Embracing cultural humility in clinical and public health settings: a prescription to bridge inequities

Culture matters. This is not a new concept and not even something that is debatable.

In fact, ‘traditional expressions of any culture influence everyday decisions, both big and small. They are reflected in the choice of the cake people make for their children's birthdays, and also in major decisions related to child rearing. They influence the slang children and doctors and handymen use to address their peers or others.¹ They are recalled when grandparents come to visit through the stories they transmit to the next generation. They are verbal and nonverbal cues that affect how information on any topic is received, accepted, and elaborated’.² They live through performing and visual arts, through stories and narratives, and are key to providing comfort at times of crisis.

The importance of such cultural expressions has been long integrated in public agendas and policies, both formally and informally. For example, the American Folklife Preservation Act (P.L. 94–201)³ passed by the United States Congress in 1976 recognizes the importance of preserving cultural diversity, as ‘a resource worthy of protection’, and defines ‘folklife’ as following: ‘American folklife means the traditional expressive culture shared within the various groups in the United States: familial, ethnic, occupational, religious, regional; expressive culture includes a wide range of creative and symbolic forms such as custom, belief, technical skill, language, literature, art, architecture, music, play, dance, drama, ritual, pageantry, handicraft; these expressions are mainly learned orally, by imitation, or in performance, and are generally maintained without benefit of formal instruction or institutional direction’.³ Similarly, in establishing a dedicated department, the Department of Canadian Heritage Act of 1995 pledges to promote multiculturalism and ‘a greater understanding of human rights, fundamental freedoms and related values’.⁴ While these and other national and global policies are essential tools for progress, we all know that policies are merely a starting point for sustainable interventions to promote and embrace cultural preservation and humility within government agencies, public and private institutions, our communities and networks.

In clinical and public health settings, understanding the cultural values of the people with whom we interact and communicate – and embracing cultural humility – are essential to improving a general feeling of belonging,^5,6 reducing bias and inequities in the healthcare system,⁷ building trust and encouraging adherence to clinical and public health recommendations,^7–9 and contributing to positive patient experiences and health outcomes.^9,10 In fact, cultural ‘traditions, habits and beliefs … influence ideas of health and illness’,² as well as the way people should be treated at vulnerable times - as patients, caregivers, concerned citizens, or members of any group interacting with their health and social systems.

Ultimately, ‘culture mediates both care-giving and care-receiving,’⁹ and is a key social determinant of health, and health equity. Among others, culture influences the language that is used to define or frame health issues, the way in which solutions are designed and implemented, and the choice of suitable measures of success.^2,11 Given the many implications of culture, ‘cultural humility’ should be systematically embraced in clinical and public health settings and interactions – both to strengthen health systems and to effectively connect with those these systems serve.⁹

But what is ‘cultural humility’? First, cultural humility goes beyond ‘cultural competence’ (a set of skills that may help individuals and organizations function ‘within the context of the cultural beliefs, behaviors and needs presented’ by those they serve and their communities¹²). ‘Cultural humility’ assumes that no one can become an expert in all kinds of cultural values but, yes, everyone can learn about the humility and empathy that are needed to truly understand other people's values and experiences, to avoid making assumptions, to treat everyone with the respect and consideration they deserve.

Among my favorite definitions, Tervalon and Murray define cultural humility as ‘a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities.’¹³ The focus of cultural humility is on a long-term journey that helps revisit the way we may perceive and act toward our fellow humans, promotes diversity, equity, and inclusion at the institutional level, and fosters a sense of belonging among those with whom we interact within health and social systems. Ultimately, cultural humility is at the core of cultural competence and of promoting cultural safety for all.

By encouraging belonging and participation, cultural humility is essential to addressing health, racial, and social inequities. Within our complex communication landscape, cultural humility can also help mitigate communication inequities by avoiding the promulgation of language that may be stigmatizing or perceived as offensive, helping integrate culturally relevant values, priorities and traditional forms of expressions (e.g. poetry, theater, spiritual rituals) in the way we communicate in clinical, public health, and social settings, and therefore improving upon people's ability to relate to and trust health information.

Practicing cultural humility is key. This may start with comprehensive trainings and coursework in healthcare and public health settings, but again the focus is on the lifelong commitment to self-evaluation and critique.

Practicing cultural humility is linked to practicing empathy and listening during all kinds of encounters. At the institutional level, sample strategies include the integration of social engagement and mindfulness¹⁴ – as inclusive of solidarity and spirituality – in the way we approach and communicate with communities and patients, and co-design solutions with them, the intended beneficiaries; and social listening - to capture emerging cultural trends on social and traditional media that may influence future interactions at the community and interpersonal level.

As Dr. Cornel West put it best in his 2010 keynote speech at the American Public Health Association¹⁴:

The words humanity and humility come from being tied to the earth and the soil. Unpretentious. Being able to tell the truth and acknowledging that to tell the truth is to allow suffering to speak. There is no real talk or engagement without the truth about our lives, individually, collectively, nationally, or globally without allowing suffering to speak.¹⁴

His words still resonate as true in our COVID-19 era and provide great impetus for cultural humility.

In this issue

Echoing the theme of this editorial, this issue of the Journal includes an article collection on Cultural and Spiritual Influences on Health and Communication. Articles included in this collection discuss how culture influences patient preferences for patient-centered care across four different countries (Hong Kong, the Philippines, Australia, and the United States); analyze the role of stigma and spirituality on mental health seeking behavior; support the importance of local language in healthcare, with particular reference to women's and menstrual health; and highlight the need for equitable and faith-based messaging to increase HPV vaccination.

The other articles in this issue focus on diverse topics, including knowledge, attitudes, and practices towards COVID-19, narrative messaging in reducing sugar-sweetened beverage consumption among Latinas, and communication in the conversation between preceptors and physicians-in-training during simulation, among others. We are grateful to our diverse pool of authors from several different countries, including Brazil, Nigeria, South Africa, and the United States.

As always, we encourage you to stay engaged with the Journal and write with ideas and feedback. Thank you for your readership and have a great summer!