Measures of cultural humility

History of cultural competence

Scholars proposed the concept of cultural humility to address concerns with the notion of cultural competency—a perspective that was central to most disciplines in the health sector.  The notion of cultural competence first became prominent in the 1950s. In the field of nursing for example, Madeline Leininger introduced and promulgated the concept of transcultural nursing around this time.  According to Leininger (1978, 1994, 2001), to accommodates the distinct needs and perspectives of all individuals, nurses should appreciate the cultural beliefs, norms, and life experiences of each patient. 

This work evolved into a definition, proposed by the American Academy of Nursing’s Expert Panel on Culturally Competent Care, that equated cultural competence with a sensitivity to issues that relate to culture, race, gender, and sexual orientation (American Academy of Nursing, 1992). This cultural competence was perceived as central to the attempts of this profession to eradicate disparities in health across demographics (Giger et al., 2007). 

In counselling and psychology, Sue (2001; Sue, Arredondo, et al., 1992; Sue, Bernier et al., 1982) developed guidelines that practitioners should follow when they counsel diverse individuals.  For example, according to these guidelines, practitioners should

• recognise that cultural identity is multifaceted and fluid,
• reflect upon their biases and attitudes towards diverse cultures,
• use language that is sensitive to the lived experience and cultural background of clients,
• prioritise interventions that are culturally sensitive,
• utilise the strengths and benefits of each individual and cultural background, and so forth.

This notion of cultural competency, also labelled as cultural awareness, cross-cultural social work, and ethnic-sensitive social work practice, has also been central to social work since the 1980s.  Cross et al. (1989), for example, defined cultural competence as a coordinated set of practices, skills, and attitudes that enable individuals and organisations to establish productive relationships, regardless of cultural differences. 

Concerns about cultural competence

Over time, most professional codes, standards, and training in health embraced the notion of cultural competence.  Many scholars raised the concern that guidelines around cultural competence, despite suitable intentions, might elicit beliefs or practices that could be unhelpful (e.g., Abrums &

Leppa, 2001; Dean, 2001; Duffy, 2001; Kumagai & Lypson, 2009).  Specifically, according to Fisher-Borne et al. (2015), scholars have raised four main concerns. 

First, the term competence implies that practitioners can become competent in a culture (cf., Summers & Nelson, 2022) and can utilise this knowledge to understand the life experiences of clients (Kumagai & Lypson, 2009).  Yet, this assumption implies that cultures are relatively homogenous, that cultures do not evolve over time, and that individuals belong to one culture.  But

• culture shapes each person uniquely,
• cultures do evolve over time in response to historical, social, economic, and political events (Ridley et al., 2001), and
• each person belongs to a dynamic blend of many ethnic, occupational, religious, and other communities.

Second, the notion of cultural competency encourages practitioners to define the culture of their clients.  To achieve this goal, practitioners may prioritise tangible features, such as race and ethnicity, to define the culture.  Clients are not always granted opportunities to indicate the cultural identities that are most relevant to their needs, such as socio-economic status, disability, or sexual orientation.  Likewise, clients may not be granted opportunities to explore the intersections between these diverse cultural identities (cf., Anastas, 2013). 

Third, the notion of cultural competence encourages practitioners to orient more to the culture of clients rather than to consider how culture affects their own practices and assumptions. Fewer models of cultural competence inspire practitioners who are members of the dominant culture in their region to consider how this culture shaped their beliefs and behaviour, such as the possibility that assumptions are biased and discriminatory (cf., Dunn, 2002).

Finally, as Jani et al. (2011) underscored, the notion of cultural competence implies that practitioners should learn about diverse cultures to assist these cultures effectively and to address inequality.  Yet, these guidelines do not encourage practitioners to challenge or change the underling barriers or sources of these inequalities, such as systematic racism or ignorance.  Thus, cultural competence does not address systematic injustices. 

Introduction to cultural humility

The concept of cultural humility was partly developed to address these concerns (Tervalon & Murray-Garcıa, 1998).  People who demonstrate cultural humility tend to

• recognise that many of their assumptions and knowledge about the culture of individuals may be limited, misguided, and biased,
• ask questions to understand diverse individuals better—such as their hopes, fears, and preferences— and to override misguided assumptions,
• develop a mindset in which they are mindful, attentive, and empathetic rather than presumptuous (Hook et al., 2017; Hook & Watkins, 2015),
• consider their privileges and biases as well as how they can challenge injustices.

The cultural humility scale

To measure the extent to which individuals develop and exhibit cultural humility, Hook et al. (2013) designed and validated the cultural humility scale.  This instrument was developed to measure the degree to which health practitioners exhibit cultural humility with diverse clients.  The scale comprises 12 items that generate two clusters:

• Is respectful
• Is open to explore
• Is considerate
• Is genuinely interested in learning more
• Is open to seeing things from my perspective
• Is open-minded
• Asks questions when he or she is uncertain
• Assumes he or she already knows a lot
• Makes assumptions about me
• Is a know-it-all
• Acts superior
• Thinks he or she understands more than he or she actually does

The first seven items are deemed as positive, and the other items are deemed as negative and thus reverse scored.  As this study demonstrated, cultural humility was positively associated with the degree to which therapists established a strong working alliance—as perceived by these clients.  This working alliance increased the degree to which clients improved during these sessions.

Evidence of validity: Association with racial micro-aggressions

As evidence to validate this Cultural Humility Scale, Hook, Farrell, et al. (2016) revealed that counsellors who exhibited cultural humility were not as likely as other health practitioners to display racial microaggressions.  Racial micro-aggressions are remarks that, although subtle and often inadvertent, denigrate a minority.  Constantine (2007) uncovered 12 distinct variants of racial micro-aggressions that counsellors might demonstrate, such as

• accepting inferior outcomes because the client is a member of a specific culture,
• suggesting that organisations are not discriminatory but choose people because of merit,
• assuming clients will demonstrate some unique or special attribute because of their race or ethnicity,
• minimising the impact of race or ethnicity on the experience of individuals, and so forth.

These racial micro-aggressions decrease the benefits of counselling.  For example, racial micro-aggressions impair the working alliance and diminish the wellbeing of clients (e.g., Owen, Imel, et al., 2011).  To assess whether cultural humility is inversely associated with racial microaggressions, Hook, Farrell, et al. (2016) administered a survey to over 2000 Americans.  The survey included

• the Cultural Humility Scale,
• the Racial Micro-aggressions in Counseling Scale (Constantine, 2007), in which participants indicated the degree to which their counsellor displayed other micro-aggressions—such as minimised the relevance of cultural issues, denied cultural biases, dismissed the reality of racism, or offered advice that was inappropriate to their culture—as well as the perceived impact of these behaviours. 

As hypothesised, practitioners who were perceived as culturally humble were less likely to display racial micro-aggressions, even after controlling the perceived competence of these practitioners.  Likewise, when practitioners were perceived as culturally humble, the perceived impact of their micro-aggressions also diminished.

Cultural humility versus cultural competence

Cultural competence and cultural humility both evolved to address disparities in healthcare, or other services, across ethnicities and other demographics. Yet, in contrast to cultural competence, cultural humility prioritises self-awareness and accountability in practitioners, as well as a motivation to understand and address systematic injustices, rather than knowledge about other cultures (Summers & Nelson, 2022).  According to scholars (Fisher-Borne et al., 2015; Tervalon & Murray-Garcıa, 1998), the main differences between cultural humility and cultural competence are that

• although cultural competence revolves around acknowledging stereotypes, discrimination, and the nuances of cultural identity, cultural humility also recognises that working with diverse clients is a lifelong endeavour (Summers & Nelson, 2022), in which practitioners need to understand themselves and not merely the other culture,
• although cultural competence relates to knowledge, skills, and behaviours to help practitioners work with diverse clients, cultural humility also indicates that practitioners as well as institutions must not only understand, but also challenge, existing disparities,
• cultural competence implies the pursuit of mastery whereas cultural humility implies the necessity of accountability.

Cultural humility versus cultural competence: The perceptions of educators

Indeed, Zhu, Luke et al. (2023) conducted a qualitative study, and then a quantitative study, to characterise how counselling educators differentiate cultural humility and cultural competence.  In the qualitative study, 14 experienced counselling educators participated in two interviews each.  During the interviews, the participants were invited to discuss how they nurtured cultural humility in their students and to compare cultural humility with cultural competence.  To analyse the data 

• the responses were subjected to reflexive thematic analysis (Braun & Clarke, 2006, 2021),
• the researchers applied several methods, such as member checking, continued engagement across multiple rounds of interviews, and critical self-engagement to maintain rigour and to demonstrate the results are trustworthy (Hays & Singh, 2023).

As the first theme revealed, many participants recognised that cultural humility and cultural competence are interwoven. For example, according to one participant, counsellors cannot be culturally competent without some cultural humility.  According to other participants, both cultural humility and cultural competence underscore the need for counsellors to honour cultural values, beliefs, and practices as well as to continually improve their capacity to assist diverse clients better.

As the second theme revealed, participants recognised that, despite this overlap, cultural humility and cultural competence do not prioritise the same principles. To illustrate, according to one participant, cultural humility prioritises awareness or curiosity over knowledge and skills, whereas cultural competence prioritises knowledge.  

Finally, as the third theme revealed, some participants explored how cultural humility complements cultural competence (cf Mosher et al., 2017).  For instance, according to these participants

• cultural humility accentuates the important of deep respect towards other cultural perspectives, potentially address a shortfall of cultural competence,
• cultural humility encourages counsellors to appreciate the limitations of their knowledge about culture—such as an awareness that knowledge about a culture does not necessarily translate to useful advice or understanding,
• cultural humility motivates counsellors to recognise the source of their knowledge about culture may be biased or misleading (Zhu, Luke et al., 2023).

Cultural humility versus cultural competence: The incremental validity of cultural humility

In their quantitative study, Zhu, Luke, et al. (2023) explored whether cultural humility offers insights that transcend cultural competence.  That is, the researchers investigated whether cultural humility predicts the working alliance between therapists and clients even after controlling cultural competence. 

In this study, the researchers used Amazon Mechanical Turk, Reddit, Facebook, Twitter, and other sites to recruit 434 adults.  These participants had attended at least three sessions of therapy with a professional counsellor, clinical social worker, or another allied professional. All participants completed an online survey that included

• the Cultural Humility and Enactment Scale (Zhu et al., 2022)—a measure of cultural humility that comprises three subscales: cultural teachability (e.g., “My counsellor is open to corrective feedback for their cultural views”), limited cultural superiority or disrespect (e.g., “Imposes their cultural views on me” reverse-scored), and relational-oriented engagement (e.g., “Makes room for me to have a different cultural perspective”),
• a variant of the Cross-Cultural Counselling Inventory that comprises seven items (Drinane et al., 2016), such as “My counsellor demonstrates knowledge about my culture”, “My counsellor is comfortable with differences between us”, and “My counsellor attempts to perceive my problems within the context of my cultural experience, values, and lifestyle”,
• the shortened version of the Working Alliance Inventory (Hatcher & Gillaspy, 2006), comprising items like “My counsellor and I are working towards mutually agreed upon goals”.

As a regression analysis revealed, cultural humility was positively associated with the working alliance between counsellors and clients even after controlling cultural competence.  When the three facets of cultural humility were entered as separate predictors, only limited cultural superiority and relational-oriented engagement were positively related to working alliance.  Finally, cultural competence was positively associated with the working alliance even after controlling cultural humility. This pattern of findings suggests that cultural humility and cultural competence do indeed complement one another.

Introduction

Some researchers have raised concerns about the cultural humility scale.  Specifically, according to several researchers and scholars,

• the cultural humility scale does not encompass all the facets and nuances of cultural humility (Zhu et al., 2022; Zhang et al., 2022),
• the two dimensions of this cultural humility scale might not correspond to informative facets but may simply differentiate positively worded items from negatively worded items (Zhu et al., 2024).

The cultural humility and enactment scale, proposed and validated by Zhu et al. (2022), was designed to address these concerns.  Like the cultural humility scale, this alternative instrument measures the cultural humility of health practitioners, often counsellors, from the perspective of clients.  The scale comprises 29 items and assesses three facets. Zhu et al. (2024) replicated this factor structure but omitted 8 redundant items. The first facet, cultural teachability, measures the degree to which the practitioner seems willing to learn about cultures and to adjust their opinions and beliefs in response to additional information.  Typical items include

• Is open to changing their views on cultural issues.
• Is open to corrective feedback for their cultural views.
• Enjoys discussing ideas of different cultures.

The second facet, cultural superiority and disrespect, assesses the degree to which health practitioners imply their culture is superior and imposes their values onto clients—an indication of low cultural humility.  Sample items include

• Imposes their cultural views on me.
• Pretends to know something when they have no idea.
• Prioritizes their cultural views over mine.

The final facet, relational-oriented engagement, respectfully engages in conversations about diverse cultural values, epitomised by items such as

• Has authentic dialogue with me about our conflict.
• Makes room for me to have a different cultural perspective.
• Listens to my cultural views
• Makes me feel valued in our relationship
  

Further evidence of validity and utility

Zhu, Cook, and Wind (2024) also explored whether the Cultural Humility and Enactment Scale can be applied to assess the cultural humility of individuals who are supervising counsellors.  That is, the original scale, comprising 29 items, was designed to gauge the cultural humility of counsellors from the perspective of clients.  In contrast, this study assessed the cultural humility of supervisors from the perspective of counsellors.  To adapt the scale

• the term “counsellor” was replaced with “supervisor”,
• for example, “My counsellor is attentive to how I feel about our conflict” was supplanted with “My supervisor is attentive to how I feel about our conflict”.

In this study, the participants were 201 counsellors who were receiving supervision to seek a license to practice.  Besides this adapted variant of this Cultural Humility and Enactment Scale, these counsellors also completed a measure of the working alliance between trainees and supervisors (Efstation et al., 1990).  To analyse the data, the researchers utilised several techniques, such as confirmatory factor analysis and item response theory—specifically a multidimensional variant of the Partial Credit Model (Masters, 1982).  In short, these analyses revealed that

• like the original instrument, the items can be divided into three factors: cultural teachability, limited cultural arrogance, and relational-oriented engagement,
• these three factors were strongly related to one another, implying that perhaps some items correspond to multiple factors,
• as item-response theory indicated, the instrument can different participants along a continuum from low cultural humility to high cultural humility,
• these measures of cultural humility predicted the working alliance.  

Rationale

Despite the benefits of this cultural humility and enactment scale, the subscales might not encompass all facets of cultural humility.  To illustrate, four academics Johns Hopkins University, Foronda et al. (2016), delineated five distinct facets of cultural humility:

• openness—or a receptivity to the beliefs, perspectives, or values of diverse clients,
• self-awareness—or a tendency to seek feedback and information about personal strengths, shortcomings, values, beliefs, and tendencies that might affect interactions with diverse clients,
• egoless—in which practitioners are more concerned about the needs and worth of clients and do not feel the need to establish or to substantiate their status,
• supportive interactions—defined as proactive, supportive, and rewarding exchanges or conversations,
• self-reflection and critique—in which individuals contemplate how their beliefs or behaviour could affect their interactions. 

Previous measures of cultural humility did not assess all five features.  To address this shortfall, Gonzalez et al. (2020) developed and validated the multidimensional cultural humility scale.  Specifically, the researchers first developed items that measure each of these five facets and arranged panels of reviewers to refine the items.  Finally, a sample of 861 helping professionals completed

• a preliminary variant of this instrument, comprising 57 items,
• a measure of social desirability (Reynolds, 1982), to ascertain whether participants who attempt to depict themselves favourably might skew their responses to this measure of cultural humility,
• a measure that gauges perceptions of self-awareness (Govern & Marsch, 2001).

Evidence and final items

An exploratory factor analysis uncovered five factors, and a confirmatory factor analysis confirmed these five factors: CFI = .95, TLI = .94, RMSEA = 0.04. The following table presents the items and the corresponding facets:

In general, these sub-scales were only marginally related to social desirability and more strongly associated with perceptions of self-awareness.  

Background

When clients are members of diverse communities, such as an ethnic minority, they often prefer health practitioners, such as counsellors, who exhibit cultural humility.  These practitioners are not only motivated to learn about the cultural perspectives of their clients but also tend to feel comfortable to discuss cultural matters and perceives cultural practices as opportunities to customise health strategies effectively.  Cultural humility, comfort, and opportunities tend to improve the efficacy of mental health therapy. In practice, however,

• health practitioners often treat individuals in groups;
• in these settings, clients from members of diverse communities may also be sensitive to whether the group exhibits this cultural humility, cultural comfort, and cultural opportunities. 

Accordingly, Kivlighan et al. (2019) developed a measure of cultural humility, cultural comfort, and cultural opportunities of treatment groups, called the Multicultural Orientation Inventory—Group Version.  This inventory comprises three sub-scales.  The first subscale measures cultural humility. Each question commences with the stem “Regarding the core aspects of my cultural background, the other group members…”. Then, on a scale from 1 to 5, participants indicate the extent to which they agree or disagree that group members exhibited 12 tendencies, such as

• are respectful,
• are genuinely interested in learning more,
• act superior [reverse-scored],
• think they understand more than they actually do [reverse-scored],
• ask questions when they are uncertain.

The second subscale measures cultural comfort.  That is, participants indicate the level of comfort that group members exhibited during any dialogue about cultural issues.  In particular, on a five-point scale, respondents indicate the degree to which group members displayed 10 qualities, such as the extent to which they were

• comfortable,
• awkward [reverse-scored],
• relaxed,
• calm,
• edgy [reverse-scored], and
• genuine.

The final subscale measures the extent to which group members utilised or overlooked some opportunities to discuss certain topics around cultural matters in greater depth.  That is, participants indicated the degree to which they agree or disagree with five items, such as

• The other group members missed opportunities to discuss my cultural background [reverse-scored]
• I wish the other group members would have encouraged me to discuss my cultural background more [reverse-scored].
• The other groups discussed my cultural background in a way that worked for me.

Evidence of validity

To validate this scale, 208 individuals, derived from 49 distinct therapy groups, convened at various university counselling centre, completed a series of measures.  These measure included this Multicultural Orientation Inventory—Group Version as well as

• the Patient’s Estimate of Improvement (Hatcher & Barends, 1996), comprising 16 questions, such as “To what extent has your general social life improved or gotten worse over the course of therapy?”, designed to measure whether the therapy diminished symptoms and improved relationships, work life, behaviour, and many other spheres of life,
• the Therapeutic Factor Inventory-8 (Tasca et al., 2016), to measure the degree to which individuals felt the sessions exhibit four qualities: social learning, hope, secure emotional expressions, and awareness of relation impact—such as “in the group, I have learned that I have more similarities with others than I would have guessed”.

The data largely validate the Multicultural Orientation Inventory—Group Version. Confirmatory factor analysis validated the three distinct subscales: cultural humility, cultural comfort, and cultural opportunities.  These three subscales were positively associated with the therapeutic factor that blends social learning, hope, secure emotional expressions, and awareness of relation impact (Kivlighan et al., 2019). Finally, cultural humility and cultural opportunities, but not cultural comfort, were positively associated with improvements or benefits from these group sessions (Kivlighan et al., 2019).   

Associations between cultural humility, cultural comfort, and cultural opportunities

Although research has differentiated cultural humility, cultural comfort, and cultural opportunities convincingly, fewer studies have explored the relationship between these three facets of the multicultural orientation framework.  One exception was a study that Fischer et al. (2025) published. 

In this study, 483 individuals who identified as members of a sexual or gender minority and were receiving therapy completed a survey online.  The survey included

• questions about the therapy they were receiving, such as the duration of this therapy,
• demographic questions, such as socioeconomic status and sexual orientation,
• the Cultural Humility Scale (Hook et al., 2013), in which the positive items assess cultural humility, such as “My therapist is open to explore”, and the negative items assess cultural arrogance, such as “My therapist makes assumptions about me”,
• a set of items, some of which were developed by the authors, to measure both cultural opportunities, such as “My therapist and I had some deep discussions about my cultural background and identities”, and missed cultural opportunities, such as “My therapist missed opportunities to discuss my cultural background and identities”,
• the Therapist Cultural Comfort Scale (Pérez-Rojas et al., 2019) to gauge both cultural comfort, such as “My therapist seems comfortable talking to me [about cultural matters]” and cultural discomfort, such as “ My therapist seems unsure of how to behave [when discussing cultural matters]”.

The researchers then analysed the positive attributes—cultural humility, cultural opportunities, and cultural comfort—separately from the negative attributes—cultural arrogance, missed cultural opportunities, and cultural discomfort.  The analysis of positive attributes supported the hypotheses.  That is, cultural humility was positively associated with cultural opportunities.  And, when cultural comfort was elevated, this association between cultural humility and cultural opportunities was especially pronounced (Fischer et al., 2025).  Presumably

• when practitioners feel inspired to learn about the culture of clients, exemplifying cultural humility, they are more likely to uncover opportunities to embed the cultural values and beliefs of clients into the intervention,
• furthermore, when practitioners feel comfortable to discuss the culture of clients, the two individuals are likely to explore these opportunities in greater depth rather than hastily.

The negative attributes, however, generated a more nuanced pattern.  Cultural arrogance was positively associated with missed cultural opportunities, as hypothesised.  However, contrary to the hypotheses, this positive association diminished when cultural discomfort was pronounced.  Arguably,

• when practitioners exhibit cultural discomfort, clients may perceive this discomfort as relatable and authentic; this discomfort might humanise the practitioner,
• consequently, even if the practitioner seems culturally arrogant, clients may still be willing to explore opportunities to embed their cultural beliefs in the therapeutic plan. 

Further research is thus warranted to explore the associations between cultural humility, cultural opportunities, cultural comfort, and their negative equivalents in more detail.