Nutrition from the kitchen: culinary medicine impacts students' counseling confidence

Emily Magallanes
Ahana Sen
Milette Siler
Jaclyn Albin
Nutrition from the kitchen: culinary medicine impacts students' counseling confidence
10.1186/s12909-021-02512-2R E S E A R C H A R T I C L E Open Access
Background: Although a poor diet is the number one risk factor for early death in the United States and globally, physicians receive little to no training in dietary interventions and lack confidence counseling patients about lifestyle modifications. Innovative, interprofessional strategies to address these gaps include the emergence of culinary medicine, a hands-on approach to teaching the role of food in health outcomes. We sought to assess the impact of a culinary medicine elective on counseling confidence, awareness of an evidence-based approach to nutrition, and understanding of the role of interprofessional teamwork in dietary lifestyle change among medical students at one undergraduate medical school. Methods: We administered pre-and post-course surveys to two cohorts of medical students (n = 64 at pre-test and n = 60 at post-test) participating in a culinary medicine enrichment elective. Chi-square analysis was used to assess the relationship between participation in the course and a positive response to each survey item. Results: Compared with the baseline, students participating in culinary medicine were more likely to feel confident discussing nutrition with patients (29% vs 92%; p < 0.001), to feel familiar with the Mediterranean diet (54% vs. 97%; p < 0.001), and to understand the role of dietitians in patient care (37% vs. 93%; p < 0.001).Conclusions: Culinary medicine shows promise as an impactful educational strategy among first-year medical students for increasing counseling confidence, promoting familiarity with evidence-based nutrition interventions, and augmenting understanding of the role of interprofessional engagement to address lifestyle-related disease.

nutrition education efforts as primarily in a preclinical didactic setting with minimal emphasis on the role of nutrition in clinical practice [20]. Ensuring adequate preventative care for patients is a complex issue that is not easily solved by any institution or program. However, institutions can more feasibly focus efforts on educational innovation to ensure that medical students, residents, and fellows receive adequate nutrition education in order to support the preventative health goals of patients.

There have been many prior efforts to establish effective nutrition education programs in medical schools. Perhaps most notable is the Nutrition Academic Award (NAA) funded by the National Institutes of Health which supported medical schools in the development of enhanced nutrition education programs. Participating schools developed such programs as part of their required undergraduate medical education (UME) curricula and networked with national organizations to promote furtherance of national UME nutrition education standards [35]. An impact evaluation of one NAA curriculum implemented at a single medical school found that participating students had greater nutrition knowledge and self-efficacy compared to controls [36]. Other nutrition and preventive medicine curricula implemented at US medical schools, many of whom also received an NAA, have had similar findings with increases in counseling confidence and knowledge as well as improved self-reports of personal dietary habits [37,38]. Unfortunately, although nutrition education among medical students is effective, the lasting impact of many prior interventions remains disappointing. Neither the efforts of the NAA nor of independent medical schools have resulted in the creation of widely accepted or implemented standards for curricula, with nutrition education adoption still sparse and heterogeneous [20,21,26,32,39].

In contrast, a nutrition teaching innovation known as Culinary Medicine (CM) has rapidly gained popularity and prominence among medical schools and community health programs across the US [21]. The most widely adopted CM curriculum, Health meets Food, began at Tulane University in 2013 [40]. In 2015, Moncrief Cancer Institute at the University of Texas Southwestern Medical Center was the first to license and launch the Health meets Food curriculum. Just five short years later, more than 55 medical schools, residency programs, and nursing schools have adopted Health meets Food [41], and many other schools have developed their own programs [42] following a similar model of instruction. The exact reason for the unprecedented success of CM programs is currently unknown but may be due to the unique hands-on teaching model, strong interprofessional collaboration, and a centralized approach that is easy to license and adapt [21,39].

Unlike nutrition programs based on traditional teaching methods, CM programs teach the role that food plays in health through experiential learning in a kitchen [40,42]. Interprofessional teams of physicians, dietitians, and chefs combine skills to highlight data-driven strategies that promote delicious, accessible, and healthy cooking. In turn, eating healthy meals serves as a prevention and treatment modality for major chronic diseases. Rooted in a simulation-based medical education approach with deliberate practice (SBME-DP), a model shown to be superior for acquiring and mastering new skills, CM offers learners the opportunity to immediately apply new knowledge with peer support and expert guidance [43]. Guided practice fosters self-efficacy regarding dietary choices, culinary skills, and nutrition counseling as students cook together, eat together, and teach each other about the nutritional value of various foods [44]. While some students may go on to lead culinary demonstrations in their practices or in the community, a growing strategy, all students will gain practical skills that can be applied to discussions with patients about specific dietary changes to improve health. This interactive approach also enables instructors to observe higher level skill competence as defined by Miller's pyramid [45]. For example, educators can informally assess their students' knowledge ("knows") via topic-specific nutrition quizzes, application ("knows how") via patient case discussions, and demonstration of learning ("shows") via both live culinary skill demonstration and peer education presentations. This observation of rich educational data happens in real time and on a regular basis.

The Health meets Food curriculum has been especially widely adopted through licensing of their convenient and comprehensive courseware. Health meets Food espouses the evidence-based Mediterranean diet [46] which emphasizes vegetables, fruits, whole grains, fish, legumes, nuts, and seeds, with olive oil as a primary source of fat [46][47][48][49][50][51][52][53]. The complete courseware currently encompasses over 30 modules on various topics in nutrition. Eight core modules cover foundational principles and additional modules focus on disease or population specific topics such as nutrition and cancer, nutrition in pregnancy, nutrition for heart disease, and mindfulness with motivational interviewing. At Tulane University, all first-and second-year medical students participate in several modules from the core curriculum in addition to elective opportunities. For other institutions utilizing the Health meets Food curriculum, the implementation varies both in terms of level of training, timing, and modules selected.

Although CM has been enthusiastically adopted, the reasons for this adoption and the outcomes of such programs on students are still under evaluation. A large prospective, observational cohort study of CM education for medical students at Tulane University demonstrated greater improvement in personal dietary patterns and attitudes about the efficacy of nutrition counseling as compared to traditional clinical education [43]. These results are promising and support the aforementioned premise that any enhanced nutrition education for students is impactful. However, additional research is needed to fully understand the specific potential of the CM approach as a solution to the deficit of medical nutrition education in the US, especially when curricula are implemented outside of the institution of origin through licensure. In this study, we will report how a CM elective course implemented among first-year students at one US medical school unaffiliated with Tulane University affected student counseling confidence, familiarity with evidence-based nutrition interventions, and understanding of the role of interprofessional engagement to address lifestyle-related disease. We will also propose directions for future research to build on the current understanding of CM as a nutrition education strategy that is both educationally effective and widely adopted in a sustainable way.

Method

Subjects

We surveyed 64 first-year medical students participating in the CM elective at our medical school using an uncontrolled before-and-after study design. The first cohort of 32 students enrolled during the 2017-18 school year. The second cohort of 32 students enrolled during 2018-19.

All first-year medical students (class size approximately 240 students) at our institution were eligible for participation in this study. No other inclusion or exclusion criteria were defined. Recruitment occurred through informal announcement at an enrichment elective fair, by email, and through a first-year class social media page. Electronic enrollment opened at a pre-advertised time, and the available elective slots filled in under a minute in a first-come, first-served manner.

Intervention

Prior to this study, there were no cohesive electives or required nutrition, prevention, or lifestyle medicine educational courses available for students at our medical school. Consequently, we designed a CM elective using the Health meets Food curriculum to meet student demand for enhanced clinically relevant nutrition education.

We divided the 32 students enrolled annually into two groups of 16 to optimize the hands-on nature of the course for a total of 4 groups and 64 students over 2 years. Each group met monthly in the evening for a 3-h module in an on-campus teaching kitchen and experienced an identical curriculum. We utilized the first eight modules in the Health meets Food curriculum to teach this course. These topics encompassed the core CM curriculum for medical students and included 1) Introduction to Culinary Medicine, 2) Weight Management and Portion Control, 3) Fats, 4) Food Allergy and Intolerance, 5) Protein, Amino Acids, Vegetarian Diets, and Eating Disorders, 6) Sodium, Potassium, and Hypertension, 7) Carbohydrates, and 8) The Pediatric Diet.

Participants spent most of class time in the teaching kitchen developing practical skills for making appetizing, nutritious, and economical dishes while learning how to discuss health behaviors with patients. Each class started with a small group discussion about clinical cases related to the module topic and a culinary demonstration to illustrate a relevant food science principle. Students then worked in small groups of 4 to prepare assigned recipes and presented their dishes to the rest of the class, highlighting palatable features of the food as well as nutrition content relevant to the module topic. Students subsequently ate together during a discussion about the nutrition science, medical research, and patient care applications relevant to the module.

A medical doctor (MD) and a registered dietitian (RD) co-facilitated the course and group discussions. We further promoted interprofessional education by engaging medical students (prior culinary medicine program graduates) and dietetic student interns as peer mentors in a variety of modalities. Medical student peer mentors supported grassroots recruitment efforts, organized volunteers for kitchen cleaning, and guided the elective participants in patient case discussions related to the module topic. Dietetic student peer mentors aided the course facilitators in pre-module kitchen set-up and with practical support for elective participants during the live cooking, particularly by helping participants prepare to discuss the nutrition highlights of their food during the peer education portion of class. An average of 3-5 peer mentors supported each of the 32 classes in this study.

Survey instrument and administration

With a multidisciplinary team of dietitians, physicians, and students, we developed a survey unique to this intervention to assess student eating patterns and perceived awareness about the importance of nutrition in health outcomes before and after taking this course. We scored responses based on a traditional 5-point Likert scale ranging from strongly agree to strongly disagree.

Our pre-course survey (Additional file 1) included questions regarding students' personal wellness habits, beliefs about nutrition and nutrition counseling, confidence discussing nutrition with patients, and perceived familiarity with the Mediterranean diet and the role of RDs in a patient-care team. The post-course survey (Additional file 2) included additional questions related to students' satisfaction with the course and the extent to which they incorporated learned habits into their personal routines.

Students completed pre-course surveys during the first class and post-course surveys on the last day of class. Participation was voluntary and did not affect students' grade or academic standing, and students completed surveys on paper.

Statistical analysis

Survey data from the 64 participants were compiled into a single data set. We completed chi-square analysis and calculated odds ratios to assess the association between the CM course and a response of "agree" or "strongly agree" to each question on the survey. The Yates correction for continuity was used for contingency tables with any cell having a value of 5 or less.

Results

Of the 64 first-year medical student participants, all completed the pre-test, and 60 students completed the post-test. Four students over the two-year period were unable to attend the last day of class, and thus they did not complete a post-course survey. While we did not formally collect student-reported demographic data from elective participants, student characteristics reflected the overall class profile and statistics of our institution's medical students which currently includes a 50/50 mixture of male and female students, 42.6% Asian/Pacific Islander students, 29.6% Caucasian students, 24.8% underrepresented minority students, and diverse backgrounds as evidenced by 11 home countries, 21 home states, and 12% first generation college students.

Confidence and beliefs about nutrition in patient care

Baseline and post-test confidence, beliefs, and familiarity with the Mediterranean diet and the role of dietitians are summarized in Table 1. At baseline, most students (94%) agreed or strongly agreed that speaking to patients about their food choices is essential. However, only a minority (29%) of students felt comfortable doing so. Few students (37%) understood the role of a dietitian, and just over half (54%) were familiar with the Mediterranean diet.

The post-test assessment demonstrated significant increases in a number of measures. Notably, 92% felt comfortable discussing nutrition with a patient (OR = 26.8), 97% felt familiar with the Mediterranean diet (OR = 25.59), and 93% were confident they understood the role of a dietitian (OR = 23.3).

Perceptions about personal Health habits

As demonstrated in Table 2, the CM intervention significantly increased the number of students that felt confident in the kitchen (OR = 3.26) and significantly decreased those that believed healthy eating is expensive and time-consuming (OR = 0.43). There was no significant change in the number of students that made food for themselves at home.

Course satisfaction

Participants were overwhelmingly satisfied with their CM experience. 100% agreed that the information they learned was helpful; 93% planned to implement what they learned into their daily lifestyle, and 98% agreed they would recommend this course to others.

Discussion

Culinary Medicine education has emerged as one intervention in response to calls for better nutrition education for patients and practitioners. This study is one of the first to evaluate the outcomes of using the Health meets Food CM curriculum to teach nutrition to medical students and, to our knowledge, is the first study to do so independently of the institution of curricular origin, Tulane University. The impact of CM on the attitudes and behaviors of participants, especially within patient encounters, needs further study. CM training for first-year medical student participants at our institution increased awareness of an evidencebased dietary pattern, familiarity with dietitians and their role on interdisciplinary teams, and self-reported confidence to discuss nutrition in patient care settings. These findings are consistent with other studies that observed increases in confidence and self-efficacy among medical students participating in various forms of nutrition education [36,37]. We also showed that CM can facilitate changes in beliefs and attitudes about nutrition, an important predictor of student and physician likelihood of providing dietary counseling to their patients [16,27,34,[54][55][56]. This builds upon prior findings in the Tulane University study that demonstrated that CM improves medical student attitudes about nutrition counseling even more than other forms of nutrition education [43]. Our study enhances prior findings by demonstrating similar student outcomes through licensing and application of the same curriculum at another medical school.

Compared to traditional methods, CM is a promising approach to nutrition education because students experience nutrition through the lens of practical, real-life eating strategies set in the context of patient care and counseling. While other curricula are didactic-based and often focus on the biochemical aspects of nutrition, CM trains the learner to first attend to his or her own personal health habits so that they are able to speak to patients with personal conviction and experience. Studies reveal that physicians who practice good personal nutrition habits are more effective and more consistent when counseling patients about diet [23,[54][55][56][57][58]. Additionally, CM introduces learners to food-specific motivational interviewing skills which are essential for carrying out patient education but sadly lacking from most other nutrition and medical school curricula. This interactive, person-centered learning approach may be the reason that CM has gained such rapid attention among the medical community and even the popular media [59][60][61].

An additional strength of using a CM approach to nutrition education is the interdisciplinary perspectivesdietitians, physicians, and chefs-and the opportunity to work hand-in-hand with professionals from these fields.

These interactions may have contributed to the observed increase in understanding of the role of dietitians and may pave the way for increased collaboration between physicians and other health and culinary professionals in the future. This interprofessional approach will likely be essential in creating cultural change regarding the emphasis on food as a prevention and wellness strategy.

There are several notable strengths of this study. First, we focused on student beliefs, attitudes, and perceptions of self-efficacy which are known to play a positive role in impacting counseling comfort with patients [62]. Second, our analysis encompasses two consecutive years of data which allowed us to demonstrate the consistent impact of our curriculum repeated for different cohorts of students. The course instructors and curricular topics presented remained unchanged across the 2 years, allowing assessment of very similar course experiences. Finally, while not a measured outcome, the ongoing peer mentor engagement enabled medical students at higher levels of training to have ongoing exposure to the nutrition curriculum through volunteering.

We encountered several limitations. First, we obtained our data from one medical school with courses taught by one set of instructors, thus limiting assumptions about generalizability. However, as previously discussed, our findings aligned with the results of prior work at the curriculum's founding institution [63]. Finally, any possible differences between the two cohorts, including demographic stratification, were not assessed.

Culinary Medicine is a promising intervention that merits further research. Specifically, future studies are needed to determine the degree to which the positive effects of CM education endure across UME into residency. Additionally, future studies need to assess student behavior in addition to attitudes and should strive to identify ways to assess the impact of CM education on medical student knowledge, interpersonal skills, and motivational interviewing competencies in real or simulated patient encounters.

Conclusion

In this study, we demonstrate that a CM curriculum can increase awareness of evidence-based nutrition principles and counseling confidence among first-year medical For this item, correlation was measured to "disagree" and "strongly disagree" students as well as improve their understanding of interprofessional teams. Additional research is needed to determine if CM increases actual counseling competency and to determine if positive outcomes persist through UME and translate to graduate medical education and physician clinical practice.

Supplementary Information

The online version contains supplementary material available at https://doi. org/10.1186/s12909-021-02512-2.

Table 1
1Medical student confidence, beliefs, and familiarity with principles of nutrition in patient careQuestion
Agree or strongly agree (%)

Baseline
Posttest
X 2
P-value
OR

Speaking with our patients about their food choices is an
essential part of any discussion about health.

94
97
0.11 a
0.736
1.93

I am comfortable having a discussion with a patient about
eating habits and health with my current level of nutrition
knowledge.

29
92
47.8 a
< 0.001
26.8

I am familiar with the basic tenets and research associated
with the Mediterranean diet.

54
97
28.43 a
< 0.001
25.59

I feel confident that I know what a dietitian does and how
they might fit into a patient care team.

37
93
39.77 a
< 0.001
23.3

I believe that a physician's personal health habits correlate
directly with patient outcomes.

66
92
10.07 a
0.002
5.5

a

Indicates use of Yates correction for continuity

Table 2
2Medical student perceptions about personal health habits Even though I am busy, I make time to prepare healthy food for myself.Question

AcknowledgementsWe would like to thank our colleagues in Culinary Medicine at Health meetsAuthors' contributions EM made substantial contributions to analysis of completed survey responses including statistician consultation, interpretation of data, drafting of the manuscript, and manuscript review. AS contributed to the data analysis and presentation process as well as the drafting and review of the manuscript. MS was integral in the conception and implementation of the work, including survey design. She also contributed to manuscript review. JA was involved at every stage including conception and implementation of the work, data collection, data analysis, drafting, and manuscript review. All authors approved this final version and agree to be accountable for the integrity of the work.FundingA small institutional educational grant from the Southwestern Academy of Teachers supported this project. The funding source had no involvement in study design, analysis, or interpretation.Availability of data and materialsThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.Ethics approval and consent to participateThis project was reviewed by the University of Texas Southwestern Medical Center Institutional Review Board and deemed exempt. Verbal consent for participation was obtained from all students, and this was approved due to the voluntary, anonymous nature of participation in the surveys.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.
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Challenges Associated with Serving the Diverse Needs of American Indian Families through Current Provisions of the Indian Child Welfare Act

Sonya Smith email@example.com
School of Public Service Leadership
Capella University
MinneapolisUSA

Yanyi K Djamba email@example.com
Department of Sociology, Anthropology and Geography
Auburn University at Montgomery
MontgomeryUSA

American Indian
Indian Child Welfare Act
AlabamaUnited States

Challenges Associated with Serving the Diverse Needs of American Indian Families through Current Provisions of the Indian Child Welfare Act
6873650341F95281E1CF81294F8F7F1110.4236/aasoci.2015.51003Received 2 December 2014; revised 19 December 2014; accepted 31 December 2014
Historical reviews of American IndianCulture reveal an indigenous population rooted in the dichotomy of societal misunderstanding and victimization.This dichotomy illustrates repeated occurrence of incidents involving the removal, assimilation or extinction of American Indian children.This analysis of the Indian Child Welfare Act focuses on the heart of American Indian culture which is the well-being of American Indian children.Information used in this paper comes from the review of literature, census data and oral narratives obtained through a convenience sample of American Indian people interviewed in Alabama.The results of this study reveal the diversity of American Indian people seen throughout the United States, as well as in the state of Alabama.Unfortunately, the provisions of the Indian Child Welfare Act are only intended for American Indian children from federally recognized tribes and exclude American Indian children from state recognized tribes.This study concludes with a discussion of the contributions and limitations of the Indian Child Welfare Act and calls for expanded services to serve all American Indian populations in the United States.

Historical Context and the Purpose of the Study

The year of 1492 is a highlighted time in American history which established detrimental stereotypes of American Indian people.Christopher Columbus's first encounter with the Taino Indian people objectified them as being well built with strong bodies.Columbus and other explorers concluded the Taino Indian's difference of dress and difference of physical appearance to be uncivilized by their standards.Stereotypes derived from this initial encounter paternalistically labeled American Indian people as inferior servant beings in need of cultural assimilation.

Columbus conveyed cultural assimilation as a means of humanizing these inferior beings in ways they could be elevated or made into suitable human slaves.Vague detail of Columbus' first departure notes him to set sail Westward (home) with a number of Taino Indians aboard his ship.This cultural separation indicates that various Taino Indian people were taken through capture and removed for intended assimilation (Gillon & Matson, 2006).These oppressive actions by Columbus became foundational for the development of the Carlisle Schools introduced by Henry Pratt in 1879.

Historical accounts of Columbus's actions parallel the involvement of individuals who premeditatedly removed Indian people from their homelands with the intent to force assimilation into a more acceptable culture.Pratt designed his Carlisle School system with a theoretical principle to "kill the Indian and save the man" (Gillon & Matson, 2006: p. 669).Pratt believed that it was possible to erase cultural identity and assimilate American Indian people into a mainstream white society.Simply stated, Pratt believed that he could cause American Indian people to become white by taking away their traditions and assimilating their appearance.

Constituents of Pratt's mission specifically targeted and removed American Indian children from their homes.The Carlisle Schools became known as Indian Boarding Schools and were located throughout the United States.The Meriam Report of 1928 identifies the primary purpose of the Indian Boarding Schools as designed to break parent-child relationships.The education provided at the boarding schools was designed to introduce Indian children to civilization by prohibiting the use of their spoken languages, taking away cultural foods and traditions and by altering their physical appearances (Mannes, 1995a).These horrors still prevail in the minds of American Indian people today.The intent to destroy culture through placement in unfamiliar surroundings remains a harsh reality in Indian Country today.Authority figures attempting cultural genocide are a proven and repetitious fact experienced by American Indian people.These attempts of cultural genocide did not stop with Columbus and Pratt.

Historical reports of cultural genocide continued throughout the nation through multiple strategic attempts.Specifically in 1886, the verbalization of Indian language was made illegal in Mississippi schools (Konstantin, 2002).Later on in 1890, the battle of Wounded Knee, which was motivated through religious hostility and misunderstanding of the Ghost Dance, took place in South Dakota.Although Jack Wilson, a Paiute gentleman known as Wovoka, spoke about his vision of the second coming of Christ and encouraged those who would participate in the Ghost Dance to dance as means of hastening the arrival of Messiah's promise (Liggett, 1998), Custer's men deemed the religious Ghost Dance enacted by the Lakota people an unacceptable practice outside Christianity.This judgment resulted in the slaughter of over three hundred American Indian people, most of whom were women and children (Gillon & Matson, 2006).

The struggle of American Indian people to maintain their cultural identity is a continuation of history without cease.To most American Indian activists, "the Indian wars never ended" (Native American Rights Fund, 2007).The loss of family preservation experienced by American Indian people is a significant problem faced by every community across Indian Country.The significant problem of loss of family preservation experienced by American Indian people in all communities is an intensified hardship experienced between human service professionals and the families being served due to greater opportunities for exposure to social problems which facilitate the situation.

The Indian Child Welfare Act is a strong tool which can help prevent this loss and needs to be studied diligently by human service professionals who are working with American Indian families, because social problems associated with historical scrutiny propelled by the mentality of assimilation and ridicule still remain evident today.Particular areas of scrutiny commonly include American Indian religion, the dance circle and authentically made goods such as crafts.Because of this scrutiny, a need to legally protect the future of cultural traditions surfaced throughout Indian Country from all walks of life.The focus of the need was to ensure traditional continuance through American Indian children.American Indian leaders diligently hoped that the laws developed for them would protect Indian families, communities and tribes against further disintegration of their tradi-tional cultural systems (Matheson, 1996).

After fifteen years of political struggle by American Indian leaders throughout the nation during the early 1960s and the late 1970s, the Indian Child Welfare Act (ICWA) of 1978 was signed into law by President Jimmy Carter (Matheson, 1996).The ICWA gives priority for the placement of American Indian children into American Indian homes.Specifically, the ICWA places American Indian children who have been removed from their home into an environment that will sustain cultural norms and traditions.The intent of the act is to protect the best interest of American Indian children and to promote stability and security of American Indian tribes and their families.It is further intended for each tribe to be given placement rights of their own children.Original organizers of the ICWA emphasize the design of this act as one that does not allow strangers to organize and continue taking American Indian children.

Prior to the ICWA, approximately 25% -35% of American Indian children were removed from their homes to be placed in foster or adoptive homes, and of those placements, 85% went to non-Indian homes (Karger & Stoesz, 2006).Such a high placement of American Indian children in non-Indian homes increased the specter of systematic and progressive genocide (Karger & Stoesz, 2006)."Ultimately, when the ICWA and Indian cultures are not respected or addressed, family malfunctioning as well as cultural loss and its devastation continues" (Haverson, 2006: p. 1).Supreme Justice Thurgood Marshall stated that "the relationship between American Indians and the United States is perhaps unlike that of any other two people in existence… marked by peculiar and cardinal distinctions which exist nowhere else" (Matheson, 1996: p. 1).

The ICWA expressly recognizes the relationship between the federal government and American Indian tribes.Implementation of the ICWA established responsibility for the protection of American Indian tribes and their resources.The primary resource in this aspect refers to American Indian children.Referring to American Indian children as a resource significantly focuses on the preservation of American Indian culture (Stark, Jason, & Stark, 2006).As an emphasis on need for cultural connectivity, the ICWA consistently focuses on the harsh psychological consequences of cultural separation and the negative impact faced by American Indian children as individuals.This area of emphasis demonstrates unwavering referral to tribal preservation and prevention of cultural genocide (Matheson, 1996).

The ICWA addresses a wide scope of American Indian culture, but it is limited by its provisions.The latter is specific to American Indian people enrolled as citizens of federally recognized tribes.However, American Indian culture consists of federally recognized tribes as well as state recognized tribes.Other categories may be considered on a state-by-state basis.The key provisions presented in this analysis will illustrate service limitations within the policy when applied towards serving the American Indian population as a whole.

The purpose of this study is to evaluate how this policy can alleviate service limitations and most effectively serve the population of American Indian people as a whole.The study addresses the challenges associated with serving the diverse needs of American Indian families through current provisions of the Indian Child Welfare Act.Evaluation of these provisions shows the need for a comprehensive policy.Human service professionals practicing with American Indian families in the area of child welfare or other areas of specialization such as family counseling and family preservation will benefit from this study, because it provides information for culturally sensitive practice.Such information is useful, especially in designing group specific services.

Data and Methods

The qualitative research design for this policy evaluation is ethnographic research.The ethnographic research design is being selected for this study because it explores the shared culture of a group of people (Plano Clark & Creswell, 2010).The content of the policy evaluation uses demographic information about American Indian people living within the state of Alabama as a state data base to illustrate diversity of the population.The demographic information from this database illustrates complexity and individualism of American Indian people.Generalization of American Indian culture within the provisions of the ICWA is detrimental to American Indian population.The primary purpose of this study is to create public awareness for improved and needed comprehensive services to American Indian families through expansion of the ICWA.

The demographic information was retrieved from the Alabama Indian Affairs Commission web site and based on the 2010 Census Report.Currently, there are 57,118 American Indian people residing within the state of Alabama (Norris, Vines, & Hoeffel, 2012).Based upon this report, the identified population collectively represents 1.2% of the state's total population.In addition to Census data, this study uses narratives from a convenience sample of 5 individuals from 5 different state recognized tribes.Individuals contributing to this study illustrate the need to evaluate implementation of a comprehensive policy with provisions for American Indian families in a diverse setting.Such insights were presented through open-ended experiences and discussions congruent with the American Indian cultural value of communal input.This form of communication incorporated into this research is a key concept of American Indian culture specifically relevant to extended kinship and group consensus.Omission of community input disregards key individuals and is considered disrespectful in American Indian culture.Cultural efficacy in this regard enhances research validity and demonstrates the ability to work on a case by case basis.

The diversity of American Indian populations mandates cultural sensitivity to individualism in order to comprehensively address service needs.Complex categorization and unique traditions of the population exemplifies nominal measurement.The following chart (Figure 1) represents a portion of community input based on statements specific to this analysis.The chart consists of five families with a total of 23 people and one person per family serving as the spokesman.The contributors were obtained through the convenience sample mentioned above.Each contributing community voice is enrolled in a state recognized American Indian tribe.Their statements provide human experience from those who have had specific experiences.The content of the statements has significant insight regarding views of cultural preservation and the need for a comprehensive policy.

Input of the five families contributing as a community voice illustrates common concerns from individual perspectives.Their backgrounds vary from tribal elders to families suffering loss and the overarching concern is the preservation of American Indian children.Notably, this concern for the preservation of American Indian children is a consistent cultural value of American Indian people, regardless of tribal recognition status or background.Due to this commonality, the dominate heartbeat of a diverse population cannot be overlooked regarding the need for a comprehensive policy.

Results and Discussion

American Indian Tribes in Alabama

Successful implementation of the ICWA is contingent upon cultural sensitivity and recognition of the diversity among American Indian people.National Census figures indicate that 51% of American Indian people reside in urban communities and 25% live on reservations (Halverson et al., 2002: p. 1).These diverse dwellings each present different needs.However, cultural preservation is vital to the population as a whole.Due to this, it is essential to evaluate the cause and course of events associated with these dwellings.

American Indian people have been faced with the Trail of Tears, Wounded Knee and later the termination era of the 1950's.Each of these produced the result of community redistribution commonly referred to as relocation or the removals.These occurrences of disruption regarding community location are complex matters because numerous American Indian people feel as though society deems them less Indian due to their dwelling place.However, culture is not constituted by dwelling alone.Rather, it is constituted by birth and by various psychosocial factors of the eco-model such as history and environmental structure which encompass cultural norms and traditions without boundary.Simply stated, geographic location is not a replacement for personal identity.American Indian people constitute a diverse demographic population and there is merit to addressing the needs of American Indian people as individuals.Alabama is home to 9 American Indian tribes.This population includes American Indian people from different tribes who encompass 3 Creek Indian tribes, 1 Choctaw Indian tribe, 3 Cherokee Indian tribes, 1 Shawnee Indian tribe and 1 joint tribe of Cherokee and Creek Indian people.Each body of people collectively identified as a tribe have their own language, dance styles, traditional clothing and cultural events.These unique aspects of cultural traditions are due to tribal identity and must be addressed with respect.Generalizing of the population is a detriment to practical service.

A closer examination of the existing population's demographics renders a more detailed description.Eight of the 9 Alabama tribes have state recognition through the Davis-Strong Act of 1984 and only one has federal recognition.Alabama acknowledges 2 geographic locations as reservation land, and they are resident to separate tribes.Specifically, one reservation is home to a federally recognized tribe and the other is home to a state recognized tribe.Each of the two tribes has an identifiable percentage of their population living in their reservation areas.Other tribal citizens may live in a more urban area, other rural surrounding areas or outside of the state.

Additional data about Alabama's American Indian population merits consideration of individuals who currently live within the state, but acknowledge a tribal home outside the state.The complexity of Alabama's American Indian population is not unusual among any of the 50 states of the United States and is applicable as a model for service provisions regarding the ICWA.The result of this analysis shows one tribe which is equal to 10% of the total American Indian population in Alabama as being federally recognized and eligible for services through current provisions of the ICWA.The other 8 tribes which equal 90% of Alabama's American Indian population are state recognized and not eligible for services through the current ICWA.This means 90% of the American Indian population in Alabama would not have access to cultural preservation for their children in cases of adoptive or foster care placement.

Policy Overview and Application

The ICWA was designed with a primary intent to preserve American Indian culture.Its primary intent encompassed preferential placement of American Indian children with American Indian families and gave priority of jurisdiction to tribal governments.The jurisdiction of tribal government is viewed as overarching authority.Issues involving American Indian children who live on reservations are exclusively dictated through tribal court systems.Issues involving American Indian children who live off the reservation are concurrently dictated by state and tribal courts.

Priority is always given to the tribal court (Stark, Jason, & Stark, 2006).Although the priority given to tribal courts presents an equal intent within the ICWA, there is a need to respect the discretion of American Indian people to take care of their own children.The underlying message attempts to restore dignity and self-determination, which were historically taken from American Indian people.Specifically, the ICWA is an endeavor to prevent ongoing assimilation and cultural genocide by respecting the values of American Indian people.

Due to this complexity, the National Indian Child Welfare Association (NICWA) which serves as a primary overseer for the ICWA governs the criteria for Indian Child Welfare Worker certification.In order to become certified, the criteria from NICWA requires as minimal: a 120 hour bachelor of arts degree with 20 hours specific to child welfare, 20 hours specific to American Indian studies and completion of the NICWA internetbased ICWA course.NICWA further requires 2000 supervised hours of employment with 1500 hours of service as a paid tribal or urban Indian child welfare worker, with specific experience pertaining to American Indian family home preservation.The documentation required to complete certification includes: letters of endorsement from a tribal administrator, a skill standard check-list with community activities, a cultural competency checklist, and a background check.

Additional information about this criterion is found on the web site for NICWA at www.nicwa.organd is also cited on the reference page.The NICWA web site also offers a full hard copy of the ICWA and a concise document with key provisions.An expounded presentation of the ICWA is offered through Native American Rights Fund (NARF).The presentation is available in the book titled: A Practical Guide to the Indian Child Welfare Act.NARF is collectively known as the oldest practitioners of federal Indian law.It is written by senior level staff attorneys in conjunction with other practitioners from various other disciplines.

As previously stated, prior to the ICWA, 25% -35% of American Indian children were removed from their homes to be placed in foster or adoptive homes and of those placements 85% went to non-Indian homes."The fact that 85% of such placements left were in non-Indian families and left the children without access to their tribal homes and relationships raised the specter of partial cultural genocide" (Karger & Stoesz, 2006: p. 406).

Further into these statistics also revealed that 17% of American Indian children lived in an institutional setting during the year of 1971.Congressional argument states the removal of American Indian children from their cultural norms as a detrimental family break-up, which perpetuates a cycle of poverty and despair.Furthermore, the loss of identity and self-esteem created by cultural separation contributes to high levels of alcoholism, drug use, school dropout rates and suicide (Stark, Jason, & Stark, 2006)."Ultimately, when the ICWA and Indian cultures are not respected or addressed, family malfunctioning as well as cultural loss and its devastation continue" (Halverson et al., 2002: p. 1).

Key Provisions

The ethical goals of the ICWA focus equally on cultural preservation and respect for tribal governments to facilitate the care for their own children.The ICWA is well organized with step-by-step procedures to ensure effectiveness.However, the policy has its limitations.It is only designed to serve American Indian children from federally recognized tribes.Key provisions listed on the NICWA website (www.nicwa.org)validate this within "definitions of a child subject to ICWA."It states:

ICWA defines a child as Indian if he or she is a member of a federally recognized tribe or if he or she is eligible for tribal membership and is the biological child of a tribal member.A child who has some Indian blood, but not enough to qualify for membership in a federally recognized tribe, or who is a member of a state recognized tribe, is not subject to the ICWA (www.nicwa.org).

Realization and enforcement of this defined provision has rather severe consequences.Only a small portion of American Indian children are served by the ICWA.As indicated, American Indian children from state recognized tribes are left without service.

The summation of unintended consequences is best described as unintended emotional harm.Many American Indian people from state recognized tribes feel that "from the earliest days of the republic, federal Indian policy was to eradicate the 'Indianness' in young people" (Mannes, 1995b: p. 1).This translates as American Indian people being made to feel that they are not Indian enough to matter due to the absence of federal recognition.This creates division in Indian Country which is not in the best interest of cultural preservation by any definition.

Theory and Management

Preservation of cultural norms and traditions often reveals an additional hardship imposed on American Indian people, which is best described as being torn between two worlds.Although all American Indian people facing the hardship of being torn between two worlds experience grief and loss, those at the peak of turmoil are children ages 6 -11 years.Children in this age group are identified by theorist Erik Erickson as being in developmental stage of Industry vs. Inferiority which focuses on coping with social and academic pressures (http://psychology.about.com/library/bl_psychosocial_summary.htm).

In regard to social and academic pressures for American Indian children and their families, key considerations which hit the hardest include a lack of sensitivity to the complex diversity of tribes, and generalizing or unfounded assumptions about American Indian people.These types of assumptions and the detrimental results create a mandate of cultural competency for all human service professionals.Cultural sensitivity must be applied in a capacity that exhibits a learning attitude or willingness to open exchanges between service providers and clients.

Additionally, each Indian culture must be recognized as unique.Identical cultural practices among American Indians are a rarity and cannot be used as a summative perspective of the American Indian culture as a whole."The point being raised is that a single minded overriding focus on protection and placement in the ICWA is too limiting and may lead to unrecognized and/or undesired consequences" (Mannes, 1995a: p. 1).Service provision for a preferred sub-population within a population is a matter that cannot be dismissed.The need for a culturally sensitive response is in order.It is reasonable to say that most states in which American Indian people live will have diverse representations.This means each different American Indian tribe should have representatives to defend their causes based on each tribe's needs.This merits concurrent identity and issue organizing which is a membership or coalition organization that focuses on issues disproportionately impacting specific identity groups (Rubin & Rubin, 2008).Exploration of additional diverse legislative policy or supplementation is needed to provide complete service to the population of American Indian people as a whole.Implementation of the ICWA as a single policy in regard to American Indian people within the state of Alabama results in the exclusion of 90% of the population.

Criteria for Differentiation of Tribal Recognition Applied to ICWA

During the years of [2001][2002][2003][2004][2005][2006][2007][2008]12 American Indian tribes appeared before the Bureau of Indian Affairs to receive the status of federal recognition.Only two of the twelve tribes have received the status of federal recognition.The lengthy journey from the status of state to federal recognition is an approximately 15 year legal process.It takes place in the Bureau of Indian Affairs (BIA) of the Department of Interior (DOI) in Washington, DC.The process begins with a letter of intent followed by an application filing process and then petitions.The office (within BIA) which administers this process is the Branch of Acknowledgement and Recognition (BAR), currently known as the Office of Federal Acknowledgement (OFA), which is staffed by anthropologists, historians and genealogists.The OFA administers the process based on seven criteria established by DOI.The seven criteria are set forth under Part 83, Title 25, Code of Federal Regulations (first issued in 1978 andrevised in 1994).

The 7 part mandatory criterion (www.bia.gov) is as follows:

1) The petitioner must demonstrate that it has been identified as an American Indian entity on a substantially continuous basis since 1900.

2) Show that a predominate portion of the petitioning group comprises a distinct community and has existed as a community from historical times until the present.

3) Demonstrate that it has maintained political influence or authority over its members as an autonomous entity from historical times until present.

4) Provide a copy of the group's present governing document including its membership criteria.5) Demonstrate that its membership consist of individuals who descend from the historical Indian tribe or from historical Indian tribes that combined and functioned as a single autonomous political entity and provide a current membership list.

6) Show that the membership of the petitioning group is composed principally of persons who are not members of any acknowledged North American Indian tribe.

7) Demonstrate that neither the petitioner nor its members are the subject of congressional legislation that has expressly terminated or forbidden Federal relationship.

Each of the above seven criteria have multiple sub-parts including, but not limited to relationship with state government based on identity, substantial social relationships affiliating group members, a collective name existing for over 50 years and the ability to resolve intra conflicts among members.Some petitioners refer to this process as almost impossible to navigate.Others refer to it as "15 years, 15 million dollars and inherent bias".All of these criteria and their sub-parts must be in place over a 50 year span despite the ongoing societal pressures of assimilation, prejudice and relocation.There is no transparent judicial underpinning for this 7 part criterion nor its sub-parts administered through the OFA.All the while, American Indian children remain ineligible for proper child welfare services due to their lack of or uncertain tribal recognition status.

Those who receive the official status of federal recognition are referred to as being "federally acknowledged" by the DOI.This acknowledgment recognizes an American Indian tribe's constitutional status to be self-governing, commonly referred to as "sovereignty".Sovereignty is a written agreement between the American Indian tribal government and Congress of the United States with jurisdiction governed on a federal level.Sovereignty is accountable only to congressional law and its jurisdictions as specified in the written agreement.State laws are non-applicable and have no legal jurisdiction over American Indian tribes who are federally recognized.

It is important to understand the completion of this process is specific to acknowledging sovereignty.The DOI is not granting sovereignty, it is returning sovereignty.It is returning the rights of American Indian people to live as they once were.This restores the rights that were taken to a position of respect and gives tribal government the discretion to take care of its own people.However, no one can afford to lose sight of the exhausting, lengthy process and its unjust effects on American Indian children.As previously stated, the average time frame is 15 years to receive a determination, and determination is not necessarily secured to be favorable.It is not un-common for a tribe to report denial of their federal acknowledgement after having worked 20 -25 years to navigate the seven mandatory criteria established by BIA within the DOI.

Organizational Implementation and Expansion

While it is not a necessity for each state to enact its own ICWA, if they do not, they rely solely on the existing federal act (Wilkins, 2004).Several states namely Iowa, Colorado and Arizona have individualized policies to address American Indian people as a whole in their respective states.The policy established by Arizona appears to be the most comprehensive.According to Wilkins (2004), Arizona requires that all children taken into custody be identified as having or not having American Indian heritage within five days of their case being opened.This means that the child welfare worker is responsible for obtaining such clarification.Arizona has also established a tribal/state workgroup designed to address ICWA related issues.The focus of this group is to establish procedures that conform to ICWA standards.

Ultimately, this will result in better service to American Indian families (Wilkins, 2004).Strategic work groups of this nature are realistic on a state-by-state basis and must be considered as a positive measure of optimal well-being.The key to strategic work groups such as the one in Arizona is team involvement, experience levels and status of decision-makers.Consideration for strategic work group members should include a representative authorized to carry out American Indian Affairs on a state level.It is also advisable to have this individual recommended by the Governor's Office.Other team members should include minimally: tribal government of varied status, tribal citizens, child welfare workers as well as administrative officials, civil rights activists and social activists.

This recommended team composition will ideally uphold the original intent of the ICWA which is to "protect the best interest of Indian children and to promote the stability and security of American Indian tribes and families."The further emphasized intent of the ICWA, which advocates for each tribe to be given placement of its own children, should not be disturbed by this team composition.The absence of this team composition and its service endeavor is likely to leave American Indian children further stranded without competent placements for an extensive time.

Concluding Remarks

The review of the ICWA shows that this law is not protecting the rights of all American Indian children.The main reason is because ICWA only serves children from federally recognized tribes.The policy needs to be more comprehensive in regard to respecting the diversity of American Indian people.Research utilizing the demographic profile of American Indian people in the state of Alabama successfully illustrates complex diversity and need for supplemental policy.Collaborative partnerships to lobby state legislators are a primary avenue of resolving provisional limitations.Public awareness in regard to the ability to utilize this avenue is essential.Lobbyists and organizers who collaborate to obtain comprehensive provisions will need to secure a competent team from diverse backgrounds.

Strategic involvement with state Indian affairs commissions will be instrumental for issues related to knowledge and planning."Jurisdictional provisions are the core of the ICWA" (Stark, Todd, & Stark, 2006: p. 3).Jurisdictional provision is a term exclusively used for federally recognized tribes.Mindell & colleagues (2003) point out that administrative complexity makes it difficult for child welfare workers and legal practitioners to even follow the minimum standards of the ICWA.The complexity of the ICWA further demonstrates necessity of additional service inclusion.Cultural preservation for all facets of American Indian people must become an understood matter of positive regard.

Fifteen years of political struggle cannot be in vain.The expansion of the current ICWA is justifiable in order to ensure the preservation of all American Indian people.Protection of traditions and the assurance of practiced continuance through American Indian children are the heart of Indian Country as a whole.Existing scrutiny makes it necessary to have legislative policies in place to prevent cultural genocide.The ICWA is vital to the preservation of Indian Country and its traditions.Absence of the ICWA poses the risk of creating a harsh repeat of historical victimization through cultural genocide commonly referred to as assimilation.Prevention of this risk requires a new evaluation and systematic change in service delivery of the ICWA to comprehensively meet the diverse needs of American Indian people which will allow accessibility and culturally traditional preservation for all American Indian people.

Figure 1 .
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Figure 1.Contributing views towards the need for policy expansion.

S Gillon, C Matson, The American Experiment: A History of the United States. BostonHoughton Mifflin Company20062nd ed.

Culture Loss: American Indian Family disruption, Urbanization, and the Indian Child Welfare Act. K Halverson, M Puig, S Byers, Child Welfare League of America. 812002

H Karger, D Stoesz, American Social Welfare Policy: The Pluralist Approach. BostonAllyn and Bacon20065th ed.

This Day in North American Indian History: Events in the History of North America's Native Peoples. P Konstantin, 2002Da Capo PressCambridge

Factors and Events Leading to the Passage of the Indian Child Welfare Act. L Liggett, The Wounded Knee Massacre. 1998. 1995a74

Seeking the Balance between Child Protection and Family Preservation in Indian Child Welfare. M Mannes, Child Welfare League of America. 721995b

The Politics of the Indian Child Welfare Act. L Matheson, Social Work. 411996

R Mindell, M Vidal De Haymes, D Francisco, A Culturally Responsive Practice Model for Urban Indian Child Welfare Services. 200382

A Practical Guide to the Indian Child Welfare Act. Native American Rights Fund. 2007Native American Rights Fund

T Norris, P L Vines, E M Hoeffel, The American Indian and Alaska Native Population: 2010. 2010 Census Briefs C2010BR-10. Washington, DCUS Census2012

Understanding Research: A Consumer's Guide. Plano Clark, V L Creswell, J W , 2010PearsonUpper Saddle River, NJ

H Rubin, I Rubin, Community Organizing and Development. BostonAllyn and Bacon20084th ed.

The Eagle Who Thought He Was a Chicken. The Native American Times. H Stark, K Jason, T Stark, 200612

The Indian Child Welfare Act and the States. National Convention of State Legislators Legisbrief. A Wilkins, 200412