Ask the Experts: Creative Solutions for Local Providers by Local Providers

Providing Food Services to Meet the Needs
of Culturally Diverse Participants

Why is cultural competence important in food services?

Many Older Americans Act Nutrition Programs and other programs providing meals to older adults are being challenged to meet the needs of their culturally diverse communities. In 1999, 16.1% of persons 65 years and older were minorities--8.1% were African-Americans, 2.3% were Asian or Pacific Islander, and less than 1% were American Indian or Native Alaskan. Persons of Hispanic origin (who may be of any race) represented 5.3% of the older population. Minority populations are projected to grow to 25.4% of the elderly population in 2030 (1). This represents an increase by 219% for older minorities, including Hispanics (328%), African-Americans (131%), American Indians, Eskimos, and Aleuts (147%), and Asians and Pacific Islanders (285%)(2).

Health disparities exist in older adults because of differences in gender, race or ethnicity, income or education, disability or living in a rural location (1). Substantial disparities exist among racial and ethnic groups and by gender in mortality from many causes of death (3). In 1998, 6,498,076 older adults were recipients of Older American Act (OAA) Title III services. Of these, 19.6% were members of racial and ethnic minority groups (4,5). African Americans constituted over half (54%) of the 1998 minority clients served, followed by 30% Hispanic, 11% Asian American or Pacific Islander and 5% American Indian or Native Alaskan (4). The National Evaluation of the Elderly Nutrition Program 1993-1995 found that 25% of congregate and home-delivered meal participants were minorities. This percentage is almost twice the national percentage of minority adults over age 60 (6).

To eliminate health disparities among older persons and in particular minority individuals, the Administration on Aging has encouraged the Aging Network to participate in the U.S. Department of Health and Human Services Healthy People 2010 initiative by using it as both a planning and evaluation tool for programs and services. The two major goals of Healthy People 2010 are to (1) increase quality and years of healthy life and (2) eliminate health disparities. Healthy People 2010 builds upon a national effort initiated over 20 years ago to develop comprehensive health objectives that can be used to effectively direct health promotion and disease prevention efforts. The initiative reinforces the concept that improving the health of the Nation requires the long-term commitment and participation of all (7,8).

The Older Americans Act encourages outreach to underserved and isolated populations in greatest social and economic need, to members of ethnic and racial minority communities and to those over age 85 (4,5,7,9,10). In response to this call and the increasing members of minority, Programs must change in order to improve the health of all citizens. To this end, Nutrition Programs need to provide culturally competent services and staff need to be culturally sensitive. Providing culturally appropriate, nutritious, high quality and tasty meals can be an effective outreach effort to bring in the target population, improve customer satisfaction, promote health and reduce health disparities.

What strategies can Nutrition Programs use to assure cultural competence?

Cultural competence is defined as a "set of attitudes, skills, behaviors and policies that help organizations and staff to work effectively with people of different cultures" (11). Serving older adults of diverse cultures requires staff and volunteers to be compassionate, respectful, warm, empathetic and genuine. It is essential to develop and enhance staff cultural competency skills in the work environment. The Administration on Aging's Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families (12) is a useful resource.

A "community" can be defined in several ways. It can refer to the people who live within a geographic boundary or to a group of people who have similar beliefs, culture or shared identity and experiences. Getting to know a "community," its people, and its resources, will help service providers identify strategies for service delivery. If a community center or church is an important local institution, developing partnerships with that organization may help reach the targeted group.

What strategies can Nutrition Programs use to meet the ethnic and cultural food preferences of participants?

Ethnic and religious customs are two of the many factors that influence our food preferences. Understanding the "culture" and its relationship to food preferences will help Nutrition Programs improve the quality of their services. Nutrition Programs should embrace their participants' diversity and focus attention on customer satisfaction. Serving familiar ethnic foods at congregate meal sites and to the homebound will increase the likelihood that the meal will be eaten and enjoyed. It may be one way to increase participation in congregate settings.

When designing menus for the Nutrition Program, the cultural food preferences of all program participants should be considered. Today, the menu often contains common ethnic foods like spaghetti and lasagna; chow mien and stir-fry beef and broccoli; corned beef and cabbage; fried chicken and sweet potatoes. However, there may be many entrees and side dishes representative of other cultures that are often overlooked. The good feeling participants have when served favorite ethnic foods partly comes from the recognition that their cultural preferences are important and respected.

Meeting the food preferences of program participants can be challenging. Nonetheless, making adaptations to menus is essential. The following strategies from a variety of settings may help:

• Make the environment welcome and attractive, reflecting participants' cultural background. Decorate dining areas with ethnic memorabilia.
• Include community input when developing programs and planning menus. Target outreach to specific ethnic, cultural, or religious communities. Many programs have an advisory or community council with participants of various ethnicities to assist with menu planning.
  • The Senior Resource Development Agency, Pueblo, Colorado, has a Nutrition Committee led by the Nutrition Director of Pueblo's Elderly Nutrition Programs. The majority of committee members are site managers, who provide feedback from older adults who eat at the congregate sites and from Meals-On-Wheels drivers, who provide feedback from homebound participants.
  • Little Havana Activities and Nutrition Center, Miami, Florida, and their nutritionist relies on a number of avenues for feedback and assistance with menu planning for their primarily Cuban-American population. Homebound participants are surveyed regularly by staff regarding satisfaction with the menu . Site managers report comments often, particularly when new items are introduced. An annual food preferences evaluation is completed and the program's advisory council also assists with menu planning.
  • Hillsborough County Aging Services, Tampa, Florida, uses a Customer Satisfaction Survey to obtain participant feedback regarding satisfaction with the program and specific menus.
  • The Life Care Alliance, Columbus, Ohio, found all Asians should not be considered as one group when considering food preferences and social needs. The Alliance initiated separate meetings with representatives from the Chinese, Korean, and Vietnamese communities.
  • Use a suggestion box to encourage participants to recommend menu ideas.
    
• Employ staff and volunteers who reflect the diversity of the community served. Use bilingual staff, volunteers and/or interpreters to solicit menu and program ideas.
  • The Hale Makua Skilled Nursing Facility, Kahului, Maui, Hawaii, staff provide input on the type of ethnic foods to include on the menus. Monthly meetings with the Resident Council (similar to a Nutrition Program's advisory council) are held to discuss which menu items have been successful and which items need to be discontinued or improved.
  • The Life Care Alliance, Columbus, Ohio, had a Vietnamese faculty member from a local University help the program meet the nutritional needs in his community through a better understanding of the culture.
• Provide authentic ethnic cuisine.
  • Although programs may do their best to provide ethnic meals, providing authentic ethnic cuisine may be difficult for cooks without such native experience. Norge Jerome, PhD, suggests having a cook "experienced" with traditional ethnic cooking be a "guest" cook or use an ethnic restaurant in the community as a caterer. This is particularly important during special occasions and holidays to carry on cultural traditions.
• Use an ethnic caterer or restaurant to serve specific ethnic and/or religious communities.
  • Senior Services of Snohomish County, Mukilteo, Washington, uses different ethnic restaurants to cater to their Korean, Chinese, and Southeast Asian groups. The restaurants follow a meal pattern provided by the nutrition provider and the caterer develops the actual menu based on the known preferences of the group.
  • Life Care Alliance, Columbus, Ohio serves similar groups. However, they transport Chinese and Vietnamese older adults to different Chinese and Vietnamese restaurants every Saturday and provide programming similar to other congregate sites. They transport Korean participants one Saturday a month to an existing congregate site, where a Korean restaurant caters the meals. Programming is also provided there. All meals follow the general meal pattern.
  • Little Havana Activities and Nutrition Center, Miami, Florida, uses a Cuban-American caterer for their congregate and home delivered meals. Ninety-five percent of the participants are minority (primarily Cuban, African American, and Caribbean). Although primarily Cuban in design, the menus are mixed with American and Caribbean foods.
• Offer a variety of meals and/or foods from different ethnic groups.
  • Linda Kautz Osterkamp of the Southern Arizona Health Promotion Network suggests featuring one ethnic cuisine per week, rotating among the different cuisines that represent their community members. For example, the Edgewater Retirement Community, Galveston, Texas, features one ethnic cuisine per week on a four-week cycle menu plus Italian, Chinese, Mexican, etc., served one or two times per week.
  • Introduce new foods to coincide with ethnic and religious holidays and nutrition education activities.
  • Educate participants on the origins and historical significance of various foods and cooking practices, as well as the nutritional contributions of each food.
• Offer cultural food items as side dishes, desserts, or snacks, if not the entrée on a regular basis.
  • The Hale Makua Skilled Nursing Facility, Kahului, Maui, Hawaii, offers comfort foods to ethnic groups if they cannot provide a familiar ethnic entrée. For example, they offer tofu/miso saimin (soup) as a meal alternate/side dish to Japanese residents and sandwiches as a meal alternate to Caucasian residents.
  • Norge Jerome suggests condiment packages that allow individuals to flavor their foods, as they are accustomed to. A "Mexican pack" may contain hot sauce and adobe seasoning. A "Chinese pack" may contain low sodium soy sauce, hot mustard, duck sauce, and chop sticks. These are the seasonings seen on Mexican or Chinese restaurant tables and are regularly placed on tables at congregate sites.

What are some of the challenges in meeting the needs of culturally diverse participants and how can they be overcome?

Nutrition Programs want to expand food choices and respect cultural preferences. However, perceived obstacles include increased costs and compliance with Dietary Reference Intakes (DRIs) and RDAs (13). Limited funding, decreasing resources, a diminishing volunteer pool, and lack of transportation also challenge Nutrition Programs. These often overshadow desires to increase menu choices. Program administrators need to weigh the benefits and drawbacks of offering more culturally representative menu choices. Consider the following:

• If a program provides only one entrée daily, the cycle menu should offer entrees that are multicultural. Such changes will not increase food costs to any significant degree.
• If a program offers a choice of side dishes to reflect the ethnicity of the community, such changes will not affect food cost significantly.
• If a program hasn't been offering a monthly "ethnic or culture" theme, begin now. Build it into nutrition education plans. Collaboration with participants and their community representatives will go a long way in establishing good rapport.
• Hispanic, Asian, African-American, and other ethnic restaurants and caterers can provide meals at costs comparable to other establishments, particularly if individuals in the community assist in negotiations, as was the experience with the Life Care Alliance in Columbus, OH. The cost of their kosher meals catered by the Jewish Community Center was reasonable.
• To comply with the DRIs and RDAs when incorporating new foods, follow a meal pattern first and know the main ingredients and nutrient content of the food. A number of nutrient databases contain foods of other regions. Commercial food purveyors can provide nutrition information about their products. Compliance with the DRIs may be challenging, but it is not an "excuse" to avoid menu variety.
• If program participation is down, attracting minority or culturally diverse participants may be the key. Consider this: A happy participant (customer) is usually a repeat customer and one who will spread the word about the fine food and service available. It is worth spending a little more on a meal if it means better participation and customer satisfaction.

Resources

• Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families http://www.aoa.dhhs.gov/minorityaccess/guidbook2001/CC-programs.html.
  This web-based document from the federal Administration on Aging outlines the principles of cultural competence and offers guidance on creating programs that work.
• www.EatEthnic.com http://www.eatethnic.com/. Everything about ethnic foods and ingredients, holiday food traditions, religious dietary practices, regional food customs, recipes, fun facts, & cultural nutrition resources. Also available, Ethnic Foods Nutrient Composition Guide, with over 700 ethnic, religious, and regional items-- from Ajwain to Zapote-- arranged by food category; indexed alphabetically, by cultural group, and scientific name. Also available from EatEthnic.com: International Quantity Foods http://www.eatethnic.com/iqf.htm. Whether you cater large events, run a restaurant, or do institutional cooking, you will enjoy International Quantity Foods. Over 150 authentic, kitchen-tested recipes from 20 different cultural groups. Introductory material on the cuisine, common ingredients, seasonings, preparation methods and meal patterns of each nation. Though this 1990 book is out of print, you can order a spiral-bound, copied black-and-white version for $32.95 plus S&H.
• Kalusagan Community Services Project FLASH (Filipino-American Lifestyle Assessment for School-lunch and Health). Nutrition and fitness education materials for Filipino-Americans targeted to the public, teachers, students, parents, food service supervisors and restaurateurs. The project aims to reduce risk factors related to heart disease and stroke. Spiral-bound guides cost $8 each. These well-written materials are packed with healthy tips and recipes. Phone 619-594-2795 or 619-293-3871 for more information or order forms. You can also write Kalusugan Community Services, c/o Dr. Ofelia Dirige, 7982-H Mission Center Court, San Diego, CA 92108.
• Vegetarian Resource Group: Vegan in Volume. http://www.vrg.org/catalog/volume.htm. Chef Nancy Berkoff, RD, shares culturally diverse (Asian, Caribbean, Latin American) quantity recipes. It offers a brief explanation of vegan nutrition, equipment suggestions, and covers catered events, college food service, and hospital food service. It can be purchased online for $20.
• A Cookbook of Healthy Vietnamese Recipes: A Collection of Vietnamese Recipes From the San Francisco Bay Area Vietnamese Community. This cookbook was made for health promotion within the ethnic community. Contact: UC Regents Vietnamese Community Health Promotion Project, 44 Montgomery Street, Suite 850, San Francisco, CA 94104; Phone: 415-476-0557. Cost: $12.50
• "Where's the dal?: Food and Nutrition Experiences of Ethnic Minority Seniors in Long-Term Care." This paper examines the dietary options currently available to ethnic minority seniors in long term care facilities and how they and their families cope with any shortcomings of the health system in meeting their needs; the literature on the meanings assigned to food, particularly as these pertain to immigrants and the elderly; and make suggestions as to the future directions that dietitians, nutritionists and health administrators might to take in order to address identified shortcomings. Submitted March 14, 2001 for the Prevention and Health Promotion Strategies, Ministry of Health, Victoria, British Columbia, Canada by Dr. Sharon Koehn, Vancouver, BC. (604) 733-8637, Email: skoehn@intouch.bc.ca.
• The National Policy and Resource Center on Nutrition and Aging provides a list of resources under the heading Special Populations.
  http://www.fiu.edu/~nutreldr/Resources/5._Special_Populations.htm

References

1. US Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. Washington, DC: US Dept Health Human Services, Government Printing Office. 2000.
2. Administration on Aging. Profile of Older Americans 2000. Available at: http://www.aoa.dhhs.gov/aoa/stats/profile/default.htm. Accessed November 6, 2001.
3. Kramarow E, Lentzner H, Rooks R, Weeks J, Saydah S. Health and Aging Chartbook. Health, United States, 1999. Hyattsville, MD: National Center for Health Statistics. 1999.
4. Administration on Aging. Facts and figures: Statistics on minority aging in the U.S. Available at: http://www.aoa.gov/minorityaccess/stats.html. Accessed November 6, 2001.
5. Administration on Aging. 1998 State Performance Reports. Available at: http://www.aoa.gov/napis/97spr/tables/table3.html. Accessed November 6,2001.
6. Mathematica Policy Research, Inc. Serving Elders at Risk, the Older Americans Act Nutrition Programs: National Evaluation of the Elderly Nutrition Program 1993-1995, Volume I: Title III Evaluation Findings. Washington, DC: US Department of Health and Human Services;1996:103-105, 203.
7. Administration on Aging. The many faces of agin: Resources to effectively serve minority older persons: Healthy People 2010. Available at: http://www.aoa.gov/minorityaccess/healthypeople2010.html. Accessed May 21, 2001.
8. US Department of Health and Human Services. Health People 2010. Available at:
   http://www.cdc.gov/nchs/about/otheract/hpdata2010/abouthp.htm. Accessed November 6, 2001.
9. Administration on Aging. The many faces of aging: Introduction and Welcome. Available at: http://www.aoa.gov/minorityaccess/intro.html. Accessed May 21, 2001.
10. Administration on Aging. The many faces of aging: Promising practices and programs. Available at: http://www.aoa.gov/minorityaccess/promising-practices.html. Accessed May 21, 2001.
11. US Dept of Health and Human Services. Health Resources Services Administration. Cultural Competency: A Journey. Available at: http://www.bphc.hrsa.gov/culturalcompetence/Default.htm. Accessed June 11, 2001.
12. Administration on Aging. Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families. Available at:
    http://www.aoa.dhhs.gov/minorityaccess/guidbook2001/CC-programs.html
    Accessed September 7, 2001.
13. 13. National Policy and Resource Center on Nutrition and Aging. Nutrition 2030 Grassroots Survey Report. December 1999. Available at:
    http://www.fiu.edu/~nutreldr/Center_Initiatives/nutrition_2030/Grassroots_Survey.PDF
    Accessed June 11, 2001.

Contributors

• Judy Arbeiter, Section Manager, Hillsborough County Aging Services, Senior Citizens Nutrition and Activity Program, Tampa, FL. arbeiterj@hillsboroughcounty.org
• Douglas Buck, PhD, Nutritionist, Division of Elderly Services, 25 Sigourney Street, 10th Floor, Hartford, CT 06106-5033. douglas.buck@po.state.ct.us
• Rosa Carranza, MS, RD, Nutritionist, Little Havana Activities and Nutrition Center, Miami, FL. rmcarranza@lhanc.org
• Edmund D. Chan, RD, Hale Makua (Skilled Nursing Facility), Kahului, Maui, HI. theechan@hotmail.com
• Peta R. Dudley, MS, RD, Edgewater Retirement Community, Galveston, TX.
  dudmeister@juno.com
• Beverly Hamilton, Program Supervisor, Fellowship Dining, Polk County Elderly Services, Bartow, FL. beverlyhamilton@polk-county.net
• Joyce Herman, Director of Meals on Wheels, Life Care Alliance, Columbus, OH, (614) 278-3141, ext.261. joyrich@lifecarealliance.org
• Linda Kautz Osterkamp, Southern Arizona Health Promotion Network. oster2@mindspring.com
• Norge W. Jerome, PhD, University of Kansas, School of Medicine, Shawnee, KS. (913) 962-9020.
• Dr. Sharon Koehn, Vancouver, BC. skoehn@intouch.bc.ca
• Danelle Looney, MSRD, MBA, Senior Resource Development Agency (SRDA), Pueblo, CO.
• Martha Peppones, MS, RD, CD, Nutrition Director, Senior Services of Snohomish County, Mukilteo, WA. mpeppones@sssc.org
• Amy Van Elzen. amy@mces.net
• Shannon Wiedmeyer. swiedmeyer@co.green-lake.wi.us
  

Compiled by Stacey Reppas, MS, RD and Lester Rosenzweig, MS, RD, and staff of the National Policy and Resource Center on Nutrition and Aging, Florida International University, Miami, FL. Contact: nutritionandaging@fiu.edu

This project is supported, in part, by a grant from the Administration on Aging,
Department of Health and Human Services (DHHS). Grantees undertaking projects under government
sponsorship are encouraged to express freely their findings and conclusions.
Points of view or opinions do not, therefore, reflect official DHHS policy.

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Posted on 05/07/2004