The CARE (Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment) Model: Operationalizing Cultural Humility in the Conduct of Clinical Research
Abstract
:1. Introduction
2. Cultural Humility
It is a process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners. It is a process that requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care. And it is a process that requires humility to develop and maintain mutually respectful and dynamic partnerships with communities on behalf of individual patients and communities in the context of community-based clinical and advocacy training models [13] (p. 118).
3. CARE: A Model for the Integration of Cultural Humility into Clinical Research
3.1. Curiosity
3.2. Attentiveness
3.3. Respect and Responsiveness
Genuine conversation, and therefore every actual fulfillment and relation between men, means acceptance of otherness … Everything depends, as far as human life is concerned, on whether each thinks of the other as the one he is, whether each, that is, with all his desire to influence the other, nevertheless unreservedly accepts and confirms him in his being this man and in his being made in this particular way [32] (p. 59).
Buber continued,
Unlike the realm of experience, the I-You is unmediated: Nothing conceptually intervenes between the I and You, no prior knowledge and no imagination, and memory itself is changed as it plunges from particularity to wholeness. No purpose intervenes between I and You, no greed and no anticipation, and longing itself is changed as it plunges from the dream into appearance. Every means is an obstacle. Only where all means have disintegrated encounters occurs [29] (pp. 62–63).
that I cannot conceive I without conceiving Thee. So, in self-consciousness, the Other has transformed into Thou in a duality with I. So as far as self-consciousness means the unity of will, it has to create the union of I and Thou [33] (p. 514).
ethical action which turns the other man into Thou, the Mitmensch, it is the effective action for eliminating his suffering … In this correlation man constitutes the Other as Thou, but at the same time, constitutes himself as Thou for the Other: thus compassion is not a reflexive feeling of a constituted Ego who, by means of reduction of the Other to himself returns to himself, but it is ethical action, while taking up the suffering Other as Mitmensch constitutes himself at the same time in correlation … This process, then, is not only recognizing the similarity of the Other, but real production of man by means of an ideal process discovering in the diversity of Nebenmensch the similarity of Mitmensch inasmuch as he is simply Mensch [35] (pp. 137–138).
When a stranger resides with you in your land, you shall not wrong him. The stranger who resides with you shall be to you as one of your citizens; you shall love him as yourself, for you were strangers in the land of Egypt: I the LORD am your God [36].
a man of another tribe or district, who, coming to sojourn in a place where he was not strengthened by the presence of his own kin, put himself under the protection of a clan or powerful chief. From the earliest times of Semitic life the lawlessness of the desert has been tempered by the principle that the guest is inviolable. A man is safe in the midst of his enemies as soon as he enters a tent or touches a rope. To harm a guest or to refuse him hospitality, is an offense against honour which covers the perpetrator with indelible shame … The obligation thus constituted is one of honour, and not enforced by human sanction except public opinion, for if the stranger is wronged he has no kinsmen to fight for him [38] (p. 76).
3.4. Embodiment
[i]mplicit within the concept of embodiment is a sense of dynamism or constantly shifting meanings and understandings. Embodiment is experienced within particular historical, cultural, political and societal frames and these experiences are also shaped by gender and race [40] (p. 41).
What is essential does not take place in each of the participants or in a neutral world which includes the two and all other things; but it takes place between them in the most precise sense, as it were in a dimension which is accessible only to them both [44] (pp. 203–204). s
3.5. Applying the CARE Model
shorthand for bioethics at a conjuncture of experiences of decolonization and struggles over sovereignty and global circulatory capacities of human rights, biomedical research ethics, and medical interventions themselves … The concept of postcolonial bioethics captures how global health science is explicitly about relations, relations intertwined with other formations of vulnerability and responsibility” [49] (p. 238).
4. Discussion
- How and to what extent has the research team familiarized itself with the social, cultural, economic, and historical context of the proposed participants/participant community?
- How and to what extent do research procedures facilitate an examination of team members’ biases and values and their potential impact on the research participants and the course of the research?
- What stereotypes or assumptions about the study site and/or participants do the researchers bring to the endeavor?
- How have individual research team members who will have contact with participants or analyze data been trained to interact with participants and/or examine how their assumptions may impact their data interpretation?
- To what extent, in what way, and for how long has the research team engaged with the prospective participant community?
- What mechanisms have been put in place to reduce the power imbalance between the researcher and research participants and/or the participant community?
- Are the research protections and levels of participant remuneration responsive to participants’ concerns, as well as federal regulations and international guidelines?
- Are representatives of the participant community consulted for their input? In other words, do they have a seat at the table?
- Have the researchers considered the potential implications for participants as a result of their contact with team members, e.g., if there may be political or social repercussions from contact with foreigners? How will they manage this potential?
- Have the researchers developed adequate measures to protect the identity of the participants?
- Have the members of the research team designed the study in such a way as to be sensitive to local customs and mores relating to personal space and interpersonal communication?
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
- Hester, R.J. The promise and paradox of cultural competence. HEC Forum 2012, 24, 279–291. [Google Scholar] [CrossRef]
- Kirmayer, L.J. Rethinking cultural competence. Transcult. Psychiatry 2012, 49, 149–164. [Google Scholar] [CrossRef]
- Saha, S.; Beach, M.C.; Cooper, L.A. Patient centeredness, cultural competence, and healthcare quality. J. Nat. Med. Assn. 2008, 100, 1275–1285. [Google Scholar] [CrossRef] [PubMed]
- Hester, R.J. Culture in medicine: An argument against incompetence. In The Edinburgh Companion to the Critical Medical Humanities; Atkinson, S., Macnaughton, J., Richards, J., Eds.; Edinburgh University Press: Edinburgh, Scotland, 2005; pp. 541–558. [Google Scholar]
- Dean, R.G. The myth of cross-cultural competence. Fam. Soc. J. Contemp. Hum. Serv. 2001, 82, 623–630. [Google Scholar] [CrossRef]
- Isaacson, M.J. Clarifying concepts: Cultural competence or cultural humility? J. Prof. Nurs. 2014, 30, 251–258. [Google Scholar] [CrossRef]
- Yee, J. Whiteout: Looking for race in Canadian social work practice. In Multicultural Social Work in Canada: Working with Diverse Ethno-Racial Communities; Al-Krenawi, A., Graham, J., Eds.; Oxford University Press: New York, NY, USA, 2003; pp. 98–121. [Google Scholar]
- Taylor, J.S. The story catches you and you fall down: Tragedy, ethnography, and “cultural competence”. Med. Anthropol. Q. 2003, 17, 159–181. [Google Scholar] [CrossRef]
- Kools, S.; Chimwaza, A.; Macha, S. Cultural humility and working with marginalized populations in developing countries. Glob. Health Promot. 2015, 22, 52–59. [Google Scholar] [CrossRef]
- Kumagai, A.K.; Lypson, M.L. Beyond cultural competence: Critical consciousness, social justice, and multicultural education. Acad. Med. 2007, 84, 782–787. [Google Scholar] [CrossRef]
- Foronda, C. Cultural sensitivity: A concept analysis. J. Transcult. Nurs. 2008, 19, 207–2012. [Google Scholar] [CrossRef]
- Gibson, D.; Zhong, M. Intercultural communication competence in the healthcare context. Int. J. Intercult. Relat. 2005, 29, 621–634. [Google Scholar] [CrossRef]
- Tervalon, M.; Murray-Garcia, J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J. Health Care Poor Underserved 1998, 9, 117–125. [Google Scholar] [CrossRef] [PubMed]
- Masters, C.; Robinson, D.; Faulkner, S.; Patterson, E.; McIlraith, T.; Ansari, A. Addressing biases in patient care with the 5Rs of cultural humility, a clinical coaching tool. J. Gen. Intern. Med. 2019, 34, 627–630. [Google Scholar] [CrossRef]
- Loue, S. Diversity, Cultural Humility, and the Helping Professions; Springer Nature Switzerland AG: Cham, Switzerland, 2022. [Google Scholar]
- Grauf-Grounds, C.; Rivera, P.M. The ORCA stance as a practice beyond cultural humility. In A Practice Beyond Cultural Humility: How Clinicians Can Work More Effectively in a Diverse World; Grauf-Grounds, C., Sellers, T.S., Edwards, S.A., Cheon, H.-S., Macdonald, D., Whitney, S., Rivera, P.M., Eds.; Routledge: New York, NY, USA, 2020; pp. 8–25. [Google Scholar]
- Chang, E.; Simon, M.; Dong, X. Integrating cultural humility into health care professional education and training. Adv. Health Sci. Educ. Theory Pract. 2012, 17, 269–278. [Google Scholar] [CrossRef] [PubMed]
- Yeager, K.A.; Bauer-Wu, S. Cultural humility: Essential foundation for clinical researchers. Appl. Nurs. Res. 2013, 26, 251–256. [Google Scholar] [CrossRef]
- Jirout, J.J. Supporting early scientific thinking through curiosity. Front. Psychol. 2020, 11, 17. [Google Scholar] [CrossRef] [PubMed]
- Kuhn, D. What is scientific thinking, and how does it develop? In Blackwell Handbook of Childhood Cognitive Development; Goswami, U., Ed.; Blackwell Publishing: Oxford, UK, 2002; pp. 371–393. [Google Scholar]
- Hunter, D. The Incredible Pleasures of Knowing: Science and the Sense of Wonder. Available online: https://blogs.scientificamerican.com/rosetta-stones/the-incredible-pleasures-ofknowing-science-and-the-sense-of-wonder/ (accessed on 26 August 2022).
- Attentiveness. Psychology Dictionary. Available online: https://psychologydictionary.org/attentiveness/ (accessed on 7 May 2023).
- Attentiveness. Oxford Learner Dictionary. Available online: https://www.oxfordlearnersdictionaries.com/us/definition/english/attentiveness?q=attentiveness (accessed on 7 May 2023).
- Weil, S. Gravity and Grace, 1st ed.; Crawford, E.; van der Ruhr, M., Translators; Routledge: New York, NY, USA, 2002. [Google Scholar]
- Wilson, M.; Gochyyev, P. Having your cake and eating it too: Multiple dimensions and a composite. Measurement 2020, 151, 107247. [Google Scholar] [CrossRef]
- Andersen, P.A.; Andersen, J.F. Measures of perceived nonverbal immediacy. In The Sourcebook of Nonverbal Measures: Going Beyond Words; Manusov, V., Ed.; Lawrence Erlbaum: Mahwah, NJ, USA, 2005; pp. 113–126. [Google Scholar]
- Jones, S.M.; Wirtz, J.G. How does the comforting process work? An empirical test of an appraisal-based model of comforting. Hum. Commun. Res. 2006, 32, 217–243. [Google Scholar] [CrossRef]
- Coker, D.A.; Burgoon, J. The nature of conversational involvement and nonverbal encoding patterns. Hum. Commun. Res. 1987, 13, 463–494. [Google Scholar] [CrossRef]
- Buber, M. I and Thou; Kaufman, W., Translator; Simon & Schuster: New York, NY, USA, 1970. [Google Scholar]
- Kvale, S.; Brinkmann, S. Interviews: Learning the Craft of Qualitative Research Interviews, 2nd ed.; Sage Publications: Los Angeles, CA, USA, 2005. [Google Scholar]
- Gordon, M. Listening as embracing the other: Martin Buber’s philosophy of dialogue. Educ. Theory 2011, 6, 207–219. [Google Scholar] [CrossRef]
- Buber, M. Knowledge of Man: Selected Essays; Humanity Books: New York, NY, USA, 1998. [Google Scholar]
- Dworkin, I. Hidden person makes dialogue present: The place of It in the system of dialogue according to Cohen, Buber and Rosenzweig. Religions 2022, 13, 514. [Google Scholar] [CrossRef]
- Cohen, H. Religion of Reason Out of the Sources of Judaism; Kaplan, S., Translator; Ungar: New York, NY, USA, 1972. [Google Scholar]
- Poma, A. Yearning for Form and Other Essays on Hermann Cohen’s Thought; Springer: Dordrecht, The Netherlands, 2006. [Google Scholar]
- JPS Torah Commentary. Leviticus; The Jewish Publication Society: Philadelphia, PA, USA, 1989. [Google Scholar]
- Pohl, C.D. Making Room: Discovering Hospitality as a Christian Tradition. William B. Eerdmans: Grand Rapids, MI, USA, 1999. [Google Scholar]
- Smith, W.R. Lectures on the Religion of the Semites: Fundamental Institutions, 3rd ed.; A. & C. Black: London, UK, 1927. [Google Scholar]
- Halpern, J. From idealized clinical empathy to empathic communication in medical care. Med. Health Care Philos. 2014, 17, 301–311. [Google Scholar] [CrossRef] [PubMed]
- Jaye, C. Talking around embodiment: The views of GPs following participation in medical anthropology courses. J. Med. Ethics Med. Humanit. 2004, 30, 41–48. [Google Scholar] [CrossRef]
- Leder, D. A tale of two bodies: The Cartesian corpse and the lived body. In The Body in Medical Thought and Practice; Leder, D., Ed.; Kluwer Academic Publishers: Dordrecht, The Netherlands, 1992; pp. 17–35. [Google Scholar]
- Gallese, V. Intentional attunement: A neurophysiological perspective on social cognition and its disruption in autism. Brain Res. 2006, 1079, 15–24. [Google Scholar] [CrossRef]
- Engelsrud, G.; Ølen, I.; Nordtug, B. Being present with the patient—A critical investigation of bodily sensitivity and presence in the field of physiotherapy. Physiother. Theory Pract. 2019, 35, 908–918. [Google Scholar] [CrossRef]
- Buber, M. Between Man and Man; Smith, R.G., Translator; Macmillan: New York, NY, USA, 1969. [Google Scholar]
- Nasello, J.A.; Triffaux, J.-M. Focusing: A new challenger for improving the empathy skills of medical students. Complement. Ther. Med. 2020, 53, 102536. [Google Scholar] [CrossRef] [PubMed]
- Page-Shafer, K.; Saphonn, V.; Sun, L.P.; Vun, M.C.; Cooper, D.A.; Kaldor, J.M. HIV prevention research in a resource-limited setting: The experience of planning a trial in Cambodia. Lancet 2005, 366, 1499–1503. [Google Scholar] [CrossRef] [PubMed]
- Dittmar, M.H.; Allman, D. An analysis of the implementation of PEPFAR’s anti-prostitution pledge and its implications for successful HIV prevention among organizations working with sex workers. J. Int. AIDS Soc. 2013, 16, 17534. [Google Scholar] [CrossRef] [PubMed]
- Cha, A.E. AIDS Drug Trial Turned Away Protests by Prostitutes in Cambodia Ended Tenofovir Testing. Washington Post, 23 May 2006. [Google Scholar]
- Grant, J.M. From subjects to relations: Bioethics and the articulation of postcolonial politics in the Cambodia pre-exposure prophylaxis trial. Soc. Stud. Sci. 2016, 46, 236–248. [Google Scholar] [CrossRef]
- Mithani, Z.; Cooper, J.; Boyd, J.W. Race, power, and COID-19: A call for advocacy within bioethics. Am. J. Bioeth. 2021, 21, 11–18. [Google Scholar] [CrossRef]
- Caradas, A.A.; Lambert, E.V.; Charlton, K.E. An ethnic comparison of eating attitudes and associated body image concerns in South African schoolgirls. J. Hum. Nutr. Diet. 2001, 14, 111–120. [Google Scholar] [CrossRef]
- Szabo, C.P.; Hollands, C. Abnormal eating attitudes in secondary schoolgirls in South Africa—A preliminary study. S. Afr. Med. J. 1997, 87, 524–530. [Google Scholar]
- Le Grange, D.; Telch, C.F.; Tibbs, T. Eating attitudes and behaviors in 1,435 South African Caucasian and non-Caucasian college students. Am. J. Psychiatry 1998, 155, 250–254. [Google Scholar] [CrossRef] [PubMed]
- Marais, D.L.; Wassenaar, D.R.; Kramer, A.L. Acculturation and eating disorder symptomatology in Black men and women. Eat. Weight. Disord. 2003, 8, 44–54. [Google Scholar] [CrossRef] [PubMed]
- Senekal, M.; Steyn, N.F.; Mashego, T.B.; Nel, J.H. Evaluation of body shape, eating disorders and weight management related parameters in Black female students of rural and urban origins. S. Afr. J. Psychol. 2001, 31, 45–53. [Google Scholar] [CrossRef]
- Wassenaar, D.R.; Le Grange, D.; Winship, J.; Lachenicht, L. The prevalence of eating disorder pathology in a cross-ethnic population of female students in South Africa. Eur. Eat. Disord. Rev. 2000, 8, 225–236. [Google Scholar] [CrossRef]
- Swartz, L. Anorexia as a culture bound syndrome. Transcult. Psychiatry Res. Rev. 1985, 22, 205–207. [Google Scholar]
- DiNicola, V. Anorexia multiforme: Self-starvation in historical and cultural context. Transcult. Psychiatr. Res. Rev. 1990, 27, 245–286. [Google Scholar] [CrossRef]
- Le Grange, D.; Louw, J.; Breen, A.; Katzman, M.A. The meaning of ‘self-starvation’ in impoverished Black adolescents in South Africa. Cult. Med. Psychiatry 2004, 28, 439–461. [Google Scholar] [CrossRef]
- Office of the Legislative Auditor, State of Minnesota. A Clinical Drug Trial at the University of Minnesota, Department of Psychiatry: The Dan Markingson Case. Special Review; Office of the Legislative Auditor: Saint Paul, MN, USA, 2015.
- Elliott, C. The Deadly Corruption of Clinical Trials. Mother Jones, 20 October 2010. [Google Scholar]
- McCarthy, M. University of Minnesota made “serious ethical errors in trial of antipsychotics”, finds report. BMJ 2015, 350, h1628. [Google Scholar] [CrossRef]
- Juarez, J.A.; Marvel, K.; Brezinski, K.L.; Glazner, C.; Towbin, M.M.; Lawton, S. Bridging the gap: A curriculum to teach residents cultural humility. Fam. Med. 2006, 38, 97–102. [Google Scholar]
- Schuessler, J.B.; Wilder, B.; Byrd, L.W. Reflective journaling and development of cultural humility in students. Nurs. Educ. Perspect. 2012, 33, 96–99. [Google Scholar] [CrossRef] [PubMed]
- Hook, J.N.; Watkins, C.E., Jr.; Davis, D.E.; Owen, J.; Vom Tongeren, D.R.; Ramos, M.J. Cultural humility in psychotherapy supervision. Am. J. Psychother. 2016, 70, 149–166. [Google Scholar] [CrossRef]
- Tryssenaar, J. Interactive journals: An educational strategy to promote reflection. Am. J. Occup. Ther. 1995, 49, 695–702. [Google Scholar] [CrossRef] [PubMed]
- Hülsheger, U.R.; Alberts, H.J.E.M.; Geinholdt, A.; Lang, J.W.B. Benefits of mindfulness at work: The role of mindfulness in emotion regulation, emotional exhaustion, and job satisfaction. J. Appl. Psychol. 2013, 98, 31–325. [Google Scholar] [CrossRef] [PubMed]
- Shapiro, S.L.; Carlson, L.E.; Astin, J.A.; Freedman, B. Mechanisms of mindfulness. J. Clin. Psychol. 2006, 62, 373–386. [Google Scholar] [CrossRef] [PubMed]
- Borders, A.; Earlywine, M.; Jajodra, A. Could mindfulness decrease anger, hostility, and aggression by decreasing rumination? Aggress. Behav. 2010, 36, 28–44. [Google Scholar] [CrossRef]
- Marcks, B.A.; Woods, D.W. A comparison of thought suppression to an acceptance-based technique in the management of personal intrusive thoughts: A controlled evaluation. Behav. Res. Ther. 2005, 43, 443–445. [Google Scholar] [CrossRef]
- Wadlinger, H.A.; Isaacowitz, D.M. Fixing our focus: Training attention to regulate emotion. Pers. Soc. Psychol. Rev. 2011, 15, 75–102. [Google Scholar] [CrossRef]
- Brown, K.W.; Ryan, R.M. The benefits of being present: Mindfulness and its role in psychological well-being. J. Pers. Soc. Psychol. 2003, 84, 822–848. [Google Scholar] [CrossRef]
- Murray, S.A.; Hinton, A., Jr.; Spencer, E.C. Developing cultural humility in immunology and STEMM mentoring. Trends Immunol. 2022, 43, 259–261. [Google Scholar] [CrossRef]
- National Council for Mental Well-Being. Cultural Humility Scale. Available online: https://www.thenationalcouncil.org/wp-content/uploads/2022/02/TI-ROC-Cultural-Humility-Scale-FINAL.pdf (accessed on 9 May 2023).
- Hook, J.N.; Davis, D.E.; Owen, J.; Worthington, E.L.; Utsey, S.O. Cultural humility: Measuring openness to culturally diverse clients. J. Couns. Psychol. 2013, 60, 353–366. [Google Scholar] [CrossRef] [PubMed]
- Zhu, P. The Development and Initial Validation of the Cultural Humility and Enactment Scale in Counseling. Doctoral Dissertation, Syracuse University, Syracuse, NY, USA, May 2020. [Google Scholar]
- Foronda, C.; Porter, A.; Phitwong, A. Psychometric testing of an instrument to measure cultural humility. J. Transcult. Nurs. 2021, 32, 399–404. [Google Scholar] [CrossRef] [PubMed]
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Loue, S.; Nicholas, T. The CARE (Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment) Model: Operationalizing Cultural Humility in the Conduct of Clinical Research. Medicina 2023, 59, 2021. https://doi.org/10.3390/medicina59112021
Loue S, Nicholas T. The CARE (Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment) Model: Operationalizing Cultural Humility in the Conduct of Clinical Research. Medicina. 2023; 59(11):2021. https://doi.org/10.3390/medicina59112021
Chicago/Turabian StyleLoue, Sana, and Timothy Nicholas. 2023. "The CARE (Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment) Model: Operationalizing Cultural Humility in the Conduct of Clinical Research" Medicina 59, no. 11: 2021. https://doi.org/10.3390/medicina59112021
APA StyleLoue, S., & Nicholas, T. (2023). The CARE (Curiosity, Attentiveness, Respect and Responsiveness, and Embodiment) Model: Operationalizing Cultural Humility in the Conduct of Clinical Research. Medicina, 59(11), 2021. https://doi.org/10.3390/medicina59112021