Cultural Humility: A Way of Thinking to Inform Practice Globally

We live in a world that is exceptionally diverse and tremendously unequal. In recent years the field of global health has grown through the recognition of these realities, but with a variety of perspectives on how they should be considered.¹ Global health has also grown in physiotherapy, with increasing numbers of Canadian physiotherapists and students engaging in initiatives abroad. In one sense, this is also a manifestation of global inequality: people with certain national and professional statuses—and the economic resources to travel—are able to intervene elsewhere, and to do so primarily on their own terms.

As physiotherapists invested in global health, we see the potential for physiotherapy to have a positive impact on important unmet needs around the world.² Concurrently, we are concerned about the potential for such initiatives to be unknowingly ineffectual, or even to create more problems than solutions.³ We consider this risk particularly high where global health involvement is shrouded in a veil of naïve altruism or domineering heroism,⁴ perpetuating colonial dynamics whereby Western knowledge and viewpoints subjugate alternatives.^5,6

To maximize the potential for positive global health involvement while heightening awareness of the potential for ineffectiveness or even harm, we propose that physiotherapists and students engage in reflective practice premised on the concept of cultural humility.⁷ Cultural humility is an ongoing process of critiquing one's own culture while striving to respectfully understand others, of recognizing and redressing power imbalances, and of contributing to partnerships that are mutually beneficial and non-paternalistic.

We have found that reflecting on experiences through the lens of cultural humility can lead to useful insights to inform our actions. Here is an example:

A Canadian physiotherapist volunteering at a hospital in a low-income country notices a local colleague, on staff at the hospital, conducting a treatment that the Canadian considers ineffectual at a critical time in the patient's recovery. Seeing the importance of effective treatment, he interrupts to present an alternative intervention.

We respect the visiting physiotherapist's intention to contribute to what he understands to be better patient care, but we also believe that this interruption would not occur if the visitor embodied the principles of cultural humility. To begin with, the Canadian's views of what constitutes “best practice” might be broader if he saw the interventions currently dominant in high-income countries as products of a specific, culturally embedded world view, as opposed to universal principles to be applied regardless of context. Furthermore, reflection with cultural humility requires considering power imbalances. We hope the Canadian could see that his ability to visit a facility in a foreign country and critique its staff is one that his local colleague is unlikely to have, and that the reasons for this should not be taken as natural. In the scenario described above, the Canadian physiotherapist did not pause to consider his local colleague's rationale for conducting the treatment, which might have been consistent with the realities of the situation and the culturally grounded world view. By not seeking this information, the visiting physiotherapist not only behaved disrespectfully but also missed an opportunity to learn about the local context and culture.

In this example, we show how cultural humility reveals considerations and opportunities that are not otherwise readily apparent. Although the example is hypothetical, it is similar to actual interactions we have experienced—interactions that raised concerns because the Canadians involved saw them not as problematic but as inherent to improving physiotherapy for the underserved. Despite these concerns, we are optimistic that by using a cultural humility lens, we can create alternative courses of action that are mutually beneficial and non-paternalistic.

In discussing the example above, we have focused on the act of reflection and not on precise courses of action. This strategy is intentional: because applying cultural humility is an ongoing process, it would be incongruent to present a scenario as resolved and definitive. Moreover, determining optimal courses of action would require considering more contextual detail than is presented above.

Although we see evidence of cultural humility being practised with zeal in the global health communities of other professions,⁸ there are few references in the physiotherapy literature, and this omission likely reflects a lack of uptake. With respect to global health involvement, we believe it is imperative that Canadian physiotherapists and students incorporate reflective practice premised on cultural humility for immediate impact.

We have grounded this editorial in the field of global health both because it is what we know best and because we see the immediate advantages of adopting cultural humility in this domain. But this grounding carries the risk of perpetuating the notion of global health as something that happens over there, as somehow distinct from normal practice in Canada. In fact, however, we see cultural humility as a concept that is useful to guide respectful and effective practice not only abroad but also in contemporary Canada, with its exceptional diversity and its areas of tremendous inequality. We believe that exposure to this way of thinking should begin as early as entry-level education and that it should be increasingly incorporated into our professional ways of being and doing.