Cultural competence vs humility - Anyone understand it?

[RethinkingLife]

I've been reading about cultural competence vs humility recently. Does anyone have any experience of it, please?

My context is healthcare but I'd appreciate a discussion in other sectors just to understand how cultural humility is implemented and the associated advantages/risks. Ditto, my strong interest is women's rights but other cases/examples are welcome.

https://www.betterup.com/blog/cultural-humility-vs-cultural-competence

I was thinking too, that curiosity is perhaps a better word than humility, as humility seems to imply some sort of power differential, and I think the issue of power is much more complicated than it is sometimes made out to be, for example, I think the role of social class and economic disadvantage is massively unrecognised. I get the point about cultural competence being the idea that you learn something and that's that, which surely you do need some level of understanding to move on from there, but then cultural humility is more of an active process of finding out things. But then this is fraught with difficulty as in the questions above.

I think there are different dynamics for different groups of people though. I talk about being from a white working class community, and I work in one of my contracts predominantly amongst middle-class people (national charity sector), and nobody has ever asked me about it, but I would be happy to talk, although I know I would hold back a lot of stuff. Yet when I worked in a job that was all working class people and very ethnically diverse we constantly talked about issues of classism and racism quite openly and easily.

One of the most powerful learning experiences I had was a woman I worked with who was deaf and she did a workshop for us about her hearing loss and hearing loss in general and how it affected her, it was great and although it must've been nearly 20 years ago, I still remember it. I think you can "educate yourself" so much, but ultimately it's being around people on a day-to-day basis that makes the most impact, as we are social beings and get much of our sense of meaning from the people around us.

I'm an immigrant and an ethnic minority; after decades of living here I have (I am told) a passable British accent.

Echoing what others have said, my experience has been that the same question "Where are you from?" can have two meanings, and generally it's obvious.

Most often, as my work and social circles are very international (academic research type of thing, even people of British origin will usually be from elsewhere in the UK) it is the positive meaning. And it's a thing that everybody asks everybody, being a good ice-breaker and a fascinating topic of conversation.

my biggest issue is the "vs" part of the thread title. Why is it necessary to choose one method exclusively over another?

It's in the article title. It's also in the title of the key publication in the area although a didn't have room for "a critical distinction…"

Tervalon M, Murray-García J. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998 May;9(2):117-25. doi: 10.1353/hpu.2010.0233. PMID: 10073197.

https://pubmed.ncbi.nlm.nih.gov/10073197/

I'm not trying to be difficult @RethinkingLife but I'm not picking up anything that helps me understand why I have to choose one or the other.
I'm aware in some professions it's viewed as a revelation you don't have to do that. For example, the author of the book donut economics says in it she feels economists too often learn & try to apply theories with too little investigation or interest in the real world. I'm going on memory, so wording might be a little off, but it feels like her view could be described as them lacking humility when it comes to recognising application of knowledge is different to learning it.

Not having worked in healthcare, perhaps it's similar in having that difficulty? Relying too heavily on education and general truths, and not enough on specifics learnt from individuals? My ignorant suspicion is perhaps, because health care depends on science, people think they're dealing with facts & don't have to listen .. which I feel is a big mistake because real people & bodies can vary unexpectedly in ways that matter

There's got to be an element of learning, but perhaps the "humility" (still hate that word) is just taking an individual approach, for example, looking at women's need for counselling, some women may think it's really important that the counsellor shares their own culture, but some women from the same culture have reasons why they only want to speak to somebody outside it. You could have one without the other, but trying to enact cultural humility, without some knowledge would be pretty exhausting for both parties. Although to me, cultural competence does imply not just knowing, but putting it into practice in an appropriate way. TBH, one of the things I often roll my eyes at is the perpetual concern with language, and what to call things that actually has absolutely no meaning whatsoever to the people that they're talking about and makes eff all difference to anything in practice (e.g. national charity sector...).

author of the book donut economics…apply theories with too little investigation or interest in the real world

Yes, it looks like an area in some disciplines where people are apprehensive about being criticised for epistemic trespass. I can see how that happens when economists (say) branch out into nudge theory (e.g., policy, markets, or individuals) or behavioral modification.

There are interesting multi-disciplinary crossovers but, in general, it's something where people are wary. The final 2 lines of this capture the source of the wariness:

Epistemic trespassers are experts who pass judgment on questions in fields where they lack expertise. What's wrong with epistemic trespassing? I identify several limitations with a seminal analysis to isolate three desiderata on an answer to this question and motivate my own answer. An answer (i) should explain what's wrong in the cases that motivate inquiry into epistemic trespassing, (ii) should explain what's wrong with epistemic trespassing even if trespassers do not acknowledge their trespassing, and (iii) these explanations should not be independent of the fact that epistemic trespassing involves expertise. I also independently motivate a fourth desideratum: (iv) this account should explain the evaluative difference between different kinds of trespassing. To satisfy these desiderata, I develop a social analysis: epistemic trespassing is wrong because it is an abuse of expert authority that neglects novice vulnerabilities.

DiPaolo J. What's wrong with epistemic trespassing? Philos Stud. 2022;179(1):223-243. doi: 10.1007/s11098-021-01657-6. Epub 2021 May 19. PMID: 34024942; PMCID: PMC8131877.

The next part of this got too long so I'm posting it below.

The No Stupid Questions podcast has some interesting discussions threaded through the episodes about differences in assumptions between psychologists and economists. Surely by disciplines being combined ultimately it helps learning. Where is the boundary between useful cross-fertilisation and stepping on people's toes? Or is this just an example of people being precious over their own viewpoint?

I've been looking at some treatment pathways for substance use disorder (SUD). And in the same way as there broadly seem to be different life histories that lead up to involvement with the criminal justice system (CJS) and how men and women are detained or imprisoned, this seems to be true for SUD.

However, as far as I can see, a lot of the CJS diversion or health/social care treatment pathways seem to be built around the (perceived?) needs or preferences of men. I checked the literature and there's a fair amount of discussion about "gender differences" (I think they mean sex) in both active addiction and in the recovery process. But, that's not apparent to me when looking at the available treatment services.

E.g., a recent pilot

The National Police Chiefs’ Council (NPCC) said: “Anecdotally, the use of cocaine and alcohol have been highlighted as exacerbating factors in domestic abuse offences, and the results from pilots in seven police forces have demonstrated significant evidence to support this.”
In one area, nearly 85 per cent of domestic abuse offenders who were tested after arrest and were positive for cocaine and overall across the pilot forces, 59 per cent of those tested were positive for cocaine.
Mark Lay, NPCC drugs coordinator lead, said: “Violent behaviours are clinically associated with cocaine use so while the results of the pilots are not particularly surprising, the high percentage of offenders testing positive was more than we had anticipated.
“We know there are many reasons behind domestic abuse offending, and drug use, while not a causal factor, can make it more extreme or frequent. These pilots help us to develop a more detailed picture of perpetrators to safeguard victims and potential victims.
“The results also show how shockingly widespread the use of cocaine is in many communities, which could indicate the need for legislative change and mandatory drug testing on arrest for a much wider array of offences.”
Assistant Commissioner Louisa Rolfe, NPCC lead for domestic abuse, added: “It wouldn’t be right to say that drug use turns anyone into an abuser, but we do know it can make existing offenders behave in a more extreme and aggressive manner.
“This evidence around the links between drug use and domestic abuse offending can help us to better manage perpetrators and protect victims, building on our work around perpetrator profiles.
“It also enables us to identify opportunities for drug treatment services in perpetrator programmes which could help prevent reoffending.”
However, Farah Nazeer, chief executive of Women’s Aid, said it was important to remember that drugs do not cause domestic abuse.
“Domestic abuse is driven by the perpetrator’s desire for power and control, as well as by the inequality between men and women, and it is important to remember that drugs, including cocaine, do not cause domestic abuse,” she said.
“However, as demonstrated by this study, there is a link between domestic abuse and drug use, which can make pre-existing violence and abuse more severe.
“This study highlights that we need to understand how other forms of harm, such as drugs, interlink with domestic abuse – and how this can help improve protection and support for survivors.”

https://www.policeprofessional.com/news/police-pilots-find-high-levels-of-drug-use-in-domestic-abuse-offenders/

There's a lot of diversion and court-ordered rehab and recovery work in every CJS. Sustained recovery seems to vary by sex and the enablers and barriers seem as if they might be different.

This is among the reasons why I wondered if anyone here had seen information about treatment and recovery services that is a good example of cultural competence/humility/personalisation whatever the useful descriptor would be.

Have you seen the Corston Report and various things that came out of it? Not specifically around substance misuse but raises that issue about previous pathways being male-focused.

@RethinkingLife Epistemic trespassers came up in donut economics. In the case of economics, she argued that the definition of what economists and economics should be concerned with had narrowed, and she was critical of this. I borrowed it, only reading once, so I can't elaborate. I'm wary of being too religious about avoiding trespassing, caution is reasonable tho. I think everything intersects with any number of domains, some seemingly unexpectedly so.

Awareness of cultural differences came up in interaction/user interface design when I studied it. This isn't wrt language & images which is obvious, but other aspects of design. Much of it, in my view, feels more like guidelines than rules and shouldn't be a substitute for prototypes, testing & feedback

I was thinking about similar issues yesterday when I watched part of teh Netflif programme again which is about first cousin marriages. The Indian middle class interviewer went up to Bradford. The science cannot be disagreed with but not everyone interviewed accepted it and plenty thought the risks were fine and worth taking for the advantages of knowing the inlaws. I thought the British Indian interviewer did a very good job at asking relevant questions without upsetting people so much they would refuse an interview.

The bottom line for me is that we - tax payers with the highest tax burden in 70 years have to pay for the massive number of resulting disabled children who cost £250,000 each child a year apparently! So may be we need a first cousin marriage financial bond deposited before people go off and take that risk for which the rest of us would be paying - although of course going back a good while the European royal families certainly went in for an awful lot of similar incest like marriages with similar results.

More generally on the thread if the healthcare worker listens to the patient then that's wise . I don't think you have to be humble if the patient believes a load of rubbish and your knowledge is superior however. We are allowed to call a spade a spade in the UK.

@RethinkingLife Sounds like the criminal justice system might have the same sex bias that's been found in medicine & healthcare. What you quoted goes to great lengths to avoid any references to sex and differences between them, which probably doesn't help. You have to do that before you can begin to look at the idea of different responses depending on sex

interviewer did a very good job at asking relevant questions without upsetting people so much they would refuse an interview.

In a Louis Theroux sort of non-offensive way but without the faux naivety? Slightly OT but skilled interviewing is an art form and I haven't seen the programme. Was it about (congenital) genetic conditions?

Was the interviewing from a placed of shared cultural understanding (competence/humility/curiosity in context of this thread) or something else? E.g., I've no idea if interviewer was

• neutral
• motivated to explore from ethical/scientific perspectives.

great lengths to avoid any references to sex and differences between them

Yes! Not until the Woman's Aid comments and even then it was almost an aside.

NB: there's a fair amount of data to support the argument that millenial women and other age groups of women are using cocaine more (and it's showing up in ONS data).

However, I'm not seeing that reflected in tx pathways.

And, this is where it would have enormously useful if the people who ran the pilot study above had released the sex dis-aggregated data. E.g., among X of arrests, Y and Z were men | women and A% and B% are those that tested positive for cocaine | cocaine + alcohol.

It is a slightly old UK programme about first cousin marriage I watched in a full a year or two ago. It is was nicely done to bring forth answers and it was good to hear the views of the families etc if only 1 in 100 or 3 in 100 children are disabled as a result but in 100% of hte cases the families know each other as the couple share grandparents the view of the families is that the benefits well outweigh the risks - definitely a valid point of view and indeed the same one (without the medical knowledge) of the European royal families in the 1800s in Europe and indeed probably back to the 1600s and earlier.

I know nothing about this humility/feminism issue, but the interviewer was respectful and drew forth answers. Only one or two white local doctors/MPs were prepared to be interviewed as everyone else thought they would be accused of being racist or saying the wrong words when talking about first cousin marriage.

I do think it is common sense that if you want to bring anyone over to your own point of view or at least listen to medical advice it is a good idea to hear their side of things. Some interviewed did not agree with the genetic science around this issue and some (those who had a better education) knew the science but thought the advantages outweighed the disadvantages and quite a few young Bradford people with parents from the Indian subcontinent thought first cousin marriage was just a force marriage route for families emotionally to blackmail teenagers to marry young and hate it and thought it felt yucky and incest-like.

I thikn it depends on the cultural issue as to how healthcare experts should handle an issue. My piano teacher (white british) was Christian scientist religion (no medicines ever - she lived into her 90s!) which always fascinated us as children of a doctor. I think she made an informed choice which is her right.

It is probably quite hard for NHS professionals to have to deal with people who have different views.

Where is the boundary between useful cross-fertilisation and stepping on people's toes?

Perhaps it's not epistemic trespass in the academic sense but I admit to being irritated when people form an impression after a relative 5mins exposure to the topic and then rock up on FWR to establish themselves as the voice of rationality who is ready to explain when various posters (with extensive experience and knowledge) are going awry.

In healthcare terms, it's certainly not uncommon to have a lot of people consider that they know better than people with experience in the particular field. And, yes, there are definitely times when the lack of openness and cross-fertilisation has led to ill health | death (e.g., missed diagnoses for cardiac episodes in women) and an over-eagerness to under-treat pain because of the default assumption that some people/groups tend to

• overdramatise their distress
• be drug-seekers.

I think pain is a really hard thing to assess, both when you are feeling it and as someone listening! I find it hard enough communicating pain that I feel. 8/10 to me might be 5/10 to someone else, and it could be for any number of reasons. I might genuinely be more or less sensitive biologically, I might just be inexperienced with severe pain, or something else. Even if a professional knew, objectively, that might still go down badly

In healthcare terms, it's certainly not uncommon to have a lot of people consider that they know better than people with experience in the particular field

But often they do because consultants know broadly about something but they may not know the specific details relating to an individual case or how a condition links with co-morbidities or even is affected by something as common as the menopause! I may be relatively unusual in that I read the medical journals, but a good doctor would engage with what the patient knows and try to establish whether actually the patient does know more than them about something. There's plenty of cutting edge research, for example around the microbiome or neuroscience, that hasn't reached most of the NHS, one journal paper I read estimated that it takes 20 years for research findings to actually become practice.

But often they do because consultants know broadly about something

I was more thinking about epidemiologists during COVID-19 who learned that, overnight, an extraordinary number of people with no background at all suddenly understood the area better than they did.

Ditto, Dave Gorski who is a breast cancer researcher and surgeon (blogs at SBM; emphatically TWAW). I've never forgotten a piece in which he discussed patients with fulminating breast ca who decided to opt for Gerson therapy rather than recommended surgery plus a mix of drugs and radiotherapy. Their choice but he was truly horrified by their suffering.

it takes 20 years for research findings to actually become practice.

It certainly can and has. However, COVID-19 demonstrated that some research findings could be implemented almost overnight. E.g., the use of dexamethasone after the publication of the RECOVERY trial results.

Various regulatory bodies are now looking to build on this by scrutinising regulatory processes and other barriers to bring well-evidenced treatments to patients sooner.

It's difficult to address the difference between factors that influence a one-on-one conversation and to consider inclusive principles to address an unknown reader or to design a different treatment/recovery service.

In a clinical sense, it may matter. E.g. if someone is of particular ethnicity it can affect their health e.g. type 2 diabetes is frequent in south Asian populations and this is related to diet.

Ms Fulani had come to a Buckingham Palace reception in order to cause trouble. I suspect she wanted to corner the Queen, but the system requires that someone else does a 'vet' first, mainly so HMQ can talk about appropriate things. Ms Fulani had arrived in a Nigerian costume (or attempt at) and thus was open to questions such as 'where are you from?' esp as this was a multi-ethnic and Commonwealth gathering for women's rights groups. Woman was wearing a recording device. She is a racist who tripped up someone who was doing the job they were paid for, and made political capital out of it - it rebounded when the truth emerged.

I have 2 friends who hate being asked this question, because the answer is never straightforward. They both are mixed race from European countries so have brown skin and a foreign accent. ‘France’ is rarely an acceptable answer if you aren’t a white person.

Jesus.

'attempt at a costume'

Do you know that second/third generation Nigerians wear traditional/traditional style outfits.

She was asked "where are you from."

Told an answer.

Then the woman said. No. That's not true. You are not from here. Where are you really from.

That's the person you think is in the right?

It is a slightly old UK programme about first cousin marriage I watched in a full a year or two ago.

I've found it on YT so I'll watch it. It would be good to have a sense of how very difficult topics can be discussed in a manner that maintains dignity and respect for all of those involved.

type 2 diabetes is frequent in south Asian populations

It would be worth me looking to see if there are written materials or public information that addresses this in a useful way.

It seemed pretty obvious looking at the transcript that she was being asked her ethnic origins, which was pretty logical given the context of the event which was an international gathering. She adopted the traditional clothing of a particular people, and had changed her name to reflect that particular people, but supposedly it's an attack when someone asks about the connection?