Cultural humility builds medical trust
As the focus on health equity sharpens, it's imperative we all better understand and address how patients' cultural needs and life experiences may shape their healthcare engagement and utilization. Cultural humility is increasingly emerging as an essential practice that helps providers better connect with patients of diverse backgrounds. With cultural humility, providers improve health outcomes of patients by demonstrating respect, empathy, and understanding that builds medical trust.
About Cultural Humility - understanding distinct cultural experiences of others
As a member of the Lumbee Tribe of North Carolina, I remember an early example of cultural humility in action: a tribal leader's visit with medical providers in Robeson County, a racially diverse region in the south of the state.
The tribal leader described how farming shapes the Lumbee people's food and cultural traditions. He explained how children are raised in a communal way with discipline a shared responsibility. He detailed the key role of smoking tobacco, and the social context surrounding its use. And he conveyed how a legacy of forced relocations has fueled deep health inequities for the Lumbee tribe and other Native and indigenous peoples.
Cultivate curiosity, lifetime learning among healthcare professionals
The discussion that day paved the way for providers to consider a different way of interacting with their Lumbee patients – as well as individuals from any culture. Cultivating a spirit of curiosity and an interest in learning about patients' background and experiences is an important step in creating an environment of cultural humility in healthcare. This awareness, respect for different beliefs, and an individualized approach to patient care provide a critical foundation for our work addressing longstanding health inequities.
This work is critical. In Robeson County, North Carolina, more than 40% of the population identifies as American Indian or Alaska Native, according to recent census figures. Nationwide, American Indian/Alaska Natives experience stark health inequities including a lower life expectancy than most other ethnic groups, and a disproportionate disease burden.
A culturally humble approach to healthcare is one tool in addressing the persistent and longstanding health inequities that plague historically marginalized groups. Delivering healthcare that meets “the social, cultural and linguistic needs of patients" can lead to improved health outcomes and reduce racial and ethnic health disparities, according to the Health Policy Institute at Georgetown University.
The difference between cultural competence and cultural humility
While the term “cultural competence" and “cultural humility" are often used interchangeably, there is an important distinction. “Cultural humility" refers more specifically to the practice of deepening connections between providers and patients and approaching each encounter with a sense of respect and curiosity—leaving behind stereotypes or biases. With cultural humility, there is no assumption that one can ever be fully competent about someone else's culture and experiences.
This approach establishes trust and improves communication while leading to specific knowledge that could inform the clinician. When treated in this manner, patients are more likely to share details of their background and experience – ones that shape their health and could influence their care.
Cultural humility in healthcare - changing clinician mindsets
In a 2022 paper published in the journal Pediatrics, Dr. E. Caroline Kibakaya and Suzette O. Oyeku described the benefits of using cultural humility to promote health equity in pediatric primary care: “Demonstrating cultural humility frees healthcare professionals from having to possess expert knowledge about a myriad of cultural differences and fosters open communication with our patients to achieve shared health and developmental outcomes."
In the exam room, this approach may translate into inquiring about a patient's identity and trying to understand the social determinants that may influence their health. Active listening and acknowledging one's own biases are also key, they wrote.
This practice involves a mindset change for many clinicians, away from a top-down authoritative approach to healthcare. Providers engage the patient as an active participant in their care, helping patients achieve their health goals in a way that best aligns with their lived experiences. For example, patients' cultural dietary and lifestyle preferences may be considered in their care plans. Even more, involving patients more actively in their healthcare can lead to better quality of care and improved treatment outcomes, numerous studies have found.
Approaching patients with cultural sensitivity
Take the case of an American Indian woman who is pregnant and smokes. Asking about her culture's relationship with tobacco and smoking might influence the health provider's approach to a care conversation. In engaging the patient with curiosity and interest, the patient might be more receptive to a discussion on smoking during pregnancy and the negative health impacts.
A similar approach of culture humility would also work with an older diabetic male member of the Lumbee tribe. A top-down, authoritative approach might simply direct him to use insulin and cut out high sugar foods. But if health providers approached him with curiosity, they might learn that changing his diet and blithely reducing sweets isn't as simple as it sounds. Desserts are woven into his cultural fabric, with Sunday visit days integral to his social life. These days are spent visiting neighbors with coffee and sweets to strengthen relationships, build community, and appreciate life's bounty. Asking the newly diagnosed diabetic to dramatically change his diet is requesting a significant change to his social interactions, too.
What if the provider had asked open-ended questions that helped align medical treatment with his own personal goals? That might lead to a connection with a diabetes educator, who could help him understand how to implement dietary changes within his own cultural context. Maybe they could brainstorm ways to maintain the spirit of the Sunday visits while reducing the harm to his blood sugar. Even more, that approach would likely create more trust between patient and provider, encouraging him to return for future health checks.
Going beyond the doctor's office
This culturally respectful approach can extend beyond the physician's office to a health system level, too. One example comes from the Agency for Healthcare Research and Quality created a reengineered discharge toolkit that address a patient's readiness to leave a healthcare setting. An expanded version now provides guidance for patients from diverse cultural backgrounds and people with non-English language preference.
The toolkit considers the challenges that can arise in cross-cultural clinical encounters, when the culture of the provider, patient and healthcare system might not immediately align.
“When these cultures clash, misunderstandings about the nature of an illness, its remedies, and appropriate health behaviors are more likely to occur," according to the Boston University guide for delivering the new toolkit. “Cross-cultural communication, which requires an exchange of shared meaning, can occur even when both parties speak the same language."
That's why it's important to bridge those gaps and improve communication, efforts that translate into improved continuity of care for patients. These toolkit components provide an example of addressing patient needs with humility – and not assuming certain key steps are met. For example, the plan includes reviewing all medicine lists with the patient and makes sure there is a realistic plan in place for obtaining them. Case studies throughout the country have shown that this approach can significantly reduce hospital readmissions.
Addressing barriers to care
Understanding and addressing barriers to care can help explain why a patient might be returning for costlier hospital visits. For example, maybe they don't understand the treatment plan or are unable to get to a pharmacy to refill a prescription. Asking questions about one's home environment may also offer valuable insights. Does the patient live alone? Is there anyone to help them? If someone is living alone, they might need to be connected to a care manager to make sure they're comfortable with the necessary home treatments and can access prescriptions and follow-up appointments. That manager can also point patients to additional social and community resources such as transportation and necessary medical equipment.
There are barriers to addressing these measures in both the primary care and hospital settings, such as workflow and resource challenges. But readmission comes at a high cost to both the patient and the health system. Creating an environment where patients are engaged participants in their care is essential to improving health outcomes and reducing disparities.
Cultural humility can improve teamwork
This shift makes sense for improving relationships among an increasingly diverse healthcare workforce as well. An “ethos of cultural humility" can nurture better teamwork and more inclusivity, according to the authors of a 2021 paper published in the Journal of Nursing Management. “Nurse managers need to consider ways of nurturing cultural humility in promoting cultural awareness, openness and mutual understanding of cultural difference, as a means of supporting effective intercultural working," the authors wrote.
Implementing the standards for a culturally humble approach to healthcare
Providers, hospitals, and health systems are increasingly taking note of the benefits of a culturally tailored approach.
The National Standards for Culturally and Linguistically Appropriate Services (CLAS) provides guidance for creating a more culturally humble approach in healthcare. This guide creates a roadmap that can help health organizations reduce healthcare disparities and improve overall quality. These steps are also gaining traction on a statewide level. In North Carolina, for example, the state has used CLAS tools to address cultural barriers that may impact quality of care. Programs to address health disparities such as diabetes rates have included faith-based organizations and tribal organizations.
Incremental yet promising advancements
As in any nascent field of study, the efficacy details are still being fine-tuned as researchers analyze which specific interventions and approaches have the most impact. In 2020, researchers combed through dozens of studies on culturally tailored interventions to gauge strengths and weaknesses, findings published in Nursing Open. Some challenges came from unclear guidelines and inadequate training for healthcare providers. Meanwhile, strengths included more culturally respectful and patient-centered care, increased family and community supports and increased participant knowledge of disease.
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We still have much work to do in improving culturally sensitive approaches to care, and, more broadly, addressing health inequities. Expanding the use of cultural humility in healthcare – on both the individual and structural levels—is an important tool in achieving these health equity goals.
Learn more about the health equity consulting services RTI Health Advance offers by contacting a team member today.