CULTURE AND CULTURAL HUMILITY
Critical issues related to conducting CBPR with racial/ ethnic minority communities are consideration of culture and approaching the research with cultural humility.
Culture has been defined as “the way of life, especially the general customs and beliefs, of a particular group of people at a particular time.”13 Culture provides implicit and explicit guidelines that people use to interact with others and with the world around them.14 Misunderstanding and misinterpretation can occur between cultures because of the differences in behaviors, attitudes, and symbols and the meanings people attach to words.15
Because of increasing racial/ethnic diversity in the United States, many researchers and authors have described the importance of cultural sensitivity in research. While CBPR contains processes that, if carried out appropriately, should lead to findings that have integrated cultural beliefs, practice, and perspectives, it is still useful to follow recommended guidelines for increasing cultural sensitivity. Many of these have focused on the importance of self-evaluation and reflection as a necessary process.15
Bennet and colleagues describe the developmental model of intercultural sensitivity, a framework for how we can increase competence and sophistication in our experience and navigate differences when they are identified.16-18 The authors report that this process begins with three ethnocentric stages-denial, defense, and minimization. Here, one’s own culture is seen as central to reality. The process continues with three ethnorelative stages, acceptance, adaptation, and integration, in which one’s own culture is viewed in the context of other cultures.19
Airhihenbuwa and colleagues describe the PEN-3 model and posit that a requirement for working in another culture is to identify and embrace positive aspects of the culture.20 They describe three cultural domains in understanding the selection of priority populations and influences on health. These domains are cultural empowerment, relationships and expectations, and cultural identity. In a later report, Ford and Airhihenbuwa describe an analytic framework called critical race theory that can be used to understand racism as a factor influencing health.15-21-24 The theory describes the importance of considering the possible influence that race and racism have on health at multiple levels (individual, interpersonal, community, societal) and advocates understanding these from the perspectives of the racial/ethnic group.15
While the concepts of cultural sensitivity and cultural competence certainly intend to convey a sense of the importance of understanding, respecting, and even celebrating culture within racial/ethnic groups, it is useful to think about cultural competency as a process rather than an attainable goal. Researchers must move beyond gaining knowledge about culture and include self-assessment of attitudes and behaviors when conducting CBPR, particularly when individuals belong to different racial/ethnic groups than the researchers. Even when researchers are of the same racial/ethnic group as the subjects, differences in socioeconomic status (SES), education, community history, geographic region, and many other factors may require careful assessment of one’s own beliefs and biases.
Because understanding and effectively interacting with racial/ethnic communities is a process, the concept of cultural humility may represent this perspective better than “cultural competence.” Tervalon25 and Tervalon and Murray-Garcia26 introduced the concept of cultural humility; they believed that healthcare professionals did not receive adequate training to prepare them to treat multicultural patients, and they pointed out that a competency-based approach to understanding culture is inappropriate because it is not possible to be fully competent and fully understand another culture.15-25-27 Hook and colleagues subsequently described this process-oriented approach as the “ability to maintain an interpersonal stance that is other-oriented (or open to the other) in relation to aspects of cultural identity that are most important to the [person].”28- p2 Researchers must also be aware of different roles and what they mean in terms of cultural and power differences.
The concept of cultural humility aligns well with basic principles and skills needed for good CBPR practice. To engage with ethnic/racial populations with cultural humility- researchers must understand their own biases and assumptions- cultural background, power dynamics, and their own roles in society. They must develop skills, attitudes, and processes that exhibit honesty, flexibility, transparency, respect, and self-reflection.29 Because researchers often work with multiple racial/ethnic groups, their ability to work effectively across cultures can allow the perspectives, strengths, and experiences of many groups to create powerful community change.15,30
Aligned with the principles of CBPR, cultural humility supports mutually beneficial relationships and a goal of reducing or eliminating power imbalances in research. Three main components to cultural humility are described by Tervalon and Murray-Garcia26 and later summarized by Waters and Asbill31: a lifelong commitment to self-evaluation and self-critique, fixing power imbalances, and developing partnerships with people and groups who advocate for others.31 The first is based on the assumption that we are never finished learning about another culture (or even perhaps our own) and therefore should be open, flexible, and self-reflective. It also underscores the importance of recognizing and being able to acknowledge that we may not know important aspects of cultures and how and why culture can influence the research process.
The desire to fix power imbalances is closely aligned with principles of CBPR and emphasizes the fact that while the researcher may have knowledge and training that the community does not, the community has information and lived experiences that are essential to understanding its problems and their solutions. The third component is the intention to develop partnerships with people and groups who advocate for others in order to make lasting change in communities and sys- tems.26 This piece underscores the intent of cultural humility to move beyond personal assessment and respect for cultural differences to include working together to make sustainable changes that improve communities.
Bartholomew and colleagues15 describe processes for preparing health promotion planners to work in multicultural settings. They underscore the importance of including community members in primary planning groups and in continuing the process of personal development to enable planners to work within and across cultures.15 Bartholomew and colleagues also advises against stereotyping based on culture. There are large variations among and within ethnic and racial groups and incorrect assumptions about beliefs or behaviors can obscure facts and inhibit researchers’ listening and learning, despite CBPR processes.
Since stereotyping or making assumptions about individuals and communities based on culture is not conducive to good CBPR, we have avoided including lists of “common cultural factors” for the groups we discuss below. Instead, we describe CBPR challenges, successes, and recommendations based on the literature and on our own work. We highlight experiences from research studies conducted with African Americans, Hispanics, Asians, and Native Americans, and specific lessons learned from each group. In many cases, there are common considerations across groups, such as the need to establish trust, as well as common recommendations for good CBPR practice.