American Indian Culture and Research Journal

As notions of cultural competency have risen to prominence in health care, some of our most powerful models and strategies come from successful tribal health care. In this chapter, we deconstruct notions of cultural competency, rebuilding this important aspect of medical practice under Bourdieu's model of reflexivity (1986). We outline a critical discourse of cultural competency based on a processual (and distinctively anthropological) model. In promoting several specific strategies for culturally competent care, we point to the assumptions regarding the boundedness and neutrality of culture within biomedical practice as well as the authority and power structures through which competency is determined. We offer two case studies: one, an examination of a community-based ambulatory care practice; the second, a consideration of both practitioners' and institutions' use of cultural capital in addressing the community they serve. We promote a reflexive form of culturally competent care that goes beyond "cookbook" uses of cultural capital to move toward an engaged and structurally flexible approach, one that allows the blending of biomedical paradigms with patient culture and history.

This article examines community-based approaches to the prevention and management of diabetes in the indigenous urban community of Toronto. A critical perspective of the concept of cultural capital in health promotion is provided to move beyond a functional representation of culture in addressing health inequalities and the production of health. Community-based programs are contextualized within the historical, cultural, and social relations of indigenous community-building, approaches to service delivery, and regional and national bureaucratization of indigenous resources.

In this article, we examine cultural capital within the contexts of ethnography, community-based participatory research (CBPR), and holism. Because many chronic diseases such as cancer and diabetes are influenced by lifestyle choices in which culture plays a central role regarding perceptions of illness and health, it is important to understand how patients and their communities perceive these cultural factors. We outline how CBPR can be used as a strategy to explore these issues among Native Americans in the northeastern United States, whose perspectives and experiences have been less visible in the published literature. As a method, CBPR provides a context to "apply" cultural capital in the research arena, while holism, as a practice, provides an excellent exemplar of how cultural capital is manifested in the day-to-day lives of Native Americans. We also illustrate the ways in which health education programs are primarily influenced by medicalized perspectives of diabetes and cancer, which demand a singular view of what should be treated, as opposed to locally produced knowledge(s) that insist on a more integrative view of health and health needs. Finally, we highlight the challenges associated with these differences through the voices and perceptions of individuals in a number of Native communities, as together we attempted to build more comprehensive and culturally appropriate health promotion programs.

Many of the leading causes of mortality and morbidity in American Indians and Alaska Natives (AI/ANs) are preventable, which indicates that lifestyle is a key risk factor. Behavioral change interventions attempted with AI/ANs that focus on lifestyle have begun to incorporate Native cultural traditions, or cultural capital. This article discusses one such Native-based intervention conducted on the Flathead Indian Reservation in Montana, which used cultural capital as the foundation for an intervention to address risk factors for cardiovascular disease. Called the Traditional Living Challenge, the specific purpose of the intervention was to revitalize community initiatives toward wellness through a cultural immersion experience, which replicated a former healthier lifestyle and diet. The long-term goal was for the cultural immersion intervention to foster personal and group motivation toward a commitment to wellness. To implement the project, the researchers developed collaborations among the tribal health department, cultural leaders, the tribal council, and various relevant tribal units. The researchers identified participants across various age ranges by involving whole families in the intervention. They also identified a broad range of community-based resources and opportunities to support ongoing lifestyle changes and developed a number of cardiovascular disease risk outcome measures that would be appropriate for use in this community

Type 2 diabetes mellitus, a disease that previously was characterized with an onset in the fourth decade of life or later, is now being diagnosed in children, particularly children from minority groups, including American Indians. Because children with the disease are frequently asymptomatic, they tend to ignore recommendations from their health care providers about appropriate self-management behaviors, thus increasing their risk for early onset of secondary complications, including retinopathy and end-stage renal disease. This problem with self-management can in part be attributed to a lack of knowledge as well as to denial about their disease. This article describes an intervention that encourages and motivates American Indian youth with type 2 diabetes to improve their diabetes self-management. The Medical Wellness Camp is a partnership program hosted by several Arizona tribes and the University of Arizona. The camp provided these youth with the education and the skills needed to prevent or delay diabetes-related complications that will negatively impact their quality of life. This camp is unique because it builds on and integrates an intertribal "cultural capital" model to help them learn how to adopt the lifestyle changes necessary to live with this chronic disease. The program emphasis is on education, not research. This position honors the wishes of tribal partners whose communities have been reluctant to involve their children in research, a reluctance fueled by reports about unethical research practices that have harmed other tribal communities.

Since 1998, the US Congress has funded the Special Diabetes Programs for American Indians and Alaskan Natives (SDPI). These funds are administered by the Indian Health Service (IHS) and have been awarded to more than 330 IHS, tribal, and urban Indian health programs in thirty-five states to build or enhance diabetes mellitus (DM) treatment and prevention programs. Over the past thirteen years, these community-directed programs have emerged as models of intervention creativity, innovation, and persistence, with program staff drawing on their cultural capital to design culturally acceptable and locally relevant strategies. These programs have achieved measurable change in Native peoples' knowledge of the diabetes risk factors, access to much needed DM related services, and in some cases, helped reduce rates of DM-related morbidity and mortality. Yet, perhaps their greatest influence has been in understanding and shaping the context of behavioral change and in promoting normative shifts in food choices, activity patterns, DM screening, and DM self-management. Systematic qualitative data collection has not played a prominent role in the evaluation of the SDPI programs, and subsequently the role of cultural capital and the subtle normative shifts over the course of the SDPI programs have not been documented. This article offers a review of the qualitative accomplishments of the SDPI programs and some methodological suggestions for capturing the impact of cultural capital.

Rare in Indian country just sixty years ago, type 2 diabetes mellitus is now woven into the fabric of losses in tribal communities across North America. Westernized lifestyles, with coincident obesity and physical inactivity, are powerful risk factors for this relatively new "disease of civilization." The web of causation is thicker and wider than obesity and physical activity alone, intertwined by historical, economic, environmental, and sociological roots. As diabetes-related morbidity, disability, and mortality continue to increase in communities around the globe, many tribal elders recall when diabetes was almost unknown. They remember being taught how to stay healthy, lessons that were part of their "traditional ecological knowledge," a symbolic and informational knowledge that is grounded in cultural values and practices, and refined through generations of observation, experimentation, and adaptation. In these conversations, the elders' traditional ecological knowledge richly illustrates the cultural capital that supported their survival and helped maintain the health of their communities even when they had to face challenging times. The purpose of this article is to describe a number of dynamic, tribally driven efforts that draw on traditional ecological knowledge to address the problem of diabetes in American Indian and Alaska Native communities