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PED22110.1177/1757975914528728CommentaryS. Kools et al.
Commentary Cultural humility and working with marginalized populations in developing countries Susan Kools1, Angela Chimwaza2 and Swebby Macha3
Abstract: Population health needs in developing countries are great and countries are scaling up health professional education to meet these needs. Marginalized populations, in particular, are vulnerable to poor health and health care. This paper presents a culturally appropriate diversity training program delivered to Global Health Fellows who are educators and leaders in health professions in Malawi and Zambia. The purpose of this interprofessional education experience was to promote culturally competent and humble care for marginalized populations. (Global Health Promotion, 2015; 22(1): 52–59) Keywords: education, equity, health care, minorities, social justice, socioeconomic status, vulnerable people Cultural competence is a standard of practice in health care. Cultural humility, emphasizing selfreflection, mutual understanding, and respect between health care providers and patients/clients, represents the contemporary conceptualization of culturally appropriate and sensitive care. It is critical to deliver culturally humble care to populations who are vulnerable due to perceived difference in social characteristics and/or experience. From 2010 to 2012, the US State Department Bureau of Educational and Cultural Affairs funded a Global Health Professional Fellowship, including faculty and health care leaders from the Universities of Alabama at Birmingham (UAB); California, San Francisco (UCSF); Zambia; and Malawi (Figure 1) to promote health care for marginalized populations by strengthening education for providers. Twentyfive Zambian and Malawian Global Health Fellows, representing leaders in nursing, medicine, midwifery, physiotherapy, pharmacy, health management, and health economics attended an interprofessional education workshop at UAB, including culturally appropriate diversity training. Cultural competence encompasses knowledge about diverse people and their needs, attitudes that
recognize and value difference, and flexible skills to provide appropriate and sensitive care to diverse populations (1–4). Cultural competence has been described (5–7) as the achievement of a particular skill or ability, implying its completion; however, it is a lifelong commitment to learning about oneself and others, built on dynamic experiences over time. Further, by focusing on the ‘cultural other,’ one can inadvertently reinforce stereotypes about a person based on social characteristics. Cultural humility extends the idea of cultural competence, recognizing that care of clients and communities is interactive (6,8–11). One can never be the ‘expert’ in understanding difference, thus taking a posture of humility is important. Cultural humility is based on intentional and ongoing self-reflection in order to understand how one’s beliefs, values, and assumptions are integral and influential to the health care relationship (7). This definitional nuance redirects the clinician from the application of fixed cultural designations to others. As a key component of humility, reflexivity, or the active examination of one’s sociocultural background and beliefs, is an intentional process
1. Department of Family Health Care Nursing, University of California, San Francisco, USA. 2. Kamuzu College of Nursing, University of Malawi, Blantyre, Malawi. 3. University Teaching Hospital of Zambia, Lusaka, Zambia. Correspondence to: Susan Kools, Department of Family Health Care Nursing, University of California – San Francisco, 2 Koret Way, Box 0606, San Francisco, CA 94143, USA. Email: [email protected] Global Health Promotion 1757-9759; Vol 22(1): 52 –59; 528728 Copyright © The Author(s) 2014, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914528728 http://ghp.sagepub.com Downloaded from ped.sagepub.com by guest on November 15, 2015
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S. Kools et al.
University of Alabama, Birmingham Samford University McWhorter School of Pharmacy University of California, San Francisco
Global Health Professional Fellowship
University of Zambia National Institute for Public Administration, Zambia University of Malawi Kamuzu College of Nursing Global AIDS Interfaith Alliance
MALAWI
ZAMBIA
Figure 1. Maps and participating institutions.
we can use to help us understand our own contribution to the caring relationship (2,12,13). It facilitates respect by acknowledging similarities and differences in perspectives and health practices (7).
Culturally appropriate diversity training Faculty diversity training modules developed by the UCSF School of Nursing Diversity in Action Committee (DIVA) (14) were tailored and implemented by a UCSF nursing professor with experience working in Malawi. Entitled ‘Working respectfully and effectively with diverse and marginalized populations,’ the overarching goal for the two day training was to enhance the ability of faculty and community leaders to provide and model culturally appropriate and sensitive care to those in their communities, especially those who are marginalized by circumstances or culture (Table 1) using the cultural humility principles outlined above.
Session 1: understanding cultural diversity Session 1 began with an exercise for Fellows to get to know one another from a diversity perspective. Fellows told each other stories about where their names came from. Guiding questions included: ‘Who named you?’ ‘Why did your parents or someone else give you your name?’ ‘What does your name mean?’ ‘Does your name link you with your ancestors or family history?’ A discussion ensued with enthusiastic storytelling and laughter. The meaning of one’s name in this region of Africa is of high significance. Many Fellows had both English and vernacular names, linking them with their family heritage. Some had context-specific names for school, church, and home. Family names were often clan names, indicating matrilineal or patrilineal lines, specific to ethnic background. While they were from two different countries, Fellows’ ethnic and linguistic roots overlapped, dating to precolonial times. A warm, open climate was created to reflect on diverse IUHPE – Global Health Promotion Vol. 22, No. 1 2015
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Table 1. Culturally appropriate diversity training. Session topic
Objectives
Activities
Understanding cultural diversity
1. To get to know yourself and one another from a diversity perspective. 2. To understand principles of cultural competence and cultural humility. 3. To identify and describe potentially marginalized populations in your country. 1. To engage in reflexivity practices to be a more culturally humble teacher and/or clinician. 2. To understand how one’s beliefs, values, and assumptions impact the caring relationship with other people. 3. To explore classroom and clinical interactions with potential for disrespect or marginalization due to interpersonal differences. 1. To explore how inclusion of diversity concepts can strengthen a course or training program. 2. To practice integrating diversity into a course syllabus or training plan.
1. ‘Getting to know you’ activity – ‘The story of your name.’ 2. Cultural competence and cultural humility lecture and discussion. 3. Small group identification of the underserved and marginalized populations in your country.
Modeling a diversity perspective in your work
Integrating diversity into courses and training
Integrating cultural humility into clinical supervision and mentoring
1. To describe clinical supervision behaviors and interactions important to developing the next generation of clinicians and leaders who work with marginalized populations. 2. To explore the role of the mentor in developing culturally humble clinicians.
1. Values clarification activity – The practice of reflexivity slide show and discussion. 2. Establishing an atmosphere of humility, respect, and understanding – the HEALS Model© and classroom guidelines. 3. Role play scenarios of challenging classroom or clinical discussions about differences. 1. Discussion of principles of integrating diversity into courses, curricula, and training programs. 2. Small group exercise to develop one course or training objective, content, and learning activity related to diversity. 1. Slide show and discussion on ‘Molding the next generation©.’ 2. Small group discussion of personal mentoring experiences and identification of qualities of a good mentor. 3. Evaluation of diversity training.
HEALS: Halt, Engage, Allow, Learn, Synthesize.
aspects of individual and group identities and how they shape who we are. An overview was then given on cultural competence, cultural humility, and providing culturally appropriate and respectful care to all members of one’s community. Marginalization devalues a person based on some social characteristic, condition, or experience (15). Populations who are marginalized by others are at risk of disrespectful treatment, poor access to care, and overall health disparities, and thus are in great
need of culturally competent care. Zambia and Malawi appear to be homogeneous societies; however, there is wide diversity within each country. Country-specific groups identified peoples in their countries marginalized based on social characteristics (e.g. race, ethnicity, gender, age, socioeconomic status) and/or experiences such as disease status and other potentially stigmatizing experiences. Guiding questions included: ‘Who is/are our dominant or majority population group(s)?’ ‘Who are the weaker,
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less powerful citizens or minority groups?’ ‘What are social characteristics or statuses that are valued in our country?’ ‘Who are stigmatized, how, and why?’ Some of the major marginalized groups included people with HIV/AIDS, women, the elderly, those with low income and low education, the physically disabled, homosexuals, orphans, prisoners, and youths. Fellows discussed commonalities and differences in their identified groups, noting the frequency of similarities. One’s engagement in the marginalization of others was thought to be influenced by family and religious values, economic and educational privilege, and beliefs that someone had done something bad or immoral. Fellows discussed why it is important to be aware of groups who are marginalized and how they are treated.
Session 2: modeling a diversity perspective in your work In Session 2, Fellows engaged in reflexivity by exploring their personal values and how these affect how they relate to others. A series of photographs of Sub-Saharan African people were shown, including urban and rural men and women in western or traditional dress, people of all ages, racial and religious minorities in this region, and those depicting a particular activity or condition such as partying, praying, and pregnancy. Fellows were asked: ‘Who is this?’ ‘What kind of person does the picture depict?’ ‘How do most people in your country view a person like this?’ ‘What are the characteristics that you notice about him/her?’ ‘What are his/her health issues?’ ‘If a person like this sought health care in a clinic or hospital or was seen in a village, how would they likely be treated?’ While their responses were to be private, the exercise quickly evolved into a group process whereby individuals shouted out their thoughts and built upon one another’s ideas. ‘He is a doctor. He would go to a private clinic.’ ‘She is a pregnant, unmarried teenager. She might not want to come to the clinic because people would chastise her.’ ‘These are miserable orphans. We would help them.’ ‘She is a witch. Because she is an old woman with no family and she might be wandering around the village.’ Fellows reflected on how our personal and social values influence what we see in others and how these may lead to marginalization. The practice of reflexivity was highlighted as the cornerstone of
cultural humility. The take home message was ‘When we know our own biases about people, it leads to awareness and greater respect for others who are different from us.’ This discussion segued into modeling cultural competence for students, staff and colleagues. Resources from the UCSF DIVA modules were used to frame how educators and health care leaders can establish an atmosphere of humility and respect so that everyone feels heard, respected, and valued. Fellows were given examples of guidelines for the classroom, clinical setting, or meetings with colleagues or staff, including respecting one another, listening without judgment, and not making stereotypical comments or jokes about others. The group added other relevant guidelines appropriate to their individual settings. The ‘HEALS model for facilitating respectful and effective classroom and clinical discussions©’ was introduced to address comments or behaviors that emerge that may be uncomfortable, offensive, or disrespectful to others. The acronym stands for Halt, Engage, Allow, Learn, Synthesize. It is an action-oriented five-step model to give a concrete process for dealing with situations as they arise (Figure 2). HEALS is introduced to students or staff with instructions that it be used by anyone, at any time when something is uncomfortable or perceived to be disrespectful. When HEALS is triggered, a time out is taken to engage in a thoughtful, nonjudgmental discussion of what occurred. Fellows described their own examples of scenarios of disrespectful or offensive situations and HEALS was applied. One Fellow recounted that a community worker at a busy rural mobile clinic shouted at the gathered villagers, ‘All patients who are here for prenatal care or vaccines line up here. All patients with sexually transmitted diseases, line up over there.’ Fellows problem-solved how an incident like this could be salvaged to be more respectful of the clinic patients, without publically embarrassing the community worker. Fellows noted that HEALS was specific to western culture where students or subordinates could be encouraged to raise issues in a public forum. This was not the cultural norm in Zambia and Malawi, so the group discussed ways in which application of the underlying principles of HEALS could be modified to be culturally appropriate to their contexts. For example, a general discussion of a IUHPE – Global Health Promotion Vol. 22, No. 1 2015
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H – Halt. Stop the discussion to reflect on the comment without making the individual feel defensive. Ask for clarification. E – Engage. Encourage discussion of the issue. Who could this potentially affect and how? Check self and others for responses, including feelings and body language. A – Allow. Facilitate sharing of thoughts, beliefs, opinions, feelings, experiences. Allow for the exchange of ideas and for all to be heard. L – Learn. Create an atmosphere to learn from the discussion. Listen and learn from one another’s perspectives and experiences. S – Synthesize. Explore why this discussion is important. How might it impact the nature and quality of care for others? Figure 2. The HEALS model for facilitating respectful and effective classroom and clinical discussions. (©University of California San Francisco, Diversity in Action Committee, 2006).
hypothetical offensive or disrespectful situation could happen, but direct confrontations in a classroom, clinical setting, or meeting would not be appropriate, nor would pointing out a superior’s behavior in public. A more acceptable guideline would be encouraging a student to approach the faculty in private, with faculty willingness to openly discuss the issue.
Session 3: integrating diversity into courses and training Educational experiences are strengthened when a diversity perspective is threaded through all of its components, thus Session 3 focused on its integration into course descriptions, objectives, readings, assignments, and training materials. Integration begins with a strong initial statement about holding a teaching philosophy and creating a learning atmosphere that values diversity. Further, respect for diversity is a major component of academic and professional integrity. In designing courses and other experiences, suggestions included the incorporation of diversity into at least one course objective, seeking course materials that reflect the diverse populations who the students or staff will be working with, developing creative learning experiences which promote awareness of those who are marginalized, and teaching reflexivity to facilitate the understanding of self and others. Fellows explored online resources
about curricular enhancements (16–19), considering the benefits of and challenges to integrating diversity into an educational experience once they returned home.
Session 4: integrating cultural humility into clinical supervision and mentoring Session 4 applied cultural competence and humility to supervising students or staff in the clinical area. These are core professional values that are essential for shaping the next generation of health care providers. Fellows discussed ways that they could model a diversity perspective in their settings. In addition to identifying their unconscious biases toward others, they explored how they might model and teach reflexivity to their students and staff. Fellows were enthusiastic to try leading open and non-judgmental forums for their students to safely discuss difference and marginalization in their communities. They stressed the importance of setting an example of respectful communication as well as modeling culturally sensitive, respectful, and empathetic care of patients. Fellows discussed how to train others to deal with cultural insensitivity in the clinical setting. They agreed that addressing disrespectful behavior was essential and derived culturally appropriate strategies for doing so. Communication styles that respected hierarchical relationships and dealt with sensitive issues indirectly, in private, and with
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politeness and humility were suggested. One potential strategy was to put themselves in the learner role by asking general questions, such as, ‘How can we be more sensitive to our adolescent patients in the family planning clinic?’ or ‘How can we help our poor patients feel more comfortable when they come to the emergency department?’ These more general questions may open up an opportunity for discussing the promotion of culturally humble interactions. Fellows were encouraged to explore the role of the mentor by considering people who had been influential to their careers. Guiding questions included: ‘Who has been a good mentor to you?’ ‘What did they do to help you?’ ‘How did your relationship with them shape who you are today?’ ‘What can you do to mentor others?’ They summarized the positive qualities of a mentor, including listening, being a positive role model, sharing ideas and experiences, and being genuinely interested in the mentee’s development (20,21). We ended by exploring ways that cultural competence and humility could be integrated into advising and mentoring and how the Fellows could be good mentors, even across social differences and experiences.
Experiences of the Global Health Fellows Fellows expressed that learning about cultural humility was interesting and helpful. Most of them were somewhat familiar with cultural competence; however, many had a narrow comprehension of the social differences to be addressed in practice and these were associated with an overtly stigmatized status in their cultures like being gay or having HIV/AIDS. Cultural humility allowed Fellows to broaden their definitions of potentially marginalized populations to include people with poor social status based on income, education, or orphanhood, and socially unacceptable behavior such as premarital sex, adolescent pregnancy, and transactional sex. For many, it was the first time they had directly examined their own beliefs, values, assumptions, and practices within a group and how these influence how they relate to other people in their everyday lives, as well as in health care and teaching encounters. One Zambian Fellow expressed
appreciation for the opportunity to self-reflect and dialogue with Zambian and Malawian colleagues about cultural competence, humility and educating students to better care for those who are stigmatized. A Malawian said, ‘Although we come from different cultural settings and backgrounds, every person deserves respect and special care.’ Another reflected, ‘Diversity should not be a hindrance for working together for the common good.’ Interprofessional collaboration, role modeling, and mentoring were key responsibilities for integrating their new knowledge. Finally, although there were clear cultural distinctions from the West on the acceptable ways to confront insensitive or offensive behavior, Fellows strongly identified the need to ‘give immediate feedback to iron out issues’ with students and colleagues. One wrote, ‘I feel that these [strategies] were helpful. It’s just a matter of adapting the models to the local situations.’ Further exploration of culturally appropriate ways of giving feedback or addressing negative behavior across social hierarchies is needed.
Discussion In developing countries, building the capacity of the health care workforce is greatly needed and many national and international efforts are directed toward this important goal (22,23). At a time when professional education is scaling up to meet this demand, it is opportune to build in standards of cultural competence and humility as interprofessional values. The World Health Organization (23) stresses that educating health professionals has three interrelated goals: quantity, quality, and relevance. In addition to increasing the numbers (quantity) of health professionals of all types, an emphasis on the development of competencies (quality) is crucial and cultural humility is a key competency at every level of health worker. The ability of health professionals to deliver care that is responsive and sensitive to the populations served (relevance), especially those who are marginalized, is also critical. The stress of providing care in resource-poor countries may precipitate care that is rushed, impersonal, insensitive, or even disrespectful. Fellows gave several examples of difficult care situations in hospital and community settings that IUHPE – Global Health Promotion Vol. 22, No. 1 2015
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had severe shortages of personnel and those on the front lines of care were often called upon to meet an unimaginable level of human need. Bringing local populations who may be marginalized by others into clear awareness in tandem with selfexamination of one’s personal and professional values allowed the Fellows to reflect on the ethics of providing quality and sensitive care to all people. Due to this training, Global Health Fellows from Malawi and Zambia recognized the importance of teaching and role modeling sensitive and respectful communication and care across the spectrum of people they serve. Acknowledgments The authors wish to acknowledge the leadership of the Diversity in Action Committee (DIVA) at the University of California, San Francisco School of Nursing for their development of the faculty diversity training modules modified for this program. Materials developed by the DIVA Committee are indicated with a ©.
Conflict of interest None declared.
Funding This project was a component of the Global Health Professional Fellowship, funded by the U.S. State Department, Bureau of Educational and Cultural Affairs (Grant # S-ECAPE-10-GR-S221 (SS), Principal Investigators: Lynda Wilson, RN, PhD, FAAN, University of Alabama, Birmingham and Sally Rankin, PhD, RN, FAAN, University of California, San Francisco).
References 1. Clark L, Calvillo E, Dela Cruz F, Fongwa M, Kools S, Lowe J, et al. Cultural competence for graduate nursing education. J Prof Nurs. 2011; 27(3): 133– 137. 2. Douglas MK, Pierce JU, Rosenkoetter M, Callister LC, Hattar-Pollara M, Lauderdale J, et al. Standards of practice for culturally competent nursing care: A request for comments. J Transcult Nurs. 2009; 20(3): 257–269. 3. Gilbert MJ. Principles and recommended standards for cultural competence education of health care professionals. The California Endowment. 2003. Available from: http://www.calendow.org/ uploadedFiles/principles_standards_cultural_ competence.pdf (accessed 5 May 2014). 4. Goode TD, Dunne, MC, Bronheim SM. The evidence base for cultural and linguistic competency in health care. The Commonwealth Fund; 2006. Available from: http://www.commonwealthfund.
org/Content/Publications/Fund-Reports/2006/Oct/ The-Evidence-Base-for-Cultural-and-LinguisticCompetency-in-Health-Care.aspx (accessed 21 November 2012). 5. Duffy ME. A critique of cultural education in nursing. J Adv Nurs. 2001; 36(4): 487–495. 6. Hunt LM. Beyond cultural competence, 2001. Available from: http://www.med.unc.edu/pedclerk/ files/hunthumility.pdf (accessed 5 May 2014). 7. Tervalon M, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998; 9(2): 117–125. 8. Foster J. Cultural humility and the importance of long-term relationships in international partnerships. J Obstet Gynecol Neonatal Nurs. 2009; 38: 100– 107. 9. Kumagai AK, Lypson ML. Beyond cultural competence: Critical consciousness, social justice, and multicultural education. Acad Med. 2009; 84(6): 782–787. 10. Malone B, Tagliareni ME. Diversity: Fostering a more inclusive and open understanding of difference. Imprint. 2008; 55(5): 42–45. 11. Miller S. Cultural humility is the first step to becoming global care providers. J Obstet Gynecol Neonatal Nurs. 2009; 38: 92–93. 12. Terhune CP. ‘Can we talk?’ Using critical selfreflection and dialogue to build diversity and change organizational culture in nursing schools. J Cult Divers. 2006; 13(3): 141–145. 13. Timmins F. Critical practice in nursing care: Analysis, action and reflexivity. Nurs Stand. 2006; 20(39): 49–54. 14. Kennedy HP, Fisher L, Fontaine D, Martin-Holland J. Evaluating diversity in nursing education: A mixed method study. J Transcult Nurs. 2008; 19: 363–370. 15. Lynam MJ, Cowley S. Understanding marginalization as a social determinant of health. Crit Publ Health. 2007; 7(2): 137–149. 16. University of California, Santa Cruz Center for Teaching and Learning. Writing a syllabus. (n.d.). Available from: http://ctl.ucsc.edu/resources/tips/tips-syllabus.html (accessed 5 May 2014). 17. Cuseo JB. Capitalizing on student diversity to promote deeper learning and greater appreciation of individual differences: Research-based teaching strategies for college faculty, 2009. Available from: http://www. truworld.ca/internationalization/internal/ intlcurriculum/intlcurriculum_readings.html (accessed 21 November 2012). 18. American Association of Colleges of Nursing (AACN). Toolkit of resources for preparing a culturally competent master’s and doctorally prepared workforce. AACN, 2009. Available from: http://www. aacn.nche.edu/Education/pdf/Cultural_Competency_ Toolkit_Grad.pdf (accessed 21 November 2012). 19. National Center for Cultural Competence (NCCC), Georgetown University Center for Child and
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Human Development. Curricula enhancement module series. NCCC. (n.d.). Available from: http:// www.nccccurricula.info/ (accessed 21 November 2012). 20. Standing Committee on Postgraduate Medical and Dental Educations (SCOPME). Supporting Doctors and Dentists at Work: An Inquiry into Mentoring. London: SCOPME; 1998. 21. Feldman MD. UCSF Faculty mentoring program: Mentoring facilitator toolkit. 2010. Available from: http://academicaffairs.ucsf.edu/ccfl/media/UCSF_
Faculty_Mentoring_Program_Toolkit.pdf (accessed 5 May 2014). 22. Global Health Workforce Alliance. Scaling Up, Saving Lives: Task Force for Scaling Up Education and Training for Health Workers. Geneva: Global Health Workforce Alliance; 2008. 23. World Health Organization. Transformative Scale Up of Health Professional Education: An Effort to Increase the Numbers of Health Professionals and to Strengthen their Impact on Population Health. Geneva: World Health Organization; 2011.
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research-article2014
PED22110.1177/1757975914528728CommentaryS. Kools et al.
Commentary Cultural humility and working with marginalized populations in developing countries Susan Kools1, Angela Chimwaza2 and Swebby Macha3
Abstract: Population health needs in developing countries are great and countries are scaling up health professional education to meet these needs. Marginalized populations, in particular, are vulnerable to poor health and health care. This paper presents a culturally appropriate diversity training program delivered to Global Health Fellows who are educators and leaders in health professions in Malawi and Zambia. The purpose of this interprofessional education experience was to promote culturally competent and humble care for marginalized populations. (Global Health Promotion, 2015; 22(1): 52–59) Keywords: education, equity, health care, minorities, social justice, socioeconomic status, vulnerable people Cultural competence is a standard of practice in health care. Cultural humility, emphasizing selfreflection, mutual understanding, and respect between health care providers and patients/clients, represents the contemporary conceptualization of culturally appropriate and sensitive care. It is critical to deliver culturally humble care to populations who are vulnerable due to perceived difference in social characteristics and/or experience. From 2010 to 2012, the US State Department Bureau of Educational and Cultural Affairs funded a Global Health Professional Fellowship, including faculty and health care leaders from the Universities of Alabama at Birmingham (UAB); California, San Francisco (UCSF); Zambia; and Malawi (Figure 1) to promote health care for marginalized populations by strengthening education for providers. Twentyfive Zambian and Malawian Global Health Fellows, representing leaders in nursing, medicine, midwifery, physiotherapy, pharmacy, health management, and health economics attended an interprofessional education workshop at UAB, including culturally appropriate diversity training. Cultural competence encompasses knowledge about diverse people and their needs, attitudes that
recognize and value difference, and flexible skills to provide appropriate and sensitive care to diverse populations (1–4). Cultural competence has been described (5–7) as the achievement of a particular skill or ability, implying its completion; however, it is a lifelong commitment to learning about oneself and others, built on dynamic experiences over time. Further, by focusing on the ‘cultural other,’ one can inadvertently reinforce stereotypes about a person based on social characteristics. Cultural humility extends the idea of cultural competence, recognizing that care of clients and communities is interactive (6,8–11). One can never be the ‘expert’ in understanding difference, thus taking a posture of humility is important. Cultural humility is based on intentional and ongoing self-reflection in order to understand how one’s beliefs, values, and assumptions are integral and influential to the health care relationship (7). This definitional nuance redirects the clinician from the application of fixed cultural designations to others. As a key component of humility, reflexivity, or the active examination of one’s sociocultural background and beliefs, is an intentional process
1. Department of Family Health Care Nursing, University of California, San Francisco, USA. 2. Kamuzu College of Nursing, University of Malawi, Blantyre, Malawi. 3. University Teaching Hospital of Zambia, Lusaka, Zambia. Correspondence to: Susan Kools, Department of Family Health Care Nursing, University of California – San Francisco, 2 Koret Way, Box 0606, San Francisco, CA 94143, USA. Email: [email protected] Global Health Promotion 1757-9759; Vol 22(1): 52 –59; 528728 Copyright © The Author(s) 2014, Reprints and permissions: http://www.sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1757975914528728 http://ghp.sagepub.com Downloaded from ped.sagepub.com by guest on November 15, 2015
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University of Alabama, Birmingham Samford University McWhorter School of Pharmacy University of California, San Francisco
Global Health Professional Fellowship
University of Zambia National Institute for Public Administration, Zambia University of Malawi Kamuzu College of Nursing Global AIDS Interfaith Alliance
MALAWI
ZAMBIA
Figure 1. Maps and participating institutions.
we can use to help us understand our own contribution to the caring relationship (2,12,13). It facilitates respect by acknowledging similarities and differences in perspectives and health practices (7).
Culturally appropriate diversity training Faculty diversity training modules developed by the UCSF School of Nursing Diversity in Action Committee (DIVA) (14) were tailored and implemented by a UCSF nursing professor with experience working in Malawi. Entitled ‘Working respectfully and effectively with diverse and marginalized populations,’ the overarching goal for the two day training was to enhance the ability of faculty and community leaders to provide and model culturally appropriate and sensitive care to those in their communities, especially those who are marginalized by circumstances or culture (Table 1) using the cultural humility principles outlined above.
Session 1: understanding cultural diversity Session 1 began with an exercise for Fellows to get to know one another from a diversity perspective. Fellows told each other stories about where their names came from. Guiding questions included: ‘Who named you?’ ‘Why did your parents or someone else give you your name?’ ‘What does your name mean?’ ‘Does your name link you with your ancestors or family history?’ A discussion ensued with enthusiastic storytelling and laughter. The meaning of one’s name in this region of Africa is of high significance. Many Fellows had both English and vernacular names, linking them with their family heritage. Some had context-specific names for school, church, and home. Family names were often clan names, indicating matrilineal or patrilineal lines, specific to ethnic background. While they were from two different countries, Fellows’ ethnic and linguistic roots overlapped, dating to precolonial times. A warm, open climate was created to reflect on diverse IUHPE – Global Health Promotion Vol. 22, No. 1 2015
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Table 1. Culturally appropriate diversity training. Session topic
Objectives
Activities
Understanding cultural diversity
1. To get to know yourself and one another from a diversity perspective. 2. To understand principles of cultural competence and cultural humility. 3. To identify and describe potentially marginalized populations in your country. 1. To engage in reflexivity practices to be a more culturally humble teacher and/or clinician. 2. To understand how one’s beliefs, values, and assumptions impact the caring relationship with other people. 3. To explore classroom and clinical interactions with potential for disrespect or marginalization due to interpersonal differences. 1. To explore how inclusion of diversity concepts can strengthen a course or training program. 2. To practice integrating diversity into a course syllabus or training plan.
1. ‘Getting to know you’ activity – ‘The story of your name.’ 2. Cultural competence and cultural humility lecture and discussion. 3. Small group identification of the underserved and marginalized populations in your country.
Modeling a diversity perspective in your work
Integrating diversity into courses and training
Integrating cultural humility into clinical supervision and mentoring
1. To describe clinical supervision behaviors and interactions important to developing the next generation of clinicians and leaders who work with marginalized populations. 2. To explore the role of the mentor in developing culturally humble clinicians.
1. Values clarification activity – The practice of reflexivity slide show and discussion. 2. Establishing an atmosphere of humility, respect, and understanding – the HEALS Model© and classroom guidelines. 3. Role play scenarios of challenging classroom or clinical discussions about differences. 1. Discussion of principles of integrating diversity into courses, curricula, and training programs. 2. Small group exercise to develop one course or training objective, content, and learning activity related to diversity. 1. Slide show and discussion on ‘Molding the next generation©.’ 2. Small group discussion of personal mentoring experiences and identification of qualities of a good mentor. 3. Evaluation of diversity training.
HEALS: Halt, Engage, Allow, Learn, Synthesize.
aspects of individual and group identities and how they shape who we are. An overview was then given on cultural competence, cultural humility, and providing culturally appropriate and respectful care to all members of one’s community. Marginalization devalues a person based on some social characteristic, condition, or experience (15). Populations who are marginalized by others are at risk of disrespectful treatment, poor access to care, and overall health disparities, and thus are in great
need of culturally competent care. Zambia and Malawi appear to be homogeneous societies; however, there is wide diversity within each country. Country-specific groups identified peoples in their countries marginalized based on social characteristics (e.g. race, ethnicity, gender, age, socioeconomic status) and/or experiences such as disease status and other potentially stigmatizing experiences. Guiding questions included: ‘Who is/are our dominant or majority population group(s)?’ ‘Who are the weaker,
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less powerful citizens or minority groups?’ ‘What are social characteristics or statuses that are valued in our country?’ ‘Who are stigmatized, how, and why?’ Some of the major marginalized groups included people with HIV/AIDS, women, the elderly, those with low income and low education, the physically disabled, homosexuals, orphans, prisoners, and youths. Fellows discussed commonalities and differences in their identified groups, noting the frequency of similarities. One’s engagement in the marginalization of others was thought to be influenced by family and religious values, economic and educational privilege, and beliefs that someone had done something bad or immoral. Fellows discussed why it is important to be aware of groups who are marginalized and how they are treated.
Session 2: modeling a diversity perspective in your work In Session 2, Fellows engaged in reflexivity by exploring their personal values and how these affect how they relate to others. A series of photographs of Sub-Saharan African people were shown, including urban and rural men and women in western or traditional dress, people of all ages, racial and religious minorities in this region, and those depicting a particular activity or condition such as partying, praying, and pregnancy. Fellows were asked: ‘Who is this?’ ‘What kind of person does the picture depict?’ ‘How do most people in your country view a person like this?’ ‘What are the characteristics that you notice about him/her?’ ‘What are his/her health issues?’ ‘If a person like this sought health care in a clinic or hospital or was seen in a village, how would they likely be treated?’ While their responses were to be private, the exercise quickly evolved into a group process whereby individuals shouted out their thoughts and built upon one another’s ideas. ‘He is a doctor. He would go to a private clinic.’ ‘She is a pregnant, unmarried teenager. She might not want to come to the clinic because people would chastise her.’ ‘These are miserable orphans. We would help them.’ ‘She is a witch. Because she is an old woman with no family and she might be wandering around the village.’ Fellows reflected on how our personal and social values influence what we see in others and how these may lead to marginalization. The practice of reflexivity was highlighted as the cornerstone of
cultural humility. The take home message was ‘When we know our own biases about people, it leads to awareness and greater respect for others who are different from us.’ This discussion segued into modeling cultural competence for students, staff and colleagues. Resources from the UCSF DIVA modules were used to frame how educators and health care leaders can establish an atmosphere of humility and respect so that everyone feels heard, respected, and valued. Fellows were given examples of guidelines for the classroom, clinical setting, or meetings with colleagues or staff, including respecting one another, listening without judgment, and not making stereotypical comments or jokes about others. The group added other relevant guidelines appropriate to their individual settings. The ‘HEALS model for facilitating respectful and effective classroom and clinical discussions©’ was introduced to address comments or behaviors that emerge that may be uncomfortable, offensive, or disrespectful to others. The acronym stands for Halt, Engage, Allow, Learn, Synthesize. It is an action-oriented five-step model to give a concrete process for dealing with situations as they arise (Figure 2). HEALS is introduced to students or staff with instructions that it be used by anyone, at any time when something is uncomfortable or perceived to be disrespectful. When HEALS is triggered, a time out is taken to engage in a thoughtful, nonjudgmental discussion of what occurred. Fellows described their own examples of scenarios of disrespectful or offensive situations and HEALS was applied. One Fellow recounted that a community worker at a busy rural mobile clinic shouted at the gathered villagers, ‘All patients who are here for prenatal care or vaccines line up here. All patients with sexually transmitted diseases, line up over there.’ Fellows problem-solved how an incident like this could be salvaged to be more respectful of the clinic patients, without publically embarrassing the community worker. Fellows noted that HEALS was specific to western culture where students or subordinates could be encouraged to raise issues in a public forum. This was not the cultural norm in Zambia and Malawi, so the group discussed ways in which application of the underlying principles of HEALS could be modified to be culturally appropriate to their contexts. For example, a general discussion of a IUHPE – Global Health Promotion Vol. 22, No. 1 2015
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H – Halt. Stop the discussion to reflect on the comment without making the individual feel defensive. Ask for clarification. E – Engage. Encourage discussion of the issue. Who could this potentially affect and how? Check self and others for responses, including feelings and body language. A – Allow. Facilitate sharing of thoughts, beliefs, opinions, feelings, experiences. Allow for the exchange of ideas and for all to be heard. L – Learn. Create an atmosphere to learn from the discussion. Listen and learn from one another’s perspectives and experiences. S – Synthesize. Explore why this discussion is important. How might it impact the nature and quality of care for others? Figure 2. The HEALS model for facilitating respectful and effective classroom and clinical discussions. (©University of California San Francisco, Diversity in Action Committee, 2006).
hypothetical offensive or disrespectful situation could happen, but direct confrontations in a classroom, clinical setting, or meeting would not be appropriate, nor would pointing out a superior’s behavior in public. A more acceptable guideline would be encouraging a student to approach the faculty in private, with faculty willingness to openly discuss the issue.
Session 3: integrating diversity into courses and training Educational experiences are strengthened when a diversity perspective is threaded through all of its components, thus Session 3 focused on its integration into course descriptions, objectives, readings, assignments, and training materials. Integration begins with a strong initial statement about holding a teaching philosophy and creating a learning atmosphere that values diversity. Further, respect for diversity is a major component of academic and professional integrity. In designing courses and other experiences, suggestions included the incorporation of diversity into at least one course objective, seeking course materials that reflect the diverse populations who the students or staff will be working with, developing creative learning experiences which promote awareness of those who are marginalized, and teaching reflexivity to facilitate the understanding of self and others. Fellows explored online resources
about curricular enhancements (16–19), considering the benefits of and challenges to integrating diversity into an educational experience once they returned home.
Session 4: integrating cultural humility into clinical supervision and mentoring Session 4 applied cultural competence and humility to supervising students or staff in the clinical area. These are core professional values that are essential for shaping the next generation of health care providers. Fellows discussed ways that they could model a diversity perspective in their settings. In addition to identifying their unconscious biases toward others, they explored how they might model and teach reflexivity to their students and staff. Fellows were enthusiastic to try leading open and non-judgmental forums for their students to safely discuss difference and marginalization in their communities. They stressed the importance of setting an example of respectful communication as well as modeling culturally sensitive, respectful, and empathetic care of patients. Fellows discussed how to train others to deal with cultural insensitivity in the clinical setting. They agreed that addressing disrespectful behavior was essential and derived culturally appropriate strategies for doing so. Communication styles that respected hierarchical relationships and dealt with sensitive issues indirectly, in private, and with
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politeness and humility were suggested. One potential strategy was to put themselves in the learner role by asking general questions, such as, ‘How can we be more sensitive to our adolescent patients in the family planning clinic?’ or ‘How can we help our poor patients feel more comfortable when they come to the emergency department?’ These more general questions may open up an opportunity for discussing the promotion of culturally humble interactions. Fellows were encouraged to explore the role of the mentor by considering people who had been influential to their careers. Guiding questions included: ‘Who has been a good mentor to you?’ ‘What did they do to help you?’ ‘How did your relationship with them shape who you are today?’ ‘What can you do to mentor others?’ They summarized the positive qualities of a mentor, including listening, being a positive role model, sharing ideas and experiences, and being genuinely interested in the mentee’s development (20,21). We ended by exploring ways that cultural competence and humility could be integrated into advising and mentoring and how the Fellows could be good mentors, even across social differences and experiences.
Experiences of the Global Health Fellows Fellows expressed that learning about cultural humility was interesting and helpful. Most of them were somewhat familiar with cultural competence; however, many had a narrow comprehension of the social differences to be addressed in practice and these were associated with an overtly stigmatized status in their cultures like being gay or having HIV/AIDS. Cultural humility allowed Fellows to broaden their definitions of potentially marginalized populations to include people with poor social status based on income, education, or orphanhood, and socially unacceptable behavior such as premarital sex, adolescent pregnancy, and transactional sex. For many, it was the first time they had directly examined their own beliefs, values, assumptions, and practices within a group and how these influence how they relate to other people in their everyday lives, as well as in health care and teaching encounters. One Zambian Fellow expressed
appreciation for the opportunity to self-reflect and dialogue with Zambian and Malawian colleagues about cultural competence, humility and educating students to better care for those who are stigmatized. A Malawian said, ‘Although we come from different cultural settings and backgrounds, every person deserves respect and special care.’ Another reflected, ‘Diversity should not be a hindrance for working together for the common good.’ Interprofessional collaboration, role modeling, and mentoring were key responsibilities for integrating their new knowledge. Finally, although there were clear cultural distinctions from the West on the acceptable ways to confront insensitive or offensive behavior, Fellows strongly identified the need to ‘give immediate feedback to iron out issues’ with students and colleagues. One wrote, ‘I feel that these [strategies] were helpful. It’s just a matter of adapting the models to the local situations.’ Further exploration of culturally appropriate ways of giving feedback or addressing negative behavior across social hierarchies is needed.
Discussion In developing countries, building the capacity of the health care workforce is greatly needed and many national and international efforts are directed toward this important goal (22,23). At a time when professional education is scaling up to meet this demand, it is opportune to build in standards of cultural competence and humility as interprofessional values. The World Health Organization (23) stresses that educating health professionals has three interrelated goals: quantity, quality, and relevance. In addition to increasing the numbers (quantity) of health professionals of all types, an emphasis on the development of competencies (quality) is crucial and cultural humility is a key competency at every level of health worker. The ability of health professionals to deliver care that is responsive and sensitive to the populations served (relevance), especially those who are marginalized, is also critical. The stress of providing care in resource-poor countries may precipitate care that is rushed, impersonal, insensitive, or even disrespectful. Fellows gave several examples of difficult care situations in hospital and community settings that IUHPE – Global Health Promotion Vol. 22, No. 1 2015
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had severe shortages of personnel and those on the front lines of care were often called upon to meet an unimaginable level of human need. Bringing local populations who may be marginalized by others into clear awareness in tandem with selfexamination of one’s personal and professional values allowed the Fellows to reflect on the ethics of providing quality and sensitive care to all people. Due to this training, Global Health Fellows from Malawi and Zambia recognized the importance of teaching and role modeling sensitive and respectful communication and care across the spectrum of people they serve. Acknowledgments The authors wish to acknowledge the leadership of the Diversity in Action Committee (DIVA) at the University of California, San Francisco School of Nursing for their development of the faculty diversity training modules modified for this program. Materials developed by the DIVA Committee are indicated with a ©.
Conflict of interest None declared.
Funding This project was a component of the Global Health Professional Fellowship, funded by the U.S. State Department, Bureau of Educational and Cultural Affairs (Grant # S-ECAPE-10-GR-S221 (SS), Principal Investigators: Lynda Wilson, RN, PhD, FAAN, University of Alabama, Birmingham and Sally Rankin, PhD, RN, FAAN, University of California, San Francisco).
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