Introduction
Food injustice and the lack of food sovereignty demonstrate the ways in which oppression and modern-day colonialism are maintained and perpetuated by capitalist-driven social structures (Kepkiewicz et al., Reference Kepkiewicz, Chrobok, Whetung, Cahuas, Gill, Walker and Wakefield2015; Whyte, Reference Whyte, Barnhill, Doggett and Egan2017). Claims that government food policies only reify colonial practices further demonstrate white, settler privileges (Kepkiewicz and Rotz, Reference Kepkiewicz and Rotz2018). At the same time, food evolution due to migration has contributed to the maintenance of ethnic identities (Frost and Laing, Reference Frost, Laing and Timothy2016) and in former colonies have been important portrayals of colonial resistance (Mosley, Reference Mosley2004). Medical colonial practices and the domination of Western thinking have also been described as colonial artifacts (Naidu, Reference Naidu2021). Particularly, the tension that exists between evidence-based medicine and Indigenous traditional healing requires a deeper, multi-layer analysis that goes beyond just the biological (Cohen-Fournier et al., Reference Cohen-Fournier, Brass and Kinmayer2021). For healthcare providers, understanding the history of colonialism and its modern day remnants requires cultural competency and sensitivity when providing care to ethnic minorities, including the Pacific Islanders (Ghiasuddin et al., Reference Ghiasuddin, Wong and Siu2015).
According to the Washington State Commission on Asian Pacific American Affairs (2024), there are currently 70,000 Pacific Islanders living in the state and are one of the fastest growing ethnic groups in the region. Fitzpatrick-Nietschmann (Reference Fitzpatrick-Nietschmann1983) reported how this group was ‘at the mercy of the existing government-subsidized health care facility and its health care workers’, a problem that continues to persist (Morisako et al., Reference Morisako, Taualiʻi, Ambrose and Withy2017). This paper explores the transformative power of critical theory to examine a completed quality improvement (QI) project that had the goal of creating culturally relevant dietary resources from a community of Pacific Islanders in Washington State, USA.
Methodology
Critical theory
As a form of inquiry that aims to critique social issues and the underlying oppressive forces that perpetuate them, critical theory (CT) emerged from the earlier works of the Frankfurt School that strongly rejected the positivist, Cartesian approach to knowledge production (Alirangues, Reference Alirangues2018). Critical reflection, defined as ‘a process of examining assumptions and power relations, and how these assumptions and relations shape practice’ (Ng et al., Reference Ng, Wright and Kuper2019) is central to CT (Brookfield, Reference Brookfield2009). As a commonly used pedagogical tool for transformative learning (Wittich et al., Reference Wittich, Reed, McDonald, Varkey and Beckman2010), critical reflection has been used in medical education and practice such as in emergency (Bernard et al., Reference Bernard, Gorgas, Greenberger, Jacques and Khandelwal2012) and narrative (Murphy et al., Reference Murphy, Franz and Schlaerth2018) medicine. In short, it provides structural analysis to hegemonic factors contributing to oppression (Paradis et al., Reference Paradis, Nimmon, Wondimagegn and Whitehead2020). Methodologically, and socio-politically, CT has also been used in medical education research (Chow et al., Reference Chow, Hirshfield and Wyatt2022) to question the role that powerful medical institutions play in sustaining inequity (Hodges, Reference Hodges2014).
Wittich and colleagues (Reference Wittich, Reed, McDonald, Varkey and Beckman2010) report the value that critical reflection plays in QI projects, including examining the wider social forces impacting healthcare. At the same time, Allwood and colleagues (Reference Allwood, Fisher, Warburton and Dixon2018) argue that while QI work is important, ‘improvements to care occur at the front line by a kind of osmosis or, worse still, only through new technologies or “management,” without careful ongoing systematic effort of clinical staff’. QI work is further complicated by the challenges faced by junior physicians in their workplace, primarily the lack of training (Zarkali et al., Reference Zarkali, Acquaah, Donaghy, Hutton, McLaughlin, Ngai, Parfitt, Pirkis and Till2016). At the same time, the inconsistent teaching of social medicine across US medical schools (Finnie et al., Reference Finnie, Brach, Dawson, Epstein, Goyal, Lounsbury, Eldakar-Hein and Lahey2021) can be challenging when QI projects involve the application of sociological theories to further understand clinical phenomena. Through a process of iterative group discussions and critical reflection, this paper aims to answer three research questions:
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1. How do individual and collective assumptions and biases influence the design, implementation, and evaluation of community-based QI projects?
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2. In what ways do concepts of power, privilege, and oppression shape the outcomes of these projects?
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3. What specific, actionable recommendations can be drawn from the team’s experiences to inform future QI protocols that emphasize cultural humility and community engagement?
The group’s social location and critical reflexivity
The identities of the authors reflect what Glenn (Reference Glenn2015) refers to as hybrid, where positionality and values have been shaped by the legacy of coloniality. In particular, the group’s collective identities as descendants of colonizers, colonizees, and immigrant settlers have been woven into their education and career. This intersectionality of power, privilege, and oppression are reflected in their approach to this research. As members of racialized and immigrant groups, the group perceives privilege as a double-edged sword: while their Western educational training is crucial to academic and career trajectories, the group is also acutely aware of how this has also caused the relegation of traditional knowledge from their respective cultures.
The first four authors are osteopathic medical students who completed the QI project, while the last author’s expertise in critical theory guided this research study. Four members are racialized, with three identifying themselves as second-generation immigrants to the United States and one identifying as a critical ally (Nixon, Reference Nixon2019) with European white background. All researchers acknowledge the power and privilege of their medical education. Reflexivity – the awareness of how individual social location positions oneself – has allowed the group to deeply examine their perceptions on food and colonialism. At the same time, reflexivity compels the group to re-examine the impact of their privilege and actions on the QI project life cycle. The group’s exploration into the dynamics of coloniality and its ramifications on their identities as researchers has unearthed profound insights, revealing the interplay between power, privilege, and oppression.
QI project and critical reflections: realizations
The group’s QI project provided invaluable opportunities for reflection that prompted interrogation of the impact of their actions on the communities that were served. While the Pacific Islander community was involved in the evaluation and future steps, the limitations of their methodological approach include the failure to incorporate the Pacific Islanders in initial project planning, conceptualization, and implementation, partially due to only engaging with the local religious leader once due to their overall apprehension towards QI work in the community. As an important tenet of participatory action methodology (Sadabadi and Rahimi Rad, Reference Sadabadi and Rahimi Rad2021), the team should have engaged the local community throughout the QI life cycle, which could have underscored the importance of cultural humility in community projects (CDC, 2022).
The members of the research team described (ethnic) food as ‘fusion’ or ‘blended’ and revealed not only the normalization of post-colonial influences but also how food has evolved out of migration and separation (Frost and Laing, Reference Frost, Laing and Timothy2016). The group reflected how their presence may not have been culturally appropriate given the Pacific Islanders’ complex history with food injustice (American Pacific Islander Council, 2021). In hindsight, the group entered their personal, cultural, and social spaces without first addressing their own biases, assumptions, and prejudices and therefore ‘a clear-sighted acknowledgment of the multiple and subtle ways in which power and social pathologies are reproduced’ (McArthur, Reference McArthur2022).
Similarly, the team’s critical reflection further raised concerns about how privilege as Western students may have continued the legacy of coloniality. This privilege has been amplified by the invisible power that is held as future physicians in western medicine. To this end, the team reflected on how medical schools can become anti-colonial allies or perpetrators of neocolonialism. The team agrees with Perkins and colleagues (Reference Perkins, Nishimura and Olatunde2023) on the importance of addressing colonialism in global health work or highlighting the efforts of students to address anti-racist practices in medical education (Afolabi et al., Reference Afolabi, Borowsky, Cordero, Paul, Said, Sandoval, Davis, Olveczky and Chatterjee2021). Related to this, the unintentional harms that may have been caused to the Pacific Islander community could have been avoided if a stronger pedagogical focus was placed on teaching decolonization, anti-racist practices, and social medicine prior to the commencement of a QI project. Deeply learning about the effects of colonization would have been useful to understand the community members’ perceptions about the food that they consume and the role that the group as ‘outsiders’ play. Further, how the team relied heavily on their biomedical training was evident in the various processes and tools that were used throughout the project cycle, without careful consideration on how sociological theories (e.g. Kleinman, Reference Kleinman2010) might help inform the work. As the team strives to reevaluate the effects of colonialism and work towards decolonizing their perspectives and approaches to intervention, it is imperative to prioritize a mindful consideration of cultural perspectives.
As the team further reflected on their QI experience, one critical observation was that while the QI project was important, it only addressed a small portion of a larger, systemic problem and the team’s focus did not accommodate for the social determinants of health. The determinants, including employment, access to health services, and discrimination (Chelak and Chakole, Reference Chelak and Chakole2023), profoundly influence the community and a singular intervention may have been perceived as contributing to the perpetuation of health inequality.
Discussion
The team’s project allowed reflection on the impact of their footprints within the community. Particularly, critical reflection reminded the group of their vulnerabilities, power, and privilege, and how things could have been done better. For instance, working with a historically underrepresented group underscored the importance of knowing their history. Even though the team’s focus was to create more cultural inclusivity, consideration was not taken for how this blending of cuisine could be perceived as a form of colonial practice (Bordirsky and Johnson, Reference Bodirsky and Johnson2008) and perpetuation of colonial trauma (McKinley and Jernigan, Reference McKinley and Jernigan2023).
As medical students and professionals, the group is aware of the importance of educating individuals on having balanced diets (Endrizal et al., Reference Endrizal, Fialkowski, Davis, Yuan, Novotny, Delormier and Rodriguez2018) but realize that this should have been done in conjunction with understanding the wider socio-political and historical contexts (Pescosolido and Kronenfeld, Reference Pescosolido and Kronenfeld1995). In other words, the team failed to first decolonize themselves (Nakagawa, Reference Nakagawa2021) before attempting to know the community or implementing the project. Through critical reflection and reflexivity, the team has come to understand how their lived experiences have shaped both collective and individual perceptions of food sovereignty and how oppression as entrenched within and perpetuated by social institutions, including medical schools.
Throughout reflection, it became clear to the research team how the influence of colonialism continues to organize medical education and research (Naidu, Reference Naidu2023). Therefore, the team emphasizes the need for medical schools to incorporate sociological theories into the curriculum, recognizing it as a long-term investment towards compassionate care and engaging in culturally appropriate research endeavors. Furthermore, to ensure this reflection is applicable to future QI projects, the researchers have identified several actionable recommendations based on their findings:
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1. Community Engagement at All Stages: Involve the community in every phase of the project lifecycle, including planning, implementation, and evaluation. This fosters trust and ensures that interventions align with the community’s needs and cultural practices.
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2. Learning Local Histories: Understanding the historical and socio-political context of the community being served is crucial. For Pacific Islanders, this involves recognizing the impact of colonialism on food practices and health disparities.
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3. Feedback and Reflexivity: Establish continuous feedback loops with community stakeholders and promote reflexivity among practitioners to recognize and mitigate implicit biases.
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4. Integration of Sociological Frameworks: Incorporate sociological theories, such as those proposed by Kleinman, to guide QI projects and enhance understanding of systemic inequities.
Critiquing the QI project brought transformative learning and cultural humility, recognizing the influence of power, privilege, and oppression on the team’s perspectives and practices. By acknowledging the impact of colonial legacy on cuisines and identities, the group continues to discover both the rewards and challenges of Western training when addressing issues related to food justice. The researcher’s critical reflection emphasizes the need for the medical community to dismantle neocolonialism and promote anti-colonial practices. There is a critical need to integrate principles of cultural humility, community empowerment, and food justice into medical curricula. By teaching students’ critical theory and fostering inclusive and participatory approaches to community projects, medical schools can contribute to addressing the impacts of colonialism and promoting health equity. Through these actionable recommendations, the team aims to equip future practitioners with the tools to approach QI projects with cultural humility, ensuring interventions are not only respectful and inclusive but also effective and equitable.
Conclusion
Medical institutions hold an undeniable amount of privilege but at the risk of re-traumatizing marginalized communities. The original QI work educated us about the intricacies of food, colonization, and social justice. This reflection unveiled the profound intersection of power, privilege, and oppression within healthcare systems where medical professionals occupy the center stage. By critically examining positionality and engaging in transformative learning, the team’s hope is to advocate for systemic change that can work towards a more equitable and just global healthcare system. Moving forward, the researchers are committed to fostering genuine partnerships with communities, grounded in mutual respect, understanding, and a shared commitment to social justice.
Funding statement
This research received no specific grant from any funding agency, commercial entity, or not-for-profit organization.
Competing interests
The authors have no conflicts of interest to declare.
Ethical standard
Ethical Approval per ATSU IRB: Non-jurisdiction for protocol #2024-122 (not “human research”).
Open access
