Cultural Humility: A Critical Step in Achieving Health Equity

Disparities in child and adolescent health persist despite advances in health care policy, delivery, training, and research. In this issue of Pediatrics, Okoniewski and colleagues discuss how “growing awareness that providing culturally sensitive pediatric primary care, especially during well-child visits, is a potentially modifiable way to address health care disparities and promote health equity.”¹  The authors provide a synopsis of the existing published literature related to culturally sensitive interventions and highlight how the majority of interventions were studied as pre-post evaluations, focused primarily on Hispanic populations, and only a few conditions, including obesity and depression. The studies also had limited focus on other structural factors that contribute to a person’s cultural identity. These findings are concerning given that the United States is becoming more diverse, with demographic trends showing minoritized populations becoming the majority by 2045.^2–4  Children of color (classified in United States census data as American Indian/Alaskan Native, Asian, Black, Hispanic and Native Hawaiian/other Pacific Islander) comprise 49.8% of the estimated 73 million children, most of whom are <5 years of age.⁵  In 2019, of the 10.5 million children living in poverty, 71% were children of color, primarily of Hispanic descent.⁵  These statistics underscore the importance of being culturally conscious and providing culturally sensitive pediatric care. We must develop holistic interventions that address cultural identity including the intersection of gender, class, sexuality, and religion in addition to race and ethnicity.

One of the challenges highlighted in this review is the lack of uniform terminology for culturally sensitive interventions. The authors used 14 different phrases to identify research articles pertaining to cultural sensitivity in pediatric primary care. They use the definition of culturally sensitive care as “the delivery of care within the context of appropriate physician knowledge, understanding, and appreciation of cultural distinctions.”⁶  This definition assumes that health care professionals can learn a quantifiable set of attitudes and communication skills that will allow them to work effectively within the cultural context of any patient they encounter.⁷  Caution should be exercised in attempting to provide a narrow definition that inadvertently homogenizes cultural diversity, distilling it down to something that is digestible and acceptable to health systems but that falls short of its intention. An alternative concept is one of cultural humility, which incorporates elements of self-questioning, immersion into an individual patient's point of view, active listening and flexibility, which all serve to confront and address personal and cultural biases or assumptions.^7–9  Demonstrating cultural humility frees health care 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.

The authors and other researchers posit cultural sensitivity may improve physician-patient communication and collaboration, increase patient satisfaction, and potentially enhance adherence, improve clinical outcomes, and reduce health disparities.^10–12  However, as Okoniewski and colleagues highlight, there is scarcity in breadth and depth of existing literature that addresses culturally sensitive interventions in pediatric primary care. There is a notable deficiency of research tackling the array of medical, developmental, social, and emotional issues that primary care providers address daily. For example, there was a paucity of culturally sensitive interventions related to vaccinations, a central component of pediatric primary care. Both the successes and failures that target vaccine uptake in certain communities could lend insight into the current issues of vaccine hesitancy in the COVID-19 pandemic that predominate in certain communities and lead to disparities in rates of vaccine-preventable illnesses.

One current strategy that health systems and educational institutions are leveraging to reduce such health disparities is addressing the role of implicit bias and structural racism. In response to mandates from accrediting bodies, medical schools in the United States have developed various curricula incorporating elements of cultural competence.³  However, midlevel and senior physicians, leaders, interprofessional collaborators, and health systems must fully participate in the effort to transform current practices. We should also highlight and create system-wide incentives for change. One way to optimize the ability to conduct innovative culturally sensitive research is to build the infrastructure to allow categorization and collection of race and ethnicity, sexual orientation, religious affiliation, language, and socioeconomic characteristics in a safe and ethical manner. This would help to overcome a major hurdle of research into cultural differences in treatment uptake, effectiveness, and targeted interventions.

To begin to address these issues, health care professionals and health system leaders need to build trust between our patients and their families to foster better clinical interactions. This may mean initiating culturally humble, occasionally uncomfortable conversations with patients and families. Primary care professionals are on the front lines and are uniquely positioned to be leaders in developing and evaluating approaches to providing effective culturally humble care. One way to start is to develop a rubric for culturally humble care, which could start by asking about identity first (eg, what are your pronouns?), and by understanding the influence of social determinants of health, using active listening, and acknowledging one’s own biases.¹³  As we endeavor to create open dialogue and heal past transgressions, it is imperative that we work in partnership with our patients and their families, understanding that what characterizes that partnership will differ for each individual, even within similar cultures.