islands TOM Two or more (races) US United States USAP United States Affiliated Pacific HAND Spring Conference 2019

5. Definitions Ethnic group • Community of people who identify with each other based on cultural, linguistic, and/or ancestral background 1 Indigenous • Descendants from pre-colonial/pre-invasion inhabitants of a region • Maintains close tie to land in cultural and economic practices • Suffers from economic/political marginalization as a minority group • Identifies as Indigenous 2 White • People of European descent, often referred to as “Westerners”, “Colonists”, “Settlers” 1 Sunrise in Saipan HAND Spring Conference 2019

6. Definitions Worldview • Theory/framework of values and ideas about the world and living in the world 1 Cultural Competency • Defined by NIH as “critical to reducing health disparities and improving access to high quality health care, health care that is respectful of and responsive to the needs of diverse patients”3 Health Disparity • A term used almost exclusively in the US. The terms “health inequity” or “health inequality” are more commonly used outside US4 Host Culture • Dominant culture of a particular place; Culture of descendants of population that inhabited a location prior to colonialization2 Remnants of War HAND Spring Conference 2019

7. Colonization and Cultural Trauma in the Pacific5,6 Pre-colonial time • Healthy, self-sustaining communities • Social networks and land more important for determining identity and traditional ties than for providing food • Food often seen as a means of expressing social relationships • Health was a group concept - a shared sense of well-being End of 1700’s • Traditional cultures and sovereign food systems lost • Loss of identity • Forced assimilation by colonists • New foods and cooking methods adopted, influenced by trade and food aid • A diet of processed foods, a dependency on easy-to-get, high fat, high sugar imported foods HAND Spring Conference 2019

8. Comparison of Worldviews and Values7 Indigenous Western Scientific, skeptical, require proof as basis of belief Compartmentalized, structured society, identity by jobs and possessions Progress is important – moving past “now” Time is linear and structured Large scale authority systems, relationships built on “role” • Spiritually oriented • State of relatedness – everything and everyone is related and connected • Happy to fit in with environment and what’s happening “now” • Time is non-linear, cyclical in nature • Authority based on age, cultural knowledge, relationships with people HAND Spring Conference 2019

9. “…I did not understand why Māori were stereotyped as unintelligent, irresponsible and lazy. Why Māori were demonized in the media, filled the prisons and hospitals and were told that they had same opportunities for successful social accomplishment as everyone else. My whole experience showed me that there were fundamental and brutal injustices in our society and I wanted to know how and why they got there, how they worked and how they were sustained.” (Irihapeti Ramsden, 2003)8 Cultural Safety HAND Spring Conference 2019

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11. Where are we? https://goo.gl/images/kb006e HAND Spring Conference 2019

12. American SamoaHawai‘i CMNI (Saipan) GuamRMI, FSM & Palau USAP Region https://goo.gl/images/F78vzO HAND Spring Conference 2019

13. The Federated States of Micronesia9 • Four districts: Kosrae, Pohnpei, Chuuk, and Yap • Over 2,600,000 square kilometers (land and territorial waters) • Population >100,000 citizens • Historically, the Caroline Islands - experienced some of the fiercest fighting during World War II http://thediplomat.com/wp-content/uploads/2016/02/thediplomat_2016-02-19_09-59-26.png HAND Spring Conference 2019

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15. Worldviews, Value and Belief Systems Histories of Cultural Trauma, Colonization, Loss of Identity Cultural Safety Obesity, Diabetes, Cardiovascular Disease, Renal, Western-Trained Mostly White, Females HAND Spring Conference 2019

16. What we studied… What are the characteristics of dietetics practice in the Pacific and how do they relate to cultural safety? Pohnpei HAND Spring Conference 2019

17. Closing the gap by increasing access to clinical dietetic services for urban Aboriginal and Torres Strait Islander people11 • Focus groups • (MDs, RNs, receptionist and patients) to identify: • Expectations of dietetics services • Impact of increased availability of dietitians • Referral process • Implemented dimensions of cultural safety into dietetics practice • Dietitian work days increased from 1 day/week to 4 days/week = Flexibility in scheduling • Active presence in community • Introduced to Elders and community members Foley W, Houston A. Nutrition & Dietetics. 2014;71(4):216–222 HAND Spring Conference 2019

18. Closing the gap… Dietetic clinic statistics - Inala Indigenous Health Service (IIHS) 2010–201111 Dietetic Clinic Statistics2010 2011 New referrals made 100 221 New referrals seen 32 191 P < 0.001 Total occasions of service 183 567 DNA rate (did not attend) 35% 27% P = 0.006 This research concluded: • Engaging with the community builds trust and increases access • Culturally safe service makes people initially see the dietitian, return for follow-up appointments and engage with strategies to improve their nutritional health HAND Spring Conference 2019

19. Kahana Bay, Hawai‘i Two-Part Study • Analyze the Hawai‘i Academy of Nutrition and Dietetics (HAND) 2014 member survey • Demographics of practicing dietitians and the populations we serve • What do RDNs need to provide more culturally relevant care? • Conduct key informant interviews of practicing RDNs • In various work settings in the USAP region • Learn about RDN practices that reveal dimensions of culturally safe care HAND Spring Conference 2019

20. Part 1: Findings Identified Needs for Resourcesa (a) Out of 65 respondents who identified as currently practicing and providing direct services, 3 did not respond HAND Spring Conference 2019

21. Part 1: Findings Identified Needs for Resourcesa (a) Out of 65 respondents who identified as currently practicing and providing direct services, 3 did not respond HAND Spring Conference 2019

22. Part 1: Discussion HAND 2014 Survey is helpful to describe dietetics practice in USAP Recognition of ethnically diverse populations served in USAP region RDNs need resources for this diverse population Specifically for Asian and Pacific Islanders To effectively address relatively high rates of NCDs Note: most nutrition resources are produced in the contiguous US (= Westernized) RDNs use internet for nutrition resources Important given geography in USAP A venue for future sharing and collaboration Pathway in Saipan HAND Spring Conference 2019

23. Part 1: Conclusions • Provides critical first step to assessing practice of dietetics in USAP • Validates USAP as unique for dietetics practice • Informs need for RDNs to request and/or develop region specific resources • Informs need for future research The horizon… HAND Spring Conference 2019

24. Published in June 2018 DIETETICS PRACTICE IN THE UNIQUE, CULTURALLY DIVERSE PACIFIC ISLAND REGION Cynthia L. Endrizal PhD, MPH, RDN, FAND; Marie KainoaFialkowski PhD, MS, RDN, LD; Jim Davis PhD, MS; Sarah Yuan PhD; Rachel Novotny PhD, RDN, LD; Treena Wasonti:ioDelormier PhD, PDt; and Beatriz Rodriguez PhD, MD Hawai‘i Journal of Medicine & Public Health June 2018, Volume 77, No. 6, pp 135-143 HAND Spring Conference 2019

25. Part 2: Conduct key informant interviews of RDNs in the USAP region to collect descriptions of practices that reveal dimensions of culturally safe care12-17 Hawaiʻi Guam CNMI American Samoa 4 Primary Key Informants HAND Spring Conference 2019

26. Part 2: Methods – Key Informants Saipan O‘ahu Guam Hawai‘i Island American Samoa HAND Spring Conference 2019

27. Part 2: Methods Interviews • 7/26/16 – 11/7/16 • Conducted by CE • Notes taken by MKFR • Digitally recorded (with consent) • 9 face-to-face • 5 at RDNs’ work sites • 2 in RDNs’ home • 1 in CE’s office • 1 in CE’s home • 9 via telephone • 7 outside of Hawaiʻi • 1 on Hawaiʻi Island • 1 on Oʻahu • Approval for the study was granted by the Office of Research Compliance, Human Studies Program at the University of Hawai'i at Mānoa Managaha Island HAND Spring Conference 2019

28. Part 2: Methods – Interview Question Design Pre-Interview Survey Interview Development of interview questions guided by Cultural Safety Framework • Consent • Demographics: • Gender, work setting, education, years of experience, region of practice • Cultural Competency training • Snowball – other known RDNs Pohnpei HAND Spring Conference 2019

29. Part 2: Methods Interview Question Design8,11,18-27 Cultural Safety Framework HAND Spring Conference 2019

30. Part 2: Findings: Describing RDN Participants (n) HAND Spring Conference 2019

31. Part 2: Findings: Describing RDN Participants Cultural Competency Training (CCT) 13/18 had some form of CCT 3/13 currently required to have CCT Variety of modes: online, classroom, “other” 10/13 said: CCT “useful” “I’m Samoan, I’m supposed to know the culture. I’m supposed to understand and know the culture. There’s no other training” (B) HAND Spring Conference 2019

32. Self-awareness/self-reflection to one’s own historical and social location Part 2: Findings: Themes Self-Reflection or Self-Awareness to One’s Own Historical and Social Culture and Location • Identification with Own/Host Culture • Identification as Being Outside the Host Culture • Lack of Resources • Pressure to Reach/Maintain Western Standards • Culturally Relevant Training “I lived with a Samoan family for the first year I was here. I learned how families live, prepare their food (traditional ways). I learned the language through their children” (Q) HAND Spring Conference 2019

33. Self-awareness/self-reflection to one’s own historical and social location Lack of Resources Western Standards “Because of the lack of resources, families prefer to do the tube-feeding [formulas] themselves as its not available – we do have Nepro, Glucerna, Ensure, Jevity. But we run out and it takes a long time to be shipped here. Some families just make their own – it’s cheaper.” (I) “I did my internship at [retracted] and consider myself up to date on research. The standards of practice in XXX are not up to date. It can be frustrating.” (O) “To achieve the same standard as in mainland US, to me, it’s exemplary. Especially if you’re isolated in the middle in the Pacific.” (B) HAND Spring Conference 2019

34. Relationship building between client and practitioner Part 2: Findings: Themes Relationship Building and Creating an Environment of Respect, Caring, Trust, Empathy, and Acceptance • Approaches to Relationship Building • Building an Environment of Respect • Building an Environment of Caring and Empathy • Building an Environment of Trust/Acceptance “Because, I’m Haole [term used to refer to Whites in Hawai‘i], I get a lot of “Ho, you speak Pidgin, yeah?” In talking with patients, I talk the way… I reciprocate. So, if they are speaking very straight forward English, I do that too. Yeah, I turn it on and off. It depends who I’m talking with and how they’re comfortable. I feel like being here, and being able to have that understanding, being a chameleon off and on, change as needed, I think that’s very important” (J) Environment of respect, trust, acceptance, caring and empathy HAND Spring Conference 2019

35. Showing Respect Approach “It’s not in good form to stand-up.” (A) “I tried to sit down instead of standing over them and talk at their eye level.” (C) “Towering over the patient at the side of bed – that doesn’t come off very well.” (J) Standing over patients is not good – I should be at a lower height or equal to them.” (P) “There’s a word to show respect – you say “Tulou” (B) “…it’s important to know who they are, also introduce who you are… the way we do it is saying our name, where we’re from, finding out where they’re from, what their name is – and finding any possible thing that could relate you to them. Like my family, sometimes, that is a nice way to say “OK, we have this in common” (K) HAND Spring Conference 2019

36. “We are actually really intentional about relationship building. Nothing is done without some type of relationship building. We do a lot around meals and food, whether it’s up in the garden, planting food together, down at the café serving food, or having meals together. Another thing that we do is the Aloha circle and Mahalo circle. In the Aloha circle, everyone states what their name is, where they’re from, where they live or were born and so we really feel connected, and then to bring in a Kupuna with them. What that does is level the playing field.” (G) Aloha and Mahalo Circles – Relationship Building HAND Spring Conference 2019

37. Part 2: Findings: Themes Recognizing history of repression of cultural identities Working through a Social Justice Lens, Recognizing Potential for Power Imbalances or Struggles and Loss of Cultural Identities • Western Worldviews and Values • Feelings of Power Imbalances or Struggles • Feelings of Repression, Oppression, Discrimination “With elders, I was taught to respect, and not to speak in a certain manner. I know that I can’t really tell elders what to do. Although I know better from my formal training – I knew I would find myself stuck in the middlewhen I came back to XXX. I try to say things in a caring manner vs. authoritative manner. I am comfortable to operate that way – it’s an instinct” (I) Working within social justice lens considering power imbalance HAND Spring Conference 2019

38. Power Struggles “We also serve patients with no insurance, sometimes there are patients that don’t have papers, they don’t have legal status, and we are just treating them, because we don’t turn anyone away…And so, I’m sure that some patients that don’t have paperwork - they may not feel that they have power. They just kind of come here and hope that they can get dialyzed.” (D) “You have to read the patient, determine the family involvement – sometimes, that’s very apparent. You can see who speaks up, who stands up, who gets in the way, who needs to feel like they have the power.” (J) HAND Spring Conference 2019

39. Part 2: Discussion • RDNs very self-aware – whether from host culture or not • Acknowledgement of risk for patients/clients to feel “unsafe” • RDNs are modifying their practices with skills/knowledge not necessarily learned in dietetics training • What does that mean? • Is Cultural Safety intuitive? • Immersion into the culture works! • Forget the “laundry list” (cultural competency training) Forbidden Island HAND Spring Conference 2019

40. Part 2: Limitations • Unable to assess cultural safety – from patients’ experience • Ethnicity, cultural background of RDNs • what we know is what they shared • Sample largely representative of Hawaiian Islands HAND Spring Conference 2019

41. Part 2: Conclusions • RDNs have acquired culturally safe skills in their own practices through • Their own knowledge of the host culture (10/18 identified with host culture) • Immersion, self-reflection, experience • Let us build and learn from our Pacific neighbors… • Closing the gap by increasing access to clinical dietetic services for urban Aboriginal and Torres Strait Islander people (Foley and Houston)11 • Amazingly resilient Indigenous people! Using transformative learning to facilitate positive student engagement with sensitive material (Jackson, et al)28 HAND Spring Conference 2019

42. RDNs Need Culturally Relevant Resources What are the characteristics of dietetic practice in the Pacific and how do they relate to cultural safety? Pohnpei HAND Spring Conference 2019

43. Storytelling – success stories • Region-specific dietetics practice experiences • Consideration of standardizing practice protocols specific to the region • New standards of culturally safe dietetics practice for USAP region • Incorporate cultural safety into dietetics curriculum • Create opportunities for immersion in field experiences and internships – in the USAP region • Set precedence for other practitioners and other regions Implications for Practice RDNs free-diving HAND Spring Conference 2019

44. Presented at: Manuscript in draft Eighth International Critical Dietetics Conference November 16-18, 2018 Alabama State University, Montgomery, Alabama, USA Journal of Critical Dietetics https://criticaldieteticsblog.com/journal-of-critical-dietetics/ HAND Spring Conference 2019

45. “Nutrition problems are things that you would generally see not only in our indigenous populations but due to loss of land, colonialism, loss of power within your own home state. And so, when we’re addressing them, we’re not just addressing, strictly diabetes or the general diabetes class or something like that. We’re trying to reconnect them, strengthen their cultural ties. We’re trying to strengthen all the connections they have, to make them a healthy person – whether it’s to the community, to their spirit, to their family, to their culture. And we use food to do that.” (G) Mahalo RDNs! HAND Spring Conference 2019

46. How can we continue to provide more culturally relevant care? Saipan Sunset on a Sunday at Micro Beach Thoughts? HAND Spring Conference 2019

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