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Title: Cultural Humility: People, Principles & Practices


Abstract: Cultural Humility: People, Principles & Practices is a 30 minute documentary that mixes poetry with music, interviews, archival footage, and images of community, nature and dance to describe what cultural humility is and why it’s needed. Cultural humility is introduced as a daily practice and resource for people engaged in collegial as well as hierarchical relationships to change organizational policy and build relationships based on mutual trust. Originally developed by physicians Melanie Tervalon and Jann Murray-García to address health disparities and institutional inequities in medicine, cultural humility is now used in public health, social work, education, and non-profit management to analyze the root causes of suffering and create a broader, more inclusive view of the world. More than a concept, cultural humility is a framework that contributes to the ultimate goal of working with all populations with a sense of equity and respect. The universal language of film serves to encourage audiences to examine power, privilege and stereotyping through the lens of interrelatedness and cooperation. Posted on YouTube to harness the power of the Internet, the film engages in a process of communal reflection that brings forward a range of voices, especially many young voices, to explore different aspects of cultural humility in this time when the U. S. population is growing, aging, and increasing in diversity.


Type of Product: Digital - image or multimedia


Year Created: 2012


Date Published: 11/1/2012

Author Information

Corresponding Author
Vivian Chavez
Associate Professor, San Francisco State University
1600 Holloway Ave.
San Francisco, CA 94132
United States
p: 5102907116
vchavez@sfsu.edu

Authors (listed in order of authorship):
Vivian Chavez


Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Allied Health, Medicine, Nursing, Public Health, Social & Behavioral Sciences, Social Work


What specific topics does your product address?

Access to health care, Advocacy, Community assessment, Community development, Community engagement, Community health , Community organizing, Community-based education, Cultural competency , Curriculum development, Diversity , Education, Faculty development, Institutional change , Interdisciplinary collaboration, Leadership development , Partnership building , Prevention, Public & media relations , Race & health, School-higher education partnerships, Social determinants of health, Social services, Workforce development, Community-based participatory research, Service-learning


Does your product focus on a specific population(s)?

Asian, Black or African-American, Immigrant, Latino/Hispanic, LGBTQ, Urban, Women


What methodological approaches were used in the development of your product, or are discussed in your product?

Arts-informed methodologies, Case study , Community-academic partnership, Community-based participatory research , Qualitative research, Interview


What resource type(s) best describe(s) your product?

Best practice , Curriculum, Documentary, Faculty development materials


Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

Cultural Humility: People, Principles & Practices is a 30 minute documentary that mixes poetry with music, interviews, archival footage, and images of community, nature and dance to describe what cultural humility is and why it’s needed. Cultural humility is introduced as a daily practice and resource for people engaged in collegial as well as hierarchical relationships to change organizational policy and build relationships based on mutual trust. Originally developed by physicians Melanie Tervalon and Jann Murray-García to address health disparities and institutional inequities in medicine, cultural humility is now used in public health, social work, education, and non-profit management to analyze the root causes of suffering and create a broader, more inclusive view of the world. More than a concept, cultural humility is a framework that contributes to the ultimate goal of working with all populations with a sense of equity and respect. The universal language of film serves to encourage audiences to examine power, privilege and stereotyping through the lens of interrelatedness and cooperation. Posted on YouTube to harness the power of the Internet, the film engages in a process of communal reflection that brings forward a range of voices, especially many young voices, to explore different aspects of cultural humility in this time when the U. S. population is growing, aging, and increasing in diversity.


2. What are the goals of the product?

The product aims to examine, document and disseminate specific knowledge and skills that re-imagine the health workforce through a lens of cultural humility. Cultural humility is a multi-dimensional concept based three principles. The first principle is lifelong learning and critical self-reflection. The second tenant is this notion that health professionals must recognize and mitigate the power imbalances inherent in the clinician-patient, service provider-community member, faculty-student classroom dynamic; finally, institutional accountability is integral to this process, as the institution must model these principles. The film was developed to train new health professionals as well as to support those who have been practicing for many years in the field. From a cultural humility perspective, the most serious barrier to culturally appropriate care is not a lack of knowledge of the details of any given cultural orientation but the failure to develop self-awareness and a respectful attitude toward other points of view and diverse ways of living. The goals of the product are to reflect upon and develop community capacity and individual resiliency. For example, community organizations, health departments, university professors and other stakeholders can use the film as a teaching/training tool to foster discussion around the concept and practice of cultural humility as a key ingredient in the health field workforce preparation.


3. Who are the intended audiences or expected users of the product?

The intended audiences for this video are health and social service professionals, students, faculty and staff, providers, organizers and policy makers in public health, social work, medicine, psychology, nursing and education. Expected users include on-line distance learning students, university professors, diversity trainers, and community based educators. Additionally, this tool may be helpful in cultural competence & diversity training to integrate cultural humility into program design, implementation, planning and evaluation.


4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

It is important for those facilitating workshops, courses and discussions using this film to reflect upon what Cultural Humility means to them at a personal & institutional level. The term emphasizes the need to gain a greater awareness of and sensitivity to our own worldview and the implications of our own group membership. Self-awareness, however, is only a preliminary stage in the process. A reflection on institutional practices, administration policies and service delivery is a crucial next step. It is important to provide a safe space where collegial relationships can develop and audiences can learn from each other about how to work with diversity and build relationships based on mutual trust. Using this educational tool entails making efforts to practice what the film describes.


5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

This film was inspired by the original article “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education” by Tervalon and Murray-García (1). While the concept of cultural humility is not new, best practices for teaching cultural humility remain unexplored. As McDonald and her colleagues vividly illustrate, visual arts offer important tools for research, teaching, and practice (2). A prior article by the author about video-making using community-based participatory research (CBPR) principles was used as a basis for producing Cultural Humility: People, Principles & Practices (3). In that article, the authors outline six steps on how to make a video using principles of CBPR: (a) engaging stakeholders, (b) soliciting funding and informed consent, (c) creation of shared ownership, (d) building cross-cultural collaborations, (e) writing the script together, and (f) pulling it all together: editing and music selection. Subsequent publications addressing curriculum development and the importance of cultural humility in community health and community partnerships (4, 5,6,7) as well as cultural humility as an essential tool in Community Based Participatory Research (8,9), the application of cultural humility to Child Welfare (10), Global Public Heath (11, 12) and Cultural Humility in higher education (13) were used as the context for this film.


6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

(1) M. Tervalon, J. Murray-Garcia (1998). Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education, Journal of health care for the poor and underserved, Vol. 9, No. 2. pp. 117-125.
(2) McDonald M, Sarche J, Wang C. “Using the Arts in Community Organizing and Community Building.” In: Minkler M, ed. Community Organizing and Community. Building for Health. 2nd ed. Piscataway, NJ: Rutgers University Press; 2004:346–364.
(3) V. Chávez, B. Israel, A. Allen, R. Lichenstein, M. DeCarlo, A. Schulz, R. Bayer, R. McGranaghand, “A Bridge Between Communities: Video Making and Community Based Participatory Research,” Health Promotion Practice, October, 2004, Vol. 5, No 4.
(4) Anderson J.J, Marvel K.L., Brezinski, Glazner C., Towbin M., Lawton S., (2006). Bridging the Gap: A Curriculum to Teach Residents Cultural Humility. Family Medicine 32(2): 97-102.
(5) Chang, E S, Simon, M, & Dong, X. (2010). Integrating Cultural Humility into Health Care Professional Education and Training. Advances in Health Sciences Education 1382-4996.
(6) California Health Advocates is the leading Medicare advocacy and education non-profit in California. http://www.cahealthadvocates.org/news/disparities/2007/are-you.html
(7) End of life care, Santa Clara University http://www.scu.edu/ethics/practicing/focusareas/medical/culturally-competent-care/chronic-to-critical-austerlic.html
(8) Ross, Laurie. (2010). Notes From the Field: Learning Cultural Humility Through Critical Incidents and Central Challenges in Community-Based Participatory Research. Journal of Community Practice, 18:315-335.
(9) Minkler, M. (2005). Community-Based Research Partnerships: Challenges and Opportunities. Journal of Urban Health, 82(2 Suppl 2), ii3-i12.
(10) Ortega, R. and Coulborn, K. (2012). Training Child Welfare Workers from an Intersectional cultural Humility Perspective: A Paradigm Shift. Journal of Child Welfare, Vol 90, No. 5.
(11) Miller, S. (2009). Cultural Humility is the First Step to Becoming Global Care Providers. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 38(1), 92-93.
(12) http://www.uniteforsight.org/cultural-competency/module10
(13) http://www.deanza.edu/equityoffice/cultural-humility.html
(14) L. Cohen, V. Chávez, & S. Chehimi, Prevention is Primary: Strategies for Community Well-Being, 2nd Edition, Jossey-Bass, San Francisco, 2010.
(15) V. Chávez, R. Turalba & S. Malik, “Teaching Public Health Through a Pedagogy of Collegiality,” American Journal of Public Health, July 2006, Vol. 96, No.7.
(16) UC Health Sciences Education, (2005). Workforce Needs and Enrollment Planning.
http://www.ucop.edu/hss/documents/healthsci_study.pdf
(17) Horowitz CR, Robinson M, Seifer S. Community-based participatory research from the margin to the mainstream: are researchers prepared? Circulation. 2009;119:2633–2642.


7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

  • For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
  • For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
  • For other types of work, discuss how the project was developed and reasons for the methodological choices made.

The product is the result of a larger body of work that adapted and integrated the concept of cultural humility to teaching and writing about public health:
1. The author has been teaching an introductory course in the Masters of Public Health program at San Francisco State University for the last 12 years that applies principles of cultural humility (15). Students and alumni from this course contributed to making the product and are featured in the film.
2. The author co-edited the textbook Prevention is Primary: Strategies for Community Well-Being and wrote a chapter titled “Community Organizing for Health and Social Justice” that expands upon the concept of cultural humility (14).
3. The author developed a summer seminar for the University of Colorado, School of Public Health Preventive Medicine Residency Program titled, “Cultural Humility in Public Health Practice” in 2010 that was evaluated as integral to a public health curriculum.
4. The author designed and implemented a qualitative study and video production process titled “Cultural Humility: reimagining California’s health workforce” at San Francisco State University” July 2011-July 2012 as the context for this film.

These experiences motivated the author to create a product beyond the traditional manuscript for publication. With the growth of digital technology, distance learning, Facebook and YouTube, new points of access for scholarship, teaching and service have been opened. While education and training in social determinants of health are vital to develop a culturally appropriate public health curriculum, knowledge alone is not enough. Increasing awareness of the effect of race and ethnicity on health outcomes raises questions about how to teach and prepare future health professionals to work with diverse populations (16). “Teaching Public Health with Collegial Pedagogy” (15) shifts the focus from a biomedical focus on illness and disease to an explicit language of social justice, introspection and human rights. Furthermore, teaching “Cultural Humility in Public Health Practice” provided rich data from student course evaluations, i.e.: “All health professionals should be required to take a course like this one.” “I really appreciate and agree with the idea that cultural humility is a lifelong learning process rather than a one-time seminar.” “Learning how to continuously evaluate, critique, and improve oneself is infinitely more valuable than learning a set of cultural norms and commonalities.” “This class deals with how Public Health workers can penetrate the community and work with the public to effect changes that will improve the health of the people.”

In 2011, San Francisco State University funded the author to examine the principles and practices of cultural humility with the idea of producing a documentary film. This creative project was based on interviews with key informants from the fields of public health, health care, education and community non-profit agencies. In addition, San Francisco State University MPH students as well as undergraduate students were interviewed. Faculty and staff participated in an informal survey about cultural humility in faculty development. The following learning outcomes for the film were developed jointly between the authors and the stakeholders interviewed at different stages of the production process:

1. Define Cultural Humility as a philosophy and approach.
2. Examine privilege, power, prejudice and the limitations of stereotyping through the use of music, poetry, dance, photography, interviews and commentaries from health professionals, students and community members.
3. Understand the historical context of the term and basis of the practice.
4. Reflect upon how health and social service providers, researchers, and educators can integrate attention to culture into their daily practice.
5. Discuss institutional accountability, i.e.: identify how organizations can build a work culture in which everyone is valued and contributes fully.
6. Name the values, vision, and group agreements for multicultural collaboration within health, education and social services systems.
7. Recognize and challenge power imbalances. Develop mutually beneficial partnerships based on mutual trust and respect.
8. Observe the impossibility of cultural competence when working within the dynamics of race, class, sexual orientation, gender, social inequality, institutional and interpersonal power and privilege.


8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

From the initial stages of film production the authors of the original article about Cultural Humility (1) were consulted. Dr. Tervalon agreed to be a full contributor for this project from the onset. She was interviewed on and off camera at various community events and training opportunities during the preproduction period. Through her leadership, we recruited various members of the Multicultural Curriculum Committee from Children’s Hospital. These community partners provided a historical context that served to ground the film in a very specific time in American history. In April 1992, in the wake of the Los Angeles riots following the initial not-guilty verdict of the police officers accused of beating Rodney King, The Children’s Hospital Oakland community was compelled to meet in a series of highly charged sessions to expose and critique their own patterns of institutional racism, injustice and inequity. The Multicultural Curriculum Committee at Children’s Hospital Oakland was formed to bring in the community voice into medical education and diversity training. This committee reunited twenty years later for the production of the film, April 2012 and provided guidance, permission and social context. Furthermore, they directed the author to nonprofit community organizations that use the principles of cultural humility in their delivery of services. In addition to the Multicultural Curriculum Committee, the Berkeley Media Studies as well as the Labor-Occupational Health Project, Chinese Progressive Association, San Francisco State students and alumni were involved in the project from conception to completion as collaborators.

Specific Actions and Timeline
The product was developed in two phases: (phase 1) research into the topic of cultural humility as a tool for workforce development and (phase 2) production of the video.
Questions below were asked of students, faculty and community members in individual interviews as well as two focus/community interviews.
1. When did you first hear of “cultural humility” and/or what does this term mean to you?
2. To what extent do you integrate attention to culture/diversity into your work?
3. To what extent to you see/hear other health professionals integrating attention to culture/diversity into their practice?
4. How is your organization building a work culture in which everyone is valued and contributing fully?
5. What are the values, vision, and group agreements for multicultural collaboration within your organization?
6. Are people within your organization engaging in courageous conversations about power and privilege? Do they integrate cultural humility into their work?
7. How often do you think about power dynamics when you do your work? What kinds of things do you do to shift the power imbalance inherent in your practice?
8. How often do you reflect on your own privilege & power and the role it plays in your practice? What things do you do to reflect?
9. What types of professional development have you received to assist you in thinking about some of the issues raised in the above questions?

Not every person interviewed was video-taped. Some interviews served only in an advisory capacity. An initial treatment/storyboard was developed by the author with the collaboration of the film editor and videographer, Jun Stinson. The treatment/storyboard was reviewed by Dr. Tervalon who communicated the intentions of the project to the Multicultural Committee for input and feedback. The committee’s feedback led to subsequent and different ideas for video production, further interviews and editing changes. The first screening included a new set of stakeholders who included technical expertise in order to make the film accessible to broader audiences. This new community represented people who are not health professionals but have an interest in issues of culture, health disparities, community partnerships and social justice. These stakeholders provided invaluable feedback that made the product accessible to those who had never heard of cultural humility as well as to those who are well-versed in its application and open to new learning tools on this topic. Another person who provided comprehensive feedback in various stages of video production was Rachel Poulain, MPH, documentary film producer at the SFSU Health Equity Institute and Lecturer in the Cinema Department where she teaches a course in Documentary Filmmaking for Health and Social Justice. Poulain was associate producer and director of outreach for the award-winning documentary series “Unnatural Causes: is Inequality Making Us Sick?” Her input was an invaluable asset for the product.


9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

Cultural Humility: People, Principles and Practices, is available in the public domain with a Creative Commons License that makes it available to use completely free of charge for educational purposes. Within minutes of being placed on You Tube the product was available for training and education throughout the U.S., Canada and worldwide. The film describes a set of principles that guide the thinking, behavior and actions of individuals and institutions to positively affect interpersonal relationships as well as systems change. These principles have never been outlined in a simple, practical form through stories of successes and challenges, and the road in between for those working to develop partnerships among community members, practitioners and academics. Also digitized into four segments, the complete documentary introduces the principles of Cultural Humility:
1. Lifelong learning and critical self-reflection
2. Recognizing and changing power imbalances
3. Developing institutional accountability
and features interviews with original article co-authors Melanie Tervalon and Jann Murray-Garcia as well as offers the context and setting by Multicultural Curriculum Committee members. The application of Cultural Humility to Community Based Participatory Research as well as to Teaching Public Health features the work of the Chinese Progressive Association, the Labor Occupational Health Project as well as faculty, students and alumni from San Francisco State University. A discussion on unexamined privilege by Berkeley Media Studies director, Lori Dorfman, complements poetry readings on contemporary issues. The last segment brings closure with a reflection on peace, embodied images of nature and an inspirational quote by Audre Lorde. Within the first few weeks the documentary was seen by over 1000 viewers and shared through various social networking sites. Most recently, excerpts were shown to Associate Deans of Public Health at their annual retreat to introduce “High Tech, High Touch” approaches to Teaching Public Health. Critical feedback received via e-mail points out the value of the product as well as the importance of stories of empowerment, leadership and partnerships in action that hold decision makers accountable.


10. Please describe why you chose the presentation format you did.

Documentary film offers important tools for research, teaching, and practice. The cultural diversity, personal sensitivity, and passion that characterize visual arts resonate with key principles and commitments of public health, such as the need to foster a high level of community participation by involving participants in all aspects of community assessment, planning, implementation, and evaluation. The arts can be vehicle for documenting findings and disseminating results for educational purposes and to influence policy (2). Furthermore, through the creation of a documentary film, participants who have not been involved historically in research, education and interventions have the opportunity to literally be “in the picture” expressing their contributions, assets as well as their concerns. Using film can generate curiosity and compassion as well as create stronger ties between and among diverse populations. (3) Community members, student and university partners continue to collaborate in this project through film screening events, distribution of DVDs, and online video sharing. Lastly, the use of image, music and text offers new possibilities for transformation, inclusion and change. As McDonald and her colleagues point out, “Whether in the virtual or physical world, the arts also promote health through the development and expansion of social support.” In particular, more collaborative arts such as film create a common reference point. “The arts can give voice to the heterogeneity of urban populations, breaking down barriers in the process. The arts can be used effectively to express and respect diversity in a process that can weave unity among the community’s different threads.” (p. 292)


11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

The greatest strength of the film was its low cost and wide reach. This project and product were the result of San Francisco State University’s Office of Sponsored Research Scholarship and Creative Activity Awards. The author was released from teaching a course for one semester and given approximately $8,000 to fund the videographer/editor, original musical score and sound technician. Students, community and academic collaborators volunteered their time, provided feedback and participated in interviews as well as viewed preliminary drafts of the product. The video included primarily health professional women of color from the SF Bay Area. At different points in the process, the idea of interviewing more men came-up. This idea was discussed and given consideration by various community members. It was agreed that given that the authors of the original article about cultural humility are African American women and given the diverse population of students and alumni at SF State are female, that the video accurately represents the community from which it came out of. Even though the focus of the film was not any specific population, a viewer raised the issue regarding lack of representation of Native American voices. While it is important to acknowledge indigenous knowledge from many traditions, it is also critical to point out the lack of an international perspective. In this global economy it is especially important not to be strictly U.S. centered, particularly with the wide reach of digital technology and opportunities to study/work abroad. Lastly, the concept of “cultural pride” including gay/lesbian pride could have been explored in further detail.


12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

Film production was conducted in a collaborative fashion using CBPR principles as outlined for documentary film (3). IRB approval from San Francisco State University was obtained. Ethical considerations were taken during all stages of the video-making process. Every person in the film signed an informed consent form; photographs and images included in the film were obtained with permission and given proper credit. The primary collaborator, Melanie Tervalon reviewed this manuscript and is aware that the author submitted the product to CES4Health as a single author. Having a singular author was decided because this was not a traditional research project and the author did the entire writing of this manuscript. The issue of authorship, credit and the writing priorities has been an important topic of discussion for CBPR projects (17). Community based participatory research seeks to disseminate findings and knowledge gained to all partners involved, in language that is understandable and respectful, and where ownership of knowledge is acknowledged. Authorship in film has been a persistent theme in the field of cinema studies. It is important to note that artistic and technical perspectives came from multiple sources. Not only would it have slowed the process considerably to include all stakeholders in the writing process, it also assumes that writing a manuscript is a priority for all community members involved. Other forms of inclusion in the dissemination process were chosen, including providing all stakeholders with a DVD copy and links to the complete film as well as the four separate segments. SFSU students that contributed original poetry/commentaries where provided unedited segments and invited to upload these on YouTube for wide distribution. Lastly, every person who was interviewed as well as the videographer/editor and director/producer has the right to use the product and trusted to write about their particular involvement in the project.