Working at an AIDS service organization (ASO) or community-based organization (CBO) that provides HIV care can require extensive scientific knowledge, practicing empathy, and balancing the needs of many clients who need support.
In my past work as a capacity-building specialist, I worked with providers at ASOs and CBOs across the U.S. to better understand and implement culturally responsive practices to meet the needs of clients who often did not share the same backgrounds as the providers responsible for their care.
Organizations often wanted to better address these provider-client power imbalances but felt like the work of “cultural sensitivity training” or “cultural competence continuing education” couldn’t seamlessly happen in the already time-strapped daily routines of their providers.
However, I have seen—both as a client of a CBO and as a provider—that how care is provided is as important as what care is provided. I’ve found that cultural humility can be a core, guiding framework to prepare HIV organizations to meet the needs in their community.
What Is Cultural Humility?
Melanie Tervalon, M.D., M.P.H., and Jann Murray-García, M.D., M.P.H., officially brought cultural humility as a framework into the research world in 1998. Their research focused on distinguishing cultural humility from more commonplace cultural-competence frameworks when it came to educating medical providers on how to appropriately incorporate culturally informed and responsive practices into their care.
“We were less comfortable with the term ‘competence,’” Tervalon says in a documentary on cultural humility’s history. “It implies that providers ... that you are then all-knowing and all-powerful. We felt like that was not what was happening to us as we were learning from community and understanding … [that patients] were not feeling heard.”
A competency framework mandates knowledge, training, and a belief that you can be “certified” in cultural understanding. However, a cultural humility approach necessitates introspection, appreciation, and lifetime learning. Because culture can be based on a variety of factors—ethnicity, religion, queerness, disability, and shared language, to name a few—and because it is dynamic, how can we expect our educational foundation for growth to be the same?
While cultural humility isn’t as rigid as competence-based approaches, the framework brings together a handful of core principles operating at three different levels. Researchers, providers, and community leaders have reinterpreted these core principles in many fashions, but they summarize to:
- Engage in self-reflection and lifelong learning
- Recognize and challenge power imbalances
- Model principles through institutional accountability
- Create and nurture respectful partnerships
These core principles operate at three distinct levels in order to practice cultural humility. They are:
- Intrapersonal: someone’s understanding of themself and their past experiences, beliefs, biases, and worldview.
- Interpersonal: how someone interacts with others.
- Structural: how organizations, systems, and other structural entities or forces create environments in which individuals experience access or barriers, power or disempowerment, violence or safety.
While providers who have completed cultural competence–focused continuing education may be familiar with concepts associated with the intrapersonal and interpersonal levels, ASOs and CBOs as organizations can create impactful changes at the structural level.
Focusing on Structural Cultural Humility
“Systems have their own cultures, and intrapersonal and interpersonal behavior and beliefs are affected by the systems in which individuals find themselves,” write researchers at Johns Hopkins University School of Nursing in a recent journal article. “Therefore, a systemic level of cultural humility is necessary to facilitate the seamless engagement and practice of intrapersonal and interpersonal cultural humility.”
This understanding is why activists know that removing “bad” cops to stop systemic racism won’t work—because policing as a structure is founded on racism and violence against Black communities. It’s why disabled people; Black, Indigenous, and people of color (BIPOC); elders; fat people; and people living with HIV formed the #NoBodyIsDisposable collective earlier this year, knowing full well that medical discrimination in COVID-19 triage would prevent marginalized people from being seen as a priority for lifesaving treatment, knowing that triage as a structure is inherently ableist, racist, ageist, and sizeist.
Even ASOs and CBOs can hurt, violate, and disenfranchise marginalized people. But when organizations commit to practicing cultural humility at the structural level through organizational accountability, HIV care can be far more responsive, community-focused, and of higher quality.
Cultural Humility Is Organizational Accountability
Cultural humility requires organizations to be accountable to the impact of their institutional biases and experiences on providing care. However, organizations may not invest fully into developing accountability measures for many reasons. Fear of the unknown or something new can be intimidating. Additionally, self-protection can lead to an attitude that differences between provider and client are not significant or that common humanity transcends our differences. Finally, the pressure of time constraints may lead to feeling rushed, creating an environment that prevents providers from looking in-depth at an individual person’s needs.
Committing to frame care work around humility does not provide room to excuse error; rather, it creates an expectation that the onus of “owning it” will be on the person or institution who has harmed, not on the person whom they have harmed. It provides clear expectations on how organizations respond to harm when it happens and how they change practices, policies, or procedures to prevent the harm from reoccurring.
Cultural Humility Is Better Quality of Care
From practice, we know that taking a stance of growth and introspection at the organizational level can influence policies and procedures that make or break an experience of care, especially when a client experiences oppression or is part of a group whose trust medical organizations have historically violated.
In committing to cultural humility, organizations can adapt their programs, policies, and procedures with client inputs and needs in mind. Actually listening and acting in accord with client feedback can improve the quality of care and demonstrate to your clients that they are more than a caseload to your organization—that they are the experts on their body and their care.
Beyond inked-and-signed policies and procedures, how and why an organization does its work can have lasting effects on the quality of care clients receive. Not practicing cultural humility can look like an organization’s mission centering white saviorism, leading to removing autonomy from Black clients. Chase Alston of Chase Brexton Health Care writes in this piece for TheBodyPro, “[Black] patients are no longer part of their own care team and are instead merely doing whatever is decided upon by their often white medical provider.”
Understanding and mitigating these power imbalances, whether in policies, procedures, or your organizational mission, can improve the care regardless of who you are serving.
Cultural Humility Is Organizational Long-Term Learning and Responding
You will notice this piece does not end with directives or recommendations but, rather, questions. Because cultural humility thrives on lifelong introspection and is as dynamic as culture itself, your organizations cannot begin the work simply by performing a directive.
Instead, start the conversation about structural level cultural humility by incorporating one of the following questions into your next team, leadership, or all-staff meeting.
How does the organization provide time and space for staff members to engage in self-reflection and continuing education?
What power imbalances exist in your organization? (Think power imbalances between management and direct service providers as well as those between providers and clients.) How does your organization challenge those imbalances?
What policies, procedures, or practices exist that make your organization accountable to clients? How does client feedback change policies or procedures?
Is your organizational mission centered around client empowerment? Why or why not?