BY DARRYL WASHINGTON, D.ED., MS
THE ANCIENT ISSUE OF INEQUITY
The rudiments of any developing culture begin with the creation of a common language, letters or an alphabet, religion, laws, social organization, settlements, food production and a system of healthcare. Systematic healthcare dates back as far as the ancient Mesopotamians, whose timeline was between 8,000 BCE and 2,000 BCE. Their system of healthcare predates science as we know it and was more akin to religious practices where priests served as the physician; herbs were medicine and temples were the local medical center. By 3100 BCE, the ancient Egyptians advanced healthcare by training specialized medical practitioners such as physicians and surgeons. The Egyptians were the first developing society that recorded medical knowledge in texts such as the Edwin Smith Papyrus and the Ebers Papyrus, which included descriptions of diseases, injuries and treatments. They had the Temple of Imhotep at Saqqara, which served as a center for medical education and healing. Despite the advancements made through time from the earliest civilizations to more modern times, inequities in healthcare existed in the onset and remain as a barrier today.
Social determinants of health of today have basically remained unchanged since ancient times. Healthcare for the Mesopotamians was determined by social status, wealth and power. Similarly in more recent times, social determinants of health include income, education, housing and access to healthcare. Ultimately, the social stratification of all cultures at any point in time seems to be the greatest determinant in accessing healthcare. It seems unless a society can successfully promote equity and inclusion in healthcare for all of its people, there will always be a system of “haves and have nots.”
Relatively speaking, case managers are confronted with the age-old cultural problem of health equity on a micro-level in their everyday work with clients. Generally speaking, case managers are tasked with helping their clients who “have not” access the healthcare they need. Evidence suggests that case managers are better equipped at addressing this cultural issue by developing competency in their ability to effectively interact and communicate with people from diverse cultural backgrounds. It involves developing understanding, valuing and respecting the beliefs, customs, languages, practices and needs of different cultural groups.
IS CULTURAL COMPETENCE ENOUGH?
The culturally competent case manager, in engaging with clients, must be intent on being self-aware and recognize and reflect on their biases, values and assumptions. They must actively work toward developing empathy and openness toward people from other cultures. Cultural competence can only be acquired through learning about other cultures, their histories and traditions. It is important to understand the cultural norms of the clients served. It is essential that the culturally competent person respect and value the diversity of human experiences and perspectives, while practicing openness, acceptance and non-judgment toward people from different cultural backgrounds. This is accomplished by actively listening, asking appropriate questions and seeking clarification to ensure mutual understanding. The culturally competent case manager advocates for more equitable and inclusive environments where all individuals can thrive.
Cultural competency is a skill-based approach that healthcare professionals and case managers can be trained to meet the needs of a diverse populations, especially more effectively for those that face health inequities. But some research has begun to challenge the efficacy of cultural competency as a prominent approach for advancing diversity, suggesting there are limitations in this methodology (Yoo, 2022). A criticism of cultural competency is its heavy focus on the “Other,” which is believed to reinforce Western culture as the dominant people group. Another concern for researchers is that knowledge and awareness of cultures is inadequate in terms of changing one’s internal thoughts and beliefs about other cultures. It seems that increasing cultural knowledge through learning new information or skills without changing the way people think about, understand and interact with the world around them has not been shown to create a culturally humble manner (Agner, 2020).
Cultural competency, while important and necessary, may be acquired too passively, and perhaps not fully internalized by the learner. Researchers have proposed that fostering “cultural humility,” may be a promising addition to help transform practitioners’ perspectives as it pertains to improving outcomes for diversity, and inclusion. Tervalon and Garcia (1998) were among the first researchers who applied the concept of cultural humility in the healthcare space. They advanced a framework for conveying the idea that is characterized by three main tenets: (a) commitment to lifelong, critical self-reflection; (b) recognition and mitigation of power imbalances; and (c) accountability to individuals and institutions (Tervalon & Murray-Garcia, 1998).
CULTURAL HUMILITY: NEW AND IMPROVED
There are key differences in developing cultural competency versus cultural humility. Cultural competence often involves formal training, workshops and courses designed to educate individuals about cultural differences. Cultural competence focuses on acquiring knowledge about different cultures, including their customs, traditions, beliefs and values. It emphasizes developing specific skills and strategies for effectively engaging with individuals from diverse backgrounds. Developing cultural competence is engaged by taking an interpersonal approach to learning through gaining knowledge, insights and understanding through interactions with others.
Cultural humility ascribes more to intrapersonal learning and is a process of gaining knowledge, insights and understanding within oneself, which involves self-reflection, introspection and personal growth. In acquiring cultural humility, there is an emphasis on learning from others where one acknowledges and addresses one’s own biases, assumptions and privilege. Practicing cultural humility facilitates critical reflection by assessing cultural biases and possibly ingrained stereotypes. Value is placed on building authentic relationships based on mutual respect and understanding. Cultural humility signifies more about how we engage with others as opposed to learning a specific set of knowledge or practices. Overall, cultural humility may be less static, in so much as it is not considered to be ever mastered; but rather, it is an ongoing practice of continued learning.
DEVELOPING CULTURALLY HUMBLE CASE MANAGEMENT
Case managers who strive to become culturally humble are those who recognize and respect the diversity of clients’ backgrounds, experiences and perspectives. They can acknowledge their own limitations and biases, allowing them to better address the needs and challenges faced by clients who come from different cultural, racial and socioeconomic backgrounds. Unlike cultural competency that can be taught, or learned, humility leans more toward having the willingness to do the inner work that results in developing this capacity. To be humbler, you must be willing to be vulnerable, allowing weaknesses, mistakes, and uncertainties to be exposed, to be better in the service of clients. Becoming culturally humble requires one to be intentional and willing to engage in a self-imposed metacognitive approach to investigate and adopt a new way of thinking, believing and acting as it pertains to cross-cultural issues. Specifically, be willing to have:
- Openness to Cultural Multiplicity (adjust one’s cultural perspectives)
- Lifelong Self-examination (commitment to continuously examine one’s cultural perspectives)
- Interpersonal Modesty (strive to become selfless, or have concern for the needs of others above your own)
- Lack of Defensiveness (be willing to be vulnerable, where it is safe to do so)
- Relational Orientation Focus (engage in relationship building that is more mutually beneficial).
Cultural competence and cultural humility are both effective and valuable frameworks for practitioners (case managers) to promote inclusivity and to address health inequities as it relates to access to healthcare. While some researchers suggest there may be advantages to one approach versus the other, there is a consensus among healthcare professionals that cultural competence and humility are important attributes that can reduce racial and ethnic disparities in healthcare access and outcomes. There is significant evidence to demonstrate that either is effective. Combining both approaches may be best practice for skill development in providing supports and services that are meaningful and respectful interactions across diverse cultural contexts.
Darryl Washington, D.Ed., MS, currently serves as the chief operations officer for Northern Health Care Management. He has more than 20 years of service in providing long term care and support services for older adults with disabilities, and those with intellectual disabilities. Along with his master’s degree in clinical psychology, he holds a doctorate in educational administration, and is an assistant professor teaching ungraduated psychology courses. He is currently working toward the completion of a fellowship in cultural intelligence, with the intention of addressing inequities in education and healthcare.
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