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Promoting Cultural Humility in Global Health: Lessons from a Multi-institutional Community of Practice
Demand for experiential learning opportunities and internationalization in higher education, coupled with a growing interest in global health, has led to a dramatic increase in short-term experiences in global health (STEGHs) (Melby et al. 2016). Many of these experiences inherently involve students crossing international and sociocultural borders to engage in health-focused activities in health delivery or public health settings (Crump, Sugarman, and the Working Group on Ethics Guidelines for Global Health Training 2010). While global health experiences offer benefits to both students and the institutions sending them, these experiences are sometimes problematic and raise ethical challenges with respect to working with vulnerable populations (Lasker et al. 2018). The risks and potential harms of clinical STEGHs are well documented. In the short term, they can harm patients, host communities, and visiting students when students provide patient care beyond the scope of their training. In the long term, these experiences illustrate a suboptimal use of time and scarce specialized resources, thereby perpetuating global health inequities (Evert, Todd, and Zitek 2015; Melby et al. 2016). The dramatic increase in these global health experiences, coupled with the potential harms documented in the literature, makes rigorous evaluation especially important. Frameworks for ethical engagement and assessment of responsible, culturally appropriate student learning are now emerging.
Global health educators have proposed a set of overarching competencies for global health education (Jogerst et al. 2015) that align with the Association of American Colleges and Universities’ Global Learning VALUE (Valid Assessment of Learning in Undergraduate Education) Rubric (2014) and are informed by competencies from the American Medical Association, the American Dental Association, and the International Council of Nurses, among others. The competencies from these varied disciplines focus on collaboration, partnering, communication, ethics, health equity, and social justice. Leading scholars have called for additional research focused on “evaluation of these competencies across a wide range of educational settings” (Jogerst et al. 2015, 239). To address the risks associated with short-term immersive experiences, leading practitioners call for “skills building in cross-cultural effectiveness and cultural humility” as a core principle for ethically grounded global health educational experiences (Melby et al. 2016, 634).
Tools for Peer-to-Peer Learning
The Global Engagement Survey (GES) is a multi-institutional assessment that employs quantitative and qualitative methods to better understand relationships between experiential learning program factors—such as program duration, immersion in homestay families, and language courses—and global learning goals—such as increased awareness of conscious consumerism and openness to diversity (Reynolds et al. 2018; Hartman et al. 2014). The GES considers three components of global learning (cultural humility, critical reflection, and global citizenship) and uses eight scales and sixteen open-ended questions to measure these components (see figure 1 and table 1). The GES contains two scales that specifically explore cultural humility: (1) openness to diversity and (2) cultural adaptability (Reynolds et al. 2018).
Figure 1. The Global Engagement Survey considers three components of global learning: cultural humility, critical reflection, and global citizenship. (Click on the image to enlarge.)
Table 1. The eight scales of the Global Engagement Survey. (Click on the image to enlarge.)
Now in its fourth iteration, the GES is used and administered by the globalsl community of practice, a multi-institutional hub supporting ethical global learning and community-campus partnerships, hosted in the Center for Peace and Global Citizenship at Haverford College in Haverford, Pennsylvania. Twenty-eight institutions of higher education, operating 240 global learning programs, have used the GES to date. Through the GES, we (the coauthors of this article) have each participated in the globalsl community of practice as the research project director (Reynolds) and organizational/institutional partners (McCunney, Sabato, and Young).
Because it is a multi-institutional assessment effort, the GES enables partners to look across programs and consider possible differences stemming from variations in student populations, institutional cultures, and specific programming choices and opportunities. Programming choices may include the selectivity of the program, preparatory coursework or predeparture intensive retreats, English or non-English-speaking immersion contexts, fluency of students in the local language, etc. The GES was developed as a tool for continuous reflective improvement among practitioners working across programs at diverse institutions. This has led to shifts in curriculum and preparation of students, identification of program strengths, and changes to address areas that need improvement at an institutional level. In light of this collaborative assessment work, one of the standout areas for further development—with clear connections to global health education—is the notion of teaching and learning cultural humility.
Attention to Cultural Humility
The GES draws attention explicitly to cultural humility, which has been described as follows:
Cultural humility is a commitment to critical self-reflection and lifelong reevaluation of assumptions, increasing one’s capacities for appropriate behaviors and actions in varying cultural contexts. This capacity for appropriate, culturally relevant action is coupled with awareness of one’s positionality within systems of power and aligned in service of collaboratively reconsidering and reconstructing assumptions and systems to enact a deeper and broader embrace of shared dignity, redressing historic inequities. (Hartman et al. 2018, 96–97)
This concept also supports recent work assessing community partner perspectives. In a study that examined desirable competencies of visiting trainees, more than 170 host community partners expressed their concerns: “despite general satisfaction with and appreciation of outside groups, [their] concerns focus primarily on volunteers’ lack of cultural awareness and humility, leading to offensive behavior and attitudes of superiority” (Lasker et al. 2018, 4). For short-term global health experiences, then, cultural humility emerges as a primary objective for students—if not the most important learning component—with respect to predeparture and on-site programming, over and above goals like health-focused learning and acquiring medical knowledge.
This attentiveness to understanding cultural humility as a learning goal plays out in unique ways at our home institutions/organizations. In our varied contexts as a private midsized university, a large public university, and a third-party provider, we have applied the GES to inform programming, share existing resources, and leverage results to advocate for global learning priorities. For example, many academic programs at Quinnipiac University (QU) in Hamden, Connecticut, emphasize the value of becoming a culturally competent practitioner. However, after considering the literature and best practices around these experiences, QU’s Department of Cultural and Global Engagement decided to make intentional changes to predeparture preparation to highlight the importance of cultural humility. Faculty involved in international programs supported this change. This concept is now embedded throughout all phases of programming. Reflections shared in response to open-ended GES questions show the ways in which some of our students have engaged in consistent, critical self-reflection. One student shared, “I am really good at reading body language; however, I know that feelings typically run deeper than words or visual presentation. Therefore, I will never understand someone’s events that have taken place in their home country that have affected them and their families unless I ask and try to reflect and gain knowledge on their circumstances in a culturally aware way.”
Child Family Health International (CFHI) is a nonprofit organization that provides global health education programs to interdisciplinary health students at the undergraduate and graduate levels, and partners with more than forty academic institutions to offer faculty-led and other programming. As at QU, learning competencies for CFHI’s programs center around developing cultural humility, including understanding local cultural and healthcare realities, appreciating ethical issues when serving low-resource populations, and demonstrating professionalism and respect for local expertise when in global health settings. In order to foster self-reflection and build cultural humility, CFHI asks students to engage with predeparture tools such as the Global Ambassadors for Patient Safety (GAPS) workshop (University of Minnesota, n.d.) and GlobeSmart by Aperian Global (n.d.), as well as to reflect on their experiences while on-site, facilitated by global partners. Descriptive quantitative results from GES scales indicate growth among student participants in the two subconstructs that support cultural humility (openness to diversity and cultural adaptability). Student reflective comments are positive and nuanced, illustrating a measure of complexity in their learning process. After completing a program, one student expressed greater understanding of diversity among fellow colleagues, saying, “when working with my medical classmates, I try to be understanding about our different working styles and goals. I understand that our priorities are shaped by our backgrounds and our perceptions.”
Shaping the Field of Global Health Education
This collaborative assessment work through the GES affords multiple advantages. First, the collaboration helps build a dataset that can serve as a valuable leveraging tool. Ultimately, this effort relies on the adage that “what we measure is what we value,” because it not only provides specific information about programmatic efforts but also helps partner institutions and organizations create space for deeper reflection on how they educate students. Internally, the student responses help direct changes to the current curriculum and the development of new approaches for future programs, answering the question, “Are we achieving what we say we want to achieve?” The assessment data also serve as a leveraging tool so partners can benchmark their work with other experiential educators focused on broad global learning goals. This has the power to shape institutional culture around global programming. At East Carolina University in Greenville, North Carolina, for example, this assessment work serves as a guidepost for planning, helping to bring together seemingly disparate programs—both domestic and international, student-led and faculty-led, curricular and cocurricular—under the broad umbrella of global learning.
Next, the multi-institutional nature of this assessment effort is useful not only in shaping our home institutions/organizations but also in providing an opportunity to be part of a larger reflective community of practice to validate and critique one another. This collaborative approach breaks down artificial organizational boundaries and highlights the linkages between “program providers” and “sending institutions.” The value of this global learning assessment work, with its strong spirit of collaboration, lies in its power to enable partners to speak with a collective voice to achieve change. Our collective voice is stronger than our individual voices and provides credibility to our students, colleagues, and others within the field.
Lastly, this collaborative reflective essay is but one example of the kind of peer-to-peer learning opportunity that can grow the field of global health education and catalyze collaboration. As the intersecting fields of international education and development, service learning, and global learning have moved toward language centered around cultural humility, global health education needs to be at the forefront of this trend. As one student reflected, “I have learned that there are many people in the world that are smarter than me and will never have the opportunities that I have been given to grow. I acknowledge the power that I have been given strictly for reasons I cannot control. I will use that power to educate and empower.” The call for deeper reflection on global health outcomes like collaboration, partnership, and cultural humility “across a wide range of educational settings” (Jogerst et al. 2015, 239) serves as a sustained, always incomplete, challenge for all of us.
Aperian Global. n.d. “GlobeSmart.” https://www.aperianglobal.com/modes-of-delivery/globesmart/.
Association of American Colleges and Universities. 2014. “Global Learning VALUE Rubric.” https://www.aacu.org/value/rubrics/global-learning.
Crump, John A., Jeremy Sugarman, and the Working Group on Ethics Guidelines for Global Health Training. 2010. “Ethics and Best Practice Guidelines for Training Experiences in Global Health.” The American Journal of Tropical Medicine and Hygiene 83 (6): 1178–82. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2990028/.
Evert, Jessica, Tricia Todd, and Peggy Zitek. 2015. “Do You GASP? How Pre-health Students Delivering Babies in Africa Is Quickly Becoming Consequentially Unacceptable.” The Advisor, 61–65. https://www.nafsa.org/sites/default/files/ektron/files/underscore/2016colloquia/2016_health_gasp.pdf.
Hartman, Eric, Richard Kiely, Christopher Boettcher, and Jessica Friedrichs. 2018. Community-Based Global Learning: The Theory and Practice of Ethical Engagement at Home and Abroad. Sterling, VA: Stylus Publishing.
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Lasker, Judith N., Myron Aldrink, Ramaswami Balasubramaniam, Paul Caldron, Bruce Compton, Jessica Evert, Lawrence C. Loh, Shailendra Prasad, and Shira Siegel. 2018. “Guidelines for Responsible Short-Term Global Health Activities: Developing Common Principles.” Globalization and Health 14 (1): 1–9. https://globalizationandhealth.biomedcentral.com/track/pdf/
Melby, Melissa K., Lawrence C. Loh, Jessica Evert, Christopher Prater, Henry Lin, and Omar A. Khan. 2016. “Beyond Medical ‘Missions’ to Impact-Driven Short-Term Experiences in Global Health (STEGHs): Ethical Principles to Optimize Community Benefit and Learner Experience.” Academic Medicine 91 (5): 633–38.
Reynolds, Nora P., Benjamin Lough, Cynthia Toms, and Eric Hartman. 2018. “Global Engagement Survey.” https://compact.org/global-sl/ges/.
University of Minnesota. n.d. “Global Ambassadors for Patient Safety.” https://www.healthcareers.umn.edu/courses-and-events/online-workshops/global-ambassadors-patient-safety.
Dennis McCunney is Director of Intercultural Affairs at East Carolina University. Nora P. Reynolds is Director of globalsl.org; Fellow, Ethical Global Learning, at Haverford College. Erin Sabato is Director of International Service and Learning at Quinnipiac University. Robin Young is Managing Director at Child Family Health International.