Medical students’ journey towards Cultural Humility – navigating diverse others and systems with extreme inequity

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While existing literature covers cultural humility’s why and what mainly in the context of western countries , the holistic development of its parts during medical training remains underexplored. Given the foundational role of interactions in cultural humility, this study explores its development during various interactions with peers, teachers, patients and researchers across a diversity of education and clinical health care settings marked by inherent power imbalance and inequity. Methods : An interpretivist qualitative case study approach was employed, involving purposive sampling of diverse medical students from one medical school in a country with one of the highest inequity coefficients in the world. Data collection was through semi-structured interviews and analysed using thematic analysis. Ethical clearance and participant consent was obtained. Results: Interactions between actors unfolded in multiple dimensions and layers. Findings were classified into four themes i.e. journeying from feeling like an outsider to embracing interactions, from absolute truth to questioning perceptions, journeying within power imbalance; and embracing future roles through introspection. For participants two fundamental dilemmas remained, i.e. whether to navigate social relations and how to navigate intergroup conflict. Discussion: This study argues that the development of CH is context based and dynamic; however, it’s development should not be assumed but should be considered as multifaceted and layered, where the individual process is significantly influenced by past contexts as well as enhancing interactions with peers, teachers, patients and researchers both formally and informally. Introduction In the context of globalization and diverse student and patient populations, there is increasing awareness that medical education must acknowledge and address cultural and relational injustice and disparity. However, despite efforts, both medical education and health care systems have not fully met the health-related needs of disadvantaged communities [ 1 , 2 , 3 ]. In response, training institutions need to examine their approach and enhance students’ understanding to offer comprehensive patient care [ 4 , 5 ]. In the given context of increased diversity, the concept of Cultural Humility (CH) has been proposed for sensitizing education and health care and is defined as [ 6 ]: “ A process of openness, self-awareness, being egoless, and incorporating self-reflection and critique after willingly interacting with diverse individuals. The result of achieving cultural humility are mutual empowerment, respect, partnerships, optimal care, and lifelong learning ” (Foronda et al, 2016, p213). As per this definition CH is seen as a process of discovery to understand one-self in order to develop honest and trustworthy relationships [ 6 , 7 , 8 ]. Foronda’s description builds on the conceptualization by Tervalon & Murray-García; which includes an explicit focus on agency, advocacy and partnerships [ 9 ]: ‘ … a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations ’ (p117). As such, CH is described as an endless journey that involves identifiable components, i.e. supportive interactions; self-awareness and -critique, openness (further described as flexibility, curiousness and open mindedness); as well as egolessness (explained as neutrality, modesty or humbleness) [ 6 , 7 , 8 , 9 ]. CH is said to contribute to relationships that redress power imbalance in interpersonal dynamic and in systems that perpetuate health disparity [ 7 , 9 , 10 , 11 ]. While CH’s ‘why’ (it is necessary) and ‘what’ (journey with identifiable components) are well-articulated against western country contexts such as Canada, the USA and in Europe [ 6 , 7 , 9 ], its holistic development for undergraduate medical training remains elusive. Even in these contexts, despite decades of attention to culture, CH training hasn’t been widely adopted or practiced [ 3 , 5 , 6 , 17 ]. In some studies, in which a unit of learning is described, there seems to be a fragmented view of looking at experiences, so that the focus mainly is on pedagogy or at addressing specific obstacles during care for marginalised groups [ 5 , 8 , 18 , 19 ]. Pedagogy, for example, focuses at times on specific aspects or on selected actors; for instance, Student-centred learning promotes equity between teacher and student [ 20 , 21 ], problem/case-based approaches consider patient contexts [ 22 ], role play examines caregiver-patient dynamics, socio-drama and art explores conflicting worldviews [ 23 , 24 ] service and inter-professional learning observe real-life disparities of patients [ 8 , 25 , 26 ]. The fragmented view of incorporating culture into curriculum can be further demonstrated by literature providing piecemeal directions regarding specific components at a time. As such, strategies for developing self-awareness most often include socialising agents in demonstrating relationship building and communication skills whilst also cultivating the habit of reflective practice [ 3 ]. These strategies seem to be based on social cognitive learning theories [ 27 ] and emphasise social orientations to learning such as interactive, small group, authentic learning experiences with observation, feedback and reflection. As a pre-requisite the socialising agent needs to be critically conscious of their role in enhancing relationships with patients and students [ 11 ]. It is said, critical conscious role-models facilitate dialogue to develop awareness about power imbalance in relationships and should illuminate alternative ways of seeing the world [ 3 ]. Traditional power imbalance is said to shift within a safe learning environment when the educator makes themselves vulnerable before students and shares confessional narratives about experiences in order to explore subjective, biased and potentially emotional topics together [ 3 , 10 ]. It is recommended that dialogues should be implemented as a continued critique over a range of contexts and should include reflections on different paradigms of health, illness, society, law and morality in an open, critical and reflective manner [ 3 , 24 ]. However, these recommendations do not explain how interactions between a diversity of actors across differing contexts, role-models and curriculum time impact on the holistic development of CH. As such, fragmented and indirect approaches to develop and measure cultural humility limit understanding of it (narrow it down) and overlook its component parts of reflection AND action and therefore demonstrate the same flaws as what cultural competence training were criticised for. As can be seen from literature, although these strategies play a critical role in medical education, relationship building blocks such as humility, critical consciousness and self-critique remain a challenge [ 4 , 5 , 17 ], pointing to the need to better understand factors that may impact on how CH may develop holistically during interactions between a variety of actors across time and over a whole curriculum. This knowledge gap includes not understanding the platform from which cultural humility may have to develop in societies with extreme inequity, nor describing the events, situations, processes and circumstances (the how ) that enhances or inhibits the development of cultural humility for medical students. When considering relationship building within the context of CH, the literature lacks clarity on how diverse interactions among actors, driven by distinct worldviews, histories, beliefs, and values, influence (enhance or inhibit) students’ CH journey. Given the foundational role of relationships in CH, this is where the key may lie in further investigating how CH develops for undergraduate medical students in societies where extreme inequity is the norm. To further investigate the how of CH, this study therefore explores the research question: How do experiences of medical students during student-peer, student-teacher, student-patient and student-health care system interactions enhance or inhibit the development of cultural humility and its component parts, i.e. the willingness to connect with others that are different; self-awareness of bias, prejudice and privilege; a critical consciousness about social disparities and injustices as well as the structural competence in taking up agency and/or an advocacy role in highly inequitable contexts where there are inherited power imbalance? Methods An interpretivist qualitative case study approach was employed, involving purposive sampling of diverse undergraduate medical students (academic year level, race, gender) from one medical school operating in a country with a very high inequity coefficient. Data collection was through semi-structured interviews and analysed using thematic analysis. Setting: In South Africa, a significant portion of the population experience poverty and wealth inequality (e.g. Gini coefficient of South Africa (63.0) compared to USA (41.1), Canada (33.3), UK (35.1), Netherlands (28.1), and Australia (34.1) [ 33 ]. The health care system grapples with a heavy disease burden, inequitable service delivery, and shortages of essential resources. These challenges are compounded by the historical legacy of colonization and racially-segregated policies [ 34 , 35 , 36 ]. The chosen medical school, active since 1976/7, concentrates on graduating black students over six years of undergraduate medical training [ 36 ]. Over time, the institution and its training programmes aligned with the country’s demographic profile through recruitment policies. Access pathways provide for students from disadvantaged backgrounds through mentorship and extended degree programmes. The medical curriculum integrates early clinical exposure across diverse teaching platforms, fostering engagement with a variety of patients. Cultural concepts, professionalism, and patient-doctor relationships are woven into modules and are applied during clinical rotations. The institution’s values and policies embrace principles of respect, equity, transformation, and community. Paradigmatic stance and positionality: Employing a qualitative interpretivist research paradigm, semi-structured interviews were conducted. This approach considers difference in realities to be socially constructed with multiple interpretations across various contextual layers and individual situations. This method proved suitable for investigating the research problem, particularly in addressing questions of process and change over time. This study was approved under Ethics clearance number SMU/M/325/2020:PG. Reflexivity led to an examination of how cultural backgrounds, professional experiences, and social identities influenced the research process. We positioned ourselves as researchers driven by a desire to learn from both our participants and our research, embracing the responsibility of actively listening to gain a comprehensive understanding of participants’ experiences. Our research team members engage with internationalization, globalization, and diverse cultures – across programmes, communities, students and scholars – in both developed and developing regions. Our advocacy for a socially responsive curriculum and research stemmed from recognising the valuable opportunities and strengths brought by our diverse student populations to medical education. The research team is a mix of insiders and outsiders to the research setting. GB, a white female and insider to the research setting, acknowledged potential limitations in understanding the diverse realities of all citizens of the country. However, with nearly two decades of experience as programme coordinator she promoted curriculum development that encouraged intercultural engagement, inclusivity and social responsiveness. MM, a black female and insider to the research setting, provided insights into the context and language used by participants, many of whom communicate similarly to her. MM’s presence helped maintain the authenticity and significance of the research, preventing any loss of voice or meaning. JF and AK are white females from another continent and outsiders to the research setting. They acknowledged their limitations in understanding participants’ lived realities. They approach research from constructivist lenses and from this position they asked questions about scientific rigour, collection and interpretation of data and applicability. After interviews, participants were invited to share feedback on their interview experience. Their reflections along with audio recordings, transcriptions, data-analysis frameworks and interpretations were shared amongst and discussed in the research team. The study engaged critical readers encompassing diverse backgrounds in terms of race, gender and age, who provided invaluable input. Participants: Undergraduate medical students were invited to partake in the study. To capture varied perspectives on interactions with others, the aim was to ensure diversity in recruitment, encompassing factors such as race, gender and academic year level. All students who agreed to participate were provided with an explanation of the research and the option to withdraw at any point. Participants were asked to provide consent to be interviewed and recorded and were ensured anonymity. Data collection: Semi-structured individual interviews were employed to delve deeply into student perspectives, attaining a comprehensive understanding of the topic while creating a safe environment for sharing of opinions about interactions. Virtual interviews were conducted using unique participant codes for login, ensuring privacy. A total of 17 participants from academic year levels 1–6 and a diversity of racial and gender backgrounds were interviewed with an average interview length of 52 minutes. The interview guide’s questions and prompts were developed based on CH literature, aiming to address the research question. Three short vignettes were created based on experiences students previously shared during a diversity elective. The aim of the vignettes was to prompt participants’ thinking. Interviews were conducted by three interviewers of different race (including GB), however, not all interviews were conducted by a same race interviewer. The interviewers conducted pilot interviews with colleagues representing different racial and gender backgrounds. Transcription was executed verbatim. Data analysis: Thematic analysis was employed to discern, analyse and present patterns within the data. Initial analysis involved open coding of each interview transcript. Subsequently, data codes were amalgamated in a second analysis phase, followed by recurrent categorization aligned with the research questions. This cyclic process of classifying and re-classifying codes into categories persisted until complete data analysis and happened through collaborative meetings of the research team. In the third and concluding analysis stage, categories were clustered into four overarching themes that extended beyond the research questions. Transcripts, analysis coding frameworks and key findings were shared within the research team, and collaborative discussions refined the process iteratively. Specific attention by MM was given to ensure that the quotes presented in the results reflected participants’ intended meaning and authenticity. Results This study investigated how interactions between student-peer, student-teacher, student-patient and student-system encounters enhance or inhibit the development of CH and its component parts. It was found that actor interactions dynamically influenced the progression of supportive relations, self-awareness, open-mindedness, and egolessness in multi-directional and layered ways. The findings revealed participants chartered their unique CH journey at their individual pace. The findings were classified into four themes, with two questions remaining unanswered for participants. Journeying from feeling like an outsider to embracing interactions: Participants reflected on their early life contexts as quite segregated and exclusionary. Through influences from parents, schooling, religion, community, and traditions, participants cultivated strong mind-sets about others, which shaped how they comprehended and navigated difference. They for example ‘learnt from high school about difference in terms of sexualities, but there were no different races’ (CH10), ‘so coming here you have these pre-setup ideas about how people are’ (CH3). Entering the institution was therefore akin to a ‘culture shock’ (CH1) , with students hailing from ‘ every corner of the country’ (CH7) and having varying ‘cultural, moral and religious backgrounds’ (CH1). However, this phenomenon also differs from individual to individual as illustrated by: ‘We do have different races like Indians, Black and White people and some are rich, some are not rich, the cultures in general there is some kind of segregation there but when it comes to black people who are from other countries there’s no problem mixing with the black people’ (CH13) In general, participants felt ill-equipped to deal with diversity because ‘ the way each one of us grows up is very different to the person you may sit next to on your very first day (CH7) . Some students indicated they needed a mediator to introduce them to others as demonstrated by: ‘When I was a first year last year I was standing alone at registration and then these other ladies were coming and asking ‘which course are you doing?’ And then they came with a white lady to me and said ‘you can be friends’ and all that and then we started talking. So that one was very kind. She's kind and she's open. So I talked to her and we found we have things in common’ (CH11) Some participants acknowledged and respected diversity, while others navigated it by considering individuals based on their qualities. Moreover, instances arose where participants felt ‘excluded from conversations’ (CH8). This could stem from unkindness or exclusionary behaviours by peers, or personal apprehension in approaching new groups. Most attributed such exclusivity to a tendency for people to gravitate toward those of their own race or culture for a sense of familiarity and security because ‘ that’s what they know and that’s where they feel safe’ (CH4). In general, inadequacy in skills, knowledge, experience and confidence hindered participants’ capacity to engage with others. Despite a sincere desire for interaction, many expressed apprehensions due to the ‘ fear of offending each other’ (CH2). Forced group work seemed to have assisted many students in overcoming strangeness as illustrated: ‘One thing that I do think actually helps them with the integration is the dividing of the clinical groups as well as the division for chemistry and physics in first year. During our physics practical’s … my group, we were ten but we were Tswana, we were Hindu, we were Muslim, White, Black. Everyone was mixed together and we were all kind of forced to work together, that really helps us to communicate with other students and to get to know other students. For me personally, I know that helps quite a lot’ (CH4) However, for some participants, interactions between different groups often remained confined to ‘ school related’ (CH10) contexts, with some admitting they had never engaged with their peers beyond classroom settings even halfway through their course. Although forced group work facilitated situation-specific professional collaboration, its impact was largely constrained, e.g.: ‘it depends on the setting where you are meeting for example in terms of the LGBTQ community we are expected to do group work and in such a setting we communicate well and understand each other but it might be different if we are meeting at a cafeteria or party because there you are not obliged to speak to them’ (CH6) Understanding another culture’s practices proved challenging, as interactions across cultural groups demanded stepping out of comfort zones. These interactions necessitate risk-taking ‘in spite of being scared’ (CH4), compelling participants to communicate and connect with others. Some interactions remained surface-level, such as ‘the only time I've experienced any contact with a homosexual person was in third year (CH3) . A number of participants were propelled by personal narratives, like a fellow student’s candid sharing. ‘we had a girl in our group, she was very open and willing to tell her story which I think made a few people uncomfortable, but I personally learned a lot from this lady and also how different her life is from mine, at home she had a lot of problems, but to my surprize the girl was able to compete with me head to head academically, socially and she was a very good person to be around with’ (CH1) Embracing openness to new experiences was commonly perceived as empowering, exemplified by: ‘[t]he more that you open yourself to these experiences and actually go to other people from different groups, you in the first place are very welcome, it’s very rarely that someone is being rude or outright miserable to you and in the second place you learn a lot, so it is welcoming and it’s very educational’ (CH3) . Informal encounters on campus, including sport events, led to positive interactions akin to reuniting with old acquaintances from class, fostering conversations and connections. It seemed participants valued the development of personal friendship relationships as a hallmark for developing cultural humility as exampled by: ‘On campus because as an Indian, because our race group isn't as big as the African race group, I did feel at first that people did not approach me as they approached other black people, so at the beginning I had one or two Indian friends, and we mostly study together and then only around July or about half year then I had more black friends and more white friends’ (CH16) However, participants contended that social relationships hinged on factors like living arrangements, personality, the freedom to associate and opportunity. However, they also cautioned against presuming discomfort in professional collaborations due to personal associations, asserting that others should not judge their beliefs without knowing them. Some participants noted that the depth and quality of interactions improved gradually over time e.g.: ‘We started off just knowing each other's name and then it happened that we ended up in the same clinical group year after year, you get to know a person, you build the relationship on a personal level, and eventually it formed into a friendship with honest and open conversations, and I can tell her, ‘I think you're wrong’ because that's just the relationship we've grown over the years and she can tell me she thinks I'm wrong without me getting angry’ (CH7). Journeying from the absolute truth to questioning perceptions Bias was described as a latent element that everyone carries, but may struggle to identify. This perspective deemed bias as ‘ a very bad thing’ (CH7) , capable of being directed against one’s own group or formed about others even before becoming acquainted with them. Participants became cognizant of their inclination to perceive their viewpoints as the absolute truth. They willingly question whether their perceptions about others might be incorrect or whether they regarded others as inferior. Informal social interactions played a role in unveiling subtle and overt biases and motivated efforts to correct them, as illustrated by: ‘until I got a chance to interact with them and realise that I was just biased, it's not true, it was just all in my head’ (CH6) and ‘It is up to us to realise that in certain social settings we must always be aware of the off putting things that we say, it is something as small as asking an Afrikaans guy why he arrived without the biltong, so it’s up to us to come to the understanding that listen, every Indian guy doesn't love hot curry the same way every Black person doesn’t speak nine official languages, so it's important to rather ask questions than to automatically assume’ (CH5) Modesty’s acquisition was tied to teamwork and leadership. Some recognised their role as societal leaders, therefore the ‘need to be impartial, to understand, to not judge’ (CH1). Elected leaders emphasized the imperative to ‘be neutral, to identify with all’ (CH12). Team participation highlighted how ‘others fit into the team even if you differ in leadership style’ (CH15). For many leaders, learning from mistakes, such as addressing people improperly, prompted self-reflection and change. Participants acknowledged that medical students should ‘adapt to new situations, understand that now I am meeting different people, many different beliefs, different ways of life, we should be curious about such things’ (CH1). Many participants acknowledged that being admitted to the institution, immersed into a diverse mix of individuals, having been introduced to an indigenous language course and forced to work in diverse groups served as a transformative experience. The majority of participants concurred that change yielded rewards, describing the journey as ‘ really interesting’ and ‘amazing’ (CH6) , or attributing a sense of independence from parents’ viewpoints. Journeying within power imbalance Encounters involving power imbalances were deemed significant challenges as participants lacked a suitable forum for discussing these issues openly. Participants conveyed their comprehension of gender-associated power dynamics, noting that traditional notions of males holding more power than females persist, evident in interactions like patient consultations or lecturer-student exchanges. However, participants also highlighted concerns about power imbalances between students and teachers, irrespective of gender, as illustrated: ‘I did not want to voice my opinion against the Prof because I am sure that I would face repercussions because I will be called a rude student, and you also think of your career on the line, should you report this person? What if no one believes you? And what if for now the whole department is turning against you, because you reported that’ (CH6) Participants identified interactions with peers as potentially unequal, stressing the significance of discerning individuals to approach with caution as exemplified by: ‘people who are politically connected either to the SRC or to the governing party kind of throw their weight around and they think they can tell you what to do, and then when you stand up to them you are told you are being rude, you are being disrespectful and we are scared to stand up to them because they have a certain pull, which is something that has encouraged me to learn more about politics on campus because then you know who has genuine pull, who is genuine a threat to you’ (CH4). A hindering aspect was the use of language that excluded others, with its implications tied to perceptions of privilege as seen in: ‘I can cross that line and maybe communicate with languages that I know black people only can understand, as with the white people in my group it is a bit more challenging, because we think they will understand or they already have the message, things like that’ (CH12) One participant expressed frustration when a peer assumed authority without consensus ‘taking charge without even allowing people to vote for who should be the group leader’ (CH11) prompting recourse to communication strategies to address decision-making concerns. Nonetheless, disagreement surfaced, with some participants feeling restrained from discussing issues openly. Several participants repeatedly underscored the central concern as race prejudice, exemplified by: ‘the current group of white students are intimidated to say what if I talk about this, it will be taken wrongly, for instance if as a black person I do something wrong, and now they complain that might be seen as an act of racism even though it has got nothing to do with race’ (CH2) ‘[the institution] is like a microcosm of South Africa; there’s a lot of issues that haven’t been dealt with and from time to time they spring up, and we still don’t deal with them and, you know, you just try and live with the negatives and positives as opposed to really do hard work on the social side, specifically the race prejudice. It’s a huge, huge, huge one that has not been dealt with and continues to be overlooked’ (CH5) In spite of challenges, one participant reported that interactions with peers, teachers and patients were mostly empowering as he ‘ didn’t feel that stigma; that tension anymore’ (CH8). Embracing future roles through introspection Participants realised that they will need to navigate engagement with different others ‘so you can understand your patients better one day’ (CH4) . Participants emphasised the significance of introspection from early stages of the curriculum as seen in: ‘during first year I realised it was up to me to treat the patient with respect, and even though they weren't the same race as me, even though they weren’t the same religion as me, it was an ah-ha moment because I was given the responsibility and it taught me no matter who the patient is across me, I have to treat everyone equally’ (CH16). Interactions within the health care system held notable significance for participants who identified as privileged. They recognised how their attempts to address disparities might have been perceived by others, as illustrated by: ‘if I express it coming from my point of view, because I do come from a more privileged background, it might be that they (clinic staff) see me as entitled and will laugh me out, so I should be sensitive to the circumstances that they have been used to for so many years’ (CH7) Conversely, participants from less privileged backgrounds faced the unsettling realization that transitioning from a low power group (rural patient) to a high power group (medical student) could reshape their perceptions of care, exemplified by: ‘So it's just that I am mostly here most of the time now as a student rather than going there as a patient; here we see everything like it’s normal; and you don’t have time to check the difficulties, the bad experiences that patients go through’ (CH2) The majority of participants contemplated their role as future doctors and deliberated upon the potential benefits of cultivating an internal locus of control, as exemplified by: “If you know there is a lot of inequalities at your hospital, you first have to introspect and ask yourself, "what do I feel and what are the things I see, what is my own bias, how do I treat others?", from that you have to fix yourself, only after that you can address the issues in the system” (CH15) Researcher impact Participants indicated that interviewer difference may have impacted on responses. One participant felt ‘it could possibly be more difficult for a student who is not white and not female to be as open as I have tried to be’ , however, they also indicated that they were honest in sharing their opinions because ‘the questions you are asking are pressing and should be dealt with ’ (anonymised). Participants with different race interviewers ‘ believed’ that the y ‘should only give honest and accurate answers’ because ‘ you need to report your findings as accurately as possible otherwise it is not going to help at all’ (anonymised). One participant felt ‘ideological perspectives’ may differ and ‘will sub-consciously affect’ responses, but ‘for today’s interview I spoke from my heart because these are some of the things that are very close to me’ (anonymised). One participant pointed out that the differences made him cautious, yet prompted him to look at issues from a different angle, as seen in: ‘it does affect, all the differences that we have, how we interact, for instance the fact that you are older I need to treat you with more respect and maybe not in this session, but if I come to your department I want to ask something, I need to be careful with words because I don’t really know how you going to take it, more especially the racial difference, but of course we cannot really shy away from those differences, because we really can't change, we are different that's a fact; but for this research rather than being less honest, it helped me in such a way that I needed to think on more sides, it felt like I tried to make my mind wider ’ (anonymised). From the above it became clear participants entered the institution from hugely different and segregated contexts with a diverse set of needs and they embarked on their distinct CH journeys at their own pace in unique and multi-directional and layered ways as various interactions with a host of actors affected their interpretation of situations, emotional navigation, and responses. Discussion Developing CH during medical training is a multifaceted process encompassing both planned and opportunistic learning. Its development is paradoxically enhanced and inhibited by interactions with peers, teachers, patients, the ‘system’ and even researchers. In seeking to elucidate these findings, we delve into the concepts around cultural plunge, wayfinding, transculturation theory and intergroup contact theory as potential explanatory frameworks in order to expand on explaining the how in facilitating the development of CH in societies with extreme inequity and power imbalance. The question of social relationships Our findings underscore the value of learning from and with others in diverse groups. Engaging with individuals from diverse cultural backgrounds on an equal plane in work and learning spaces was viewed as essential for professional practice. However, interactions conducive to intergroup friendships were influenced by factors like time, opportunity, and personality and were less frequently observed. The extent to which one needs to immerse oneself in friendships remained an open question, given some participants valuing it while others do not. This contemplation invites further exploration, which can be informed by literature on ‘cultural plunges’ [ 37 , 38 ] , intergroup contact [ 39 , 40 ] and transculturation [ 41 ]. Cultural plunges entail direct interaction with culturally diverse individuals or groups in real-life settings beyond one’s own group, aiming to illuminate personal biases and values [ 37 , 38 ]. Our study suggests that participants experienced a cultural plunge to some extent, as coming to the institution propelled them into a hugely diverse student community, which in turn, coupled with prolonged contact, compelled them to confront bias and prejudice and cultivate empathy. Indeed, contact theory research reveals that successful, repeated, meaningful, face-to-face interactions tend to decrease prejudice across diverse contexts, age groups, and various characteristics such as race, ethnicity, nationality and sexual orientation [ 39 , 40 ]. Initially, our participants exhibited reluctance and apprehension towards others, doubting the feasibility of positive exchanges and preferring to stay within their own cultural groups ‘ sticking together’ . In literature, Wayfinding is described as a process whereby minority group students navigate power imbalances in order to find voice and agency [ 41 , 42 , 43 ]. In contexts where power imbalance is perceived to exist, literature underscores the importance of allowing minority group students to maintain their cultural identity to foster belonging and reduce isolation [ 41 , 42 , 43 ]. Our findings did confirm that some students seem to seek friendships and academic support within an own group; however, their tenure at the institution mostly led to the development of supportive professional relationships, self-awareness and open-mindedness. As such, transculturation theory delineates a four-stage process starting with alienation, where students feel they are outsiders but then could progress to self-discovery, realignment, and participation [ 41 , 42 , 43 ]. However, some students may progress through a trajectory of disillusionment and emotional rejection to disengagement. The two opposite trajectories highlight the complexities of cultural adaptation [ 41 , 43 ]. Our findings demonstrate interactions unfolded multi-dimensionally and over successive layers, with numerous participants describing it as transformative and life-altering experiences, and although seemingly complex, most participants generally managed to fully participate in learning events and team work. While contact theory suggests a reduction in prejudice, research points to cross-group friendships remaining scarce in South Africa, with self-segregation persisting [ 44 ]. Friendship formation typically involves shared neighbourhoods, schools, or work places, while intergroup distrust is linked to residential segregation rather than diversity [ 39 , 40 , 42 , 43 , 44 ]. Our findings affirm the impact of structural barriers to contact shaped by participants’ upbringing, especially in cases where strict segregation still prevailed. Participants further pointed out limited opportunities for social engagements at the institution as a problem. While the majority of senior students seemingly succeeded in developing out-of-class acquaintances, not all participants managed to foster cross-cultural friendships, warranting interventions to facilitate opportunities for intergroup living and socialising spaces such as debate, sport, art, music etc. The question of power and conflict resolution Our findings unveiled a quandary: minority group students, formerly considered part of a high-power group, struggled to assimilate into a majority local culture that had long remained unfamiliar to them. They faced a healthcare system characterised by profound disparity, which they perceived blame them, while simultaneously feeling powerless to effect change and voice their concerns. In contrast, majority group students, assumed to possess political power, grappled with engaging cultures they had little exposure to, which engendered mistrust due to historical context and perceived enduring privilege and proximity. As literature emphasizes, systems possess distinctive cultures, and individual behaviours and beliefs are influenced by context [ 7 , 44 , 45 , 46 ]. As low and middle income countries in general and South Africa in particular have undergone substantial socio-political and economic transformations over the past decades [ 47 , 48 ] it seems pertinent that institutions engage in critical conversations about intercultural pain and misunderstanding [ 12 , 13 , 14 , 44 , 45 , 46 , 49 , 50 ]. While intergroup relations encompass both individual discomfort and perceived threats, these threats can be realistic (political, economic power) or symbolic (values, beliefs) [ 49 , 50 ]. Effective contact necessitates equal status, intergroup cooperation; shared goals; and authority sanction to reduce conflict [ 39 , 50 ]. Unequal status may lead to negative outcomes, urging contact interventions to address such challenges [ 39 , 49 , 50 ]. Conflict often arises, triggering feelings of insecurity, devaluation, and disrespect within the groups. Such conflicts lead to considerable distress, necessitating difficult, honest and courageous interventions to alter values, attitudes, norms, behaviours and interactions [ 3 , 44 ]. While intergroup contact theorized mitigation of intergroup anxiety, bias, and prejudice [ 39 , 40 , 45 , 49 , 50 ], our study highlights overlooked curriculum opportunities in addressing students’ concerns and promoting essential critical dialogues to understand their lived experiences and realities as well as the actions that need to be taken in addressing structural disparities. These findings furthermore bring to mind the importance of Freire’s pedagogical approach where people are brought together in dialogue in order to gain knowledge and reflect upon their realities to further act together to transform such realities [ 12 , 13 , 14 ]. It points to developing an approach to others at multiple levels, across varying contexts [ 15 , 16 ]; and to being a critical attribute, embedding its core values in the individual, ultimately providing an internal lens for responsive practice [ 2 , 5 , 16 ]. Conclusion In this country of extreme inequity, actors may identify with both high power (politically) and low power (economically) groups or vice versa (low power politically / high power economically). To fully develop CH as a fundamental attribute and internal perspective for medical students, exposure to all combinations of high-power: low-power actors and groups in their lived contexts will be essential. Actor interactions (student-peer, student-teacher, student-patient, student-health care professional/manager, student-researcher) should occur within a secure and inclusive environment, accommodating all actors regardless ideological, socio-economic or other backgrounds during deliberate facilitation of courageous, honest and respectful dialogues by sensitized and mindful role-models across the entire six-year long curriculum. If developing CH for medical students in South Africa is to live up to its expected outcomes ( mutual empowerment and non-paternalistic clinical and advocacy partnerships ) this approach seems essential for promoting developing humility for all actors (students, teachers, researchers, health care professionals and clinical managers) and for addressing health disparities in all clinical contexts, if not, CH will remain a nice ideal on paper with no real practical value. Our study contributes the understanding that theoretical models for the how of CH’s development should incorporate lessons from contact and transcultural theory, as well as lessons from wayfinding and cultural plunge, and that individuals will always develop at their own pace at their own time, especially given the contexts against which they were raised. In illuminating the how of developing CH during medical training our study emphasises that it should be seen as multifaceted process significantly influenced by interactions with various peers, teachers, patients, the healthcare and educational system, and even researchers, both formally and informally. Actor interactions dynamically influence the development of CH during a distinct and individual journey, where supportive relations, self-awareness and -critique, open-mindedness, and egolessness progress in multi-directional and layered ways, and not always as planned. Limitations The profile of the single institution, with a focus on students from only one professional undergraduate programme, could be a limitation in terms of the generalisability of the study to all health professions and all institutions in the country. The most salient social identity groups the main author identifies with are white, female and Afrikaans. Also, take note that this specific status might have led to some bias in interpretation in this study, however involving multiple researchers and critical readers addressed such concerns. Furthermore, responses of participants could have been influenced by their desire to please interviewers. This paper sounds a pervasive, dominant and optimistic note in its emphasis that intergroup contact along with instituting deliberate positive interactions through critical dialogue among a diversity of actors across a prolonged period of time and varied settings, as well as addressing power dynamics, will likely foster the development of CH and its component parts. The question of personal relations and systemic power dynamics need to be further explored through research. In, addition there is a need for future research to explore longitudinal and multilevel processes, assessing the effects of interactions among diverse actors in challenging and suboptimal medical education and health care environments. Declarations Competing interests The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Funding Information Sefako Makgatho Health Sciences University 1 (SMU) – Research Directorate, through the University Capacity Development Grant, provided for by the Department of Higher Education and Training in South Africa; registration fees for protocol development workshop and for registration of PHD study. Author Contribution All authors (G.B; J.F; A.K and M.M) contributed to protocol development, literature review, listening to auto-recordings and reading verbatim transcripts of data collected, data analysis and interpretation, finalizing frameworks for analysis and to writing, structuring and editing of the manuscript for language, scientific rigour etc. G.B. was to address technical and communication processes during application for ethics clearance, as well as data collection – recruitment of participants, interviewing and management of consent forms Acknowledgement The authors would like to thank Dr Zikalala and Dr Sukrajh for interviewing participants, and Prof Moodley, Prof Mabuza and Prof Mawela for encouragement and as critical readers for most valuable comments on this study and manuscript. References Ludwig S, Gruber C, Ehlers JP, Ramspott S. Diversity in Medical Education. GMS Journal for Medical Education. 2020;37(2). Abdou AS, De Pedro K, De Anda A, Merced I, Mao K. 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Cultural humility and shared learning as hallmarks for international teaching: The SWEP experience. Social Work Education , 32 (6), 818-833. Sims DA, Cilliers FJ. Clinician educators’ conceptions of assessment in medical education. Advances in Health Sciences Education. 2023 Jan 20:1-25. Maphumulo WT, Bhengu BR. Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review. Curationis. 2019 Jan 1;42(1):1-9 Benatar S, Gill S. Universal access to healthcare: the case of South Africa in the comparative global context of the late Anthropocene era. International Journal of Health Policy and Management. 2021 Feb;10(2):49. Digby A. Black doctors and discrimination under South Africa’s apartheid regime. Medical history. 2013 Apr;57(2):269-90. Nieto J. The cultural plunge: Cultural immersion as a means of promoting self-awareness and cultural sensitivity among student teachers. Teacher Education Quarterly. 2006 Jan 1;33(1):75-84. Posti-Ahokas H, Janhonen-Abruquah H, Longfor RJ. Urban spaces for intercultural encounters: teacher students’ reflections on the cultural plunge. World Studies in Education. 2015 Jan 1;16(2):45-55. Pettigrew TF, Tropp LR. A meta-analytic test of intergroup contact theory. Journal of personality and social psychology. 2006 May;90(5):751. Pettigrew TF. In pursuit of three theories: Authoritarianism, relative deprivation, and intergroup contact. Annual review of psychology. 2016 Jan 4;67:1-21. Huffman T. Resistance theory and the transculturation hypothesis as explanations of college attrition and persistence among culturally traditional American Indian students. Journal of American Indian Education. 2001 Jan 1:1-23. Brazill SC, Myers CB, Myers SM, Johnson CM. Cultural congruity and academic confidence of American Indian graduate students in STEM: Peer interactions, mentor cultural support, and university environment fit. Journal of Diversity in Higher Education. 2021 Oct 7. Page-Reeves J, Marin A, Moffett M, DeerInWater K, Medin D. Wayfinding as a concept for understanding success among Native Americans in STEM: “learning how to map through life”. Cultural Studies of Science Education. 2019 Mar 15;14:177-97. Booysen L. Societal power shifts and changing social identities in South Africa: Workplace implications. South African Journal of Economic and Management Sciences. 2007 Mar 1;10(1):1-20. Dovidio JF, Love A, Schellhaas FM, Hewstone M. Reducing intergroup bias through intergroup contact: Twenty years of progress and future directions. Group Processes & Intergroup Relations. 2017 Sep;20(5):606-20. Hughes V, Delva S, Nkimbeng M, Spaulding E, Turkson-Ocran RA, Cudjoe J, Ford A, Rushton C, D'Aoust R, Han HR. Not missing the opportunity: Strategies to promote cultural humility among future nursing faculty. Journal of Professional Nursing. 2020 Jan 1;36(1):28-33. Danhoundo G, Nasiri K, Wiktorowicz ME. Improving social accountability processes in the health sector in sub-Saharan Africa: a systematic review. BMC public health. 2018 Dec;18:1-8. Oleribe Oleribe OO, Momoh J, Uzochukwu BS, Mbofana F, Adebiyi A, Barbera T, Williams R, Taylor-Robinson SD. Identifying key challenges facing healthcare systems in Africa and potential solutions. International journal of general medicine. 2019;12:395 https://doi.org/10.2147/IJGM.S22388 Hewstone M, Lolliot S, Swart H, Myers E, Voci A, Al Ramiah A, Cairns E. Intergroup contact and intergroup conflict. Peace and Conflict: Journal of Peace Psychology. 2014 Feb;20(1):39. Al Ramiah A, Hewstone M. Intergroup contact as a tool for reducing, resolving, and preventing intergroup conflict: evidence, limitations, and potential. American Psychologist. 2013 Oct;68(7):527. Additional Declarations No competing interests reported. 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However, despite efforts, both medical education and health care systems have not fully met the health-related needs of disadvantaged communities [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In response, training institutions need to examine their approach and enhance students\u0026rsquo; understanding to offer comprehensive patient care [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In the given context of increased diversity, the concept of Cultural Humility (CH) has been proposed for sensitizing education and health care and is defined as [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eA process of openness, self-awareness, being egoless, and incorporating self-reflection and critique after willingly interacting with diverse individuals. The result of achieving cultural humility are mutual empowerment, respect, partnerships, optimal care, and lifelong learning\u003c/em\u003e\u0026rdquo; (Foronda et al, 2016, p213).\u003c/p\u003e \u003cp\u003eAs per this definition CH is seen as a process of discovery to understand one-self in order to develop honest and trustworthy relationships [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Foronda\u0026rsquo;s description builds on the conceptualization by Tervalon \u0026amp; Murray-Garc\u0026iacute;a; which includes an explicit focus on agency, advocacy and partnerships [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]:\u003c/p\u003e \u003cp\u003e\u0026lsquo;\u003cem\u003e\u0026hellip; a lifelong commitment to self-evaluation and self-critique, to redressing the power imbalances in the patient-physician dynamic, and to developing mutually beneficial and non-paternalistic clinical and advocacy partnerships with communities on behalf of individuals and defined populations\u003c/em\u003e\u0026rsquo; (p117).\u003c/p\u003e \u003cp\u003eAs such, CH is described as an endless journey that involves identifiable components, i.e. supportive interactions; self-awareness and -critique, openness (further described as flexibility, curiousness and open mindedness); as well as egolessness (explained as neutrality, modesty or humbleness) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. CH is said to contribute to relationships that redress power imbalance in interpersonal dynamic and in systems that perpetuate health disparity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWhile CH\u0026rsquo;s \u0026lsquo;why\u0026rsquo; (it is necessary) and \u0026lsquo;what\u0026rsquo; (journey with identifiable components) are well-articulated against western country contexts such as Canada, the USA and in Europe [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], its holistic development for undergraduate medical training remains elusive. Even in these contexts, despite decades of attention to culture, CH training hasn\u0026rsquo;t been widely adopted or practiced [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In some studies, in which a unit of learning is described, there seems to be a fragmented view of looking at experiences, so that the focus mainly is on pedagogy or at addressing specific obstacles during care for marginalised groups [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Pedagogy, for example, focuses at times on specific aspects or on selected actors; for instance, Student-centred learning promotes equity between teacher and student [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], problem/case-based approaches consider patient contexts [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], role play examines caregiver-patient dynamics, socio-drama and art explores conflicting worldviews [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] service and inter-professional learning observe real-life disparities of patients [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe fragmented view of incorporating culture into curriculum can be further demonstrated by literature providing piecemeal directions regarding specific components at a time. As such, strategies for developing self-awareness most often include socialising agents in demonstrating relationship building and communication skills whilst also cultivating the habit of reflective practice [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. These strategies seem to be based on social cognitive learning theories [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e] and emphasise social orientations to learning such as interactive, small group, authentic learning experiences with observation, feedback and reflection. As a pre-requisite the socialising agent needs to be critically conscious of their role in enhancing relationships with patients and students [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is said, critical conscious role-models facilitate dialogue to develop awareness about power imbalance in relationships and should illuminate alternative ways of seeing the world [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Traditional power imbalance is said to shift within a safe learning environment when the educator makes themselves vulnerable before students and shares confessional narratives about experiences in order to explore subjective, biased and potentially emotional topics together [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. It is recommended that dialogues should be implemented as a continued critique over a range of contexts and should include reflections on different paradigms of health, illness, society, law and morality in an open, critical and reflective manner [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. However, these recommendations do not explain how interactions between a diversity of actors across differing contexts, role-models and curriculum time impact on the holistic development of CH. As such, fragmented and indirect approaches to develop and measure cultural humility limit understanding of it (narrow it down) and overlook its component parts of reflection AND action and therefore demonstrate the same flaws as what cultural competence training were criticised for. As can be seen from literature, although these strategies play a critical role in medical education, relationship building blocks such as humility, critical consciousness and self-critique remain a challenge [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], pointing to the need to better understand factors that may impact on \u003cem\u003ehow\u003c/em\u003e CH may develop holistically during interactions between a variety of actors across time and over a whole curriculum.\u003c/p\u003e \u003cp\u003eThis knowledge gap includes not understanding the platform from which cultural humility may have to develop in societies with extreme inequity, nor describing the events, situations, processes and circumstances (the \u003cem\u003ehow\u003c/em\u003e) that enhances or inhibits the development of cultural humility for medical students. When considering relationship building within the context of CH, the literature lacks clarity on how diverse interactions among actors, driven by distinct worldviews, histories, beliefs, and values, influence (enhance or inhibit) students\u0026rsquo; CH journey. Given the foundational role of relationships in CH, this is where the key may lie in further investigating how CH develops for undergraduate medical students in societies where extreme inequity is the norm. To further investigate the \u003cem\u003ehow\u003c/em\u003e of CH, this study therefore explores the research question: How do experiences of medical students during student-peer, student-teacher, student-patient and student-health care system interactions enhance or inhibit the development of cultural humility and its component parts, i.e. the willingness to connect with others that are different; self-awareness of bias, prejudice and privilege; a critical consciousness about social disparities and injustices as well as the structural competence in taking up agency and/or an advocacy role in highly inequitable contexts where there are inherited power imbalance?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eAn interpretivist qualitative case study approach was employed, involving purposive sampling of diverse undergraduate medical students (academic year level, race, gender) from one medical school operating in a country with a very high inequity coefficient. Data collection was through semi-structured interviews and analysed using thematic analysis.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting:\u003c/h2\u003e \u003cp\u003eIn South Africa, a significant portion of the population experience poverty and wealth inequality (e.g. Gini coefficient of South Africa (63.0) compared to USA (41.1), Canada (33.3), UK (35.1), Netherlands (28.1), and Australia (34.1) [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. The health care system grapples with a heavy disease burden, inequitable service delivery, and shortages of essential resources. These challenges are compounded by the historical legacy of colonization and racially-segregated policies [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. The chosen medical school, active since 1976/7, concentrates on graduating black students over six years of undergraduate medical training [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Over time, the institution and its training programmes aligned with the country\u0026rsquo;s demographic profile through recruitment policies. Access pathways provide for students from disadvantaged backgrounds through mentorship and extended degree programmes. The medical curriculum integrates early clinical exposure across diverse teaching platforms, fostering engagement with a variety of patients. Cultural concepts, professionalism, and patient-doctor relationships are woven into modules and are applied during clinical rotations. The institution\u0026rsquo;s values and policies embrace principles of respect, equity, transformation, and community.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eParadigmatic stance and positionality:\u003c/h2\u003e \u003cp\u003eEmploying a qualitative interpretivist research paradigm, semi-structured interviews were conducted. This approach considers difference in realities to be socially constructed with multiple interpretations across various contextual layers and individual situations. This method proved suitable for investigating the research problem, particularly in addressing questions of process and change over time. This study was approved under Ethics clearance number SMU/M/325/2020:PG.\u003c/p\u003e \u003cp\u003eReflexivity led to an examination of how cultural backgrounds, professional experiences, and social identities influenced the research process. We positioned ourselves as researchers driven by a desire to learn from both our participants and our research, embracing the responsibility of actively listening to gain a comprehensive understanding of participants\u0026rsquo; experiences. Our research team members engage with internationalization, globalization, and diverse cultures \u0026ndash; across programmes, communities, students and scholars \u0026ndash; in both developed and developing regions. Our advocacy for a socially responsive curriculum and research stemmed from recognising the valuable opportunities and strengths brought by our diverse student populations to medical education. The research team is a mix of insiders and outsiders to the research setting. GB, a white female and insider to the research setting, acknowledged potential limitations in understanding the diverse realities of all citizens of the country. However, with nearly two decades of experience as programme coordinator she promoted curriculum development that encouraged intercultural engagement, inclusivity and social responsiveness. MM, a black female and insider to the research setting, provided insights into the context and language used by participants, many of whom communicate similarly to her. MM\u0026rsquo;s presence helped maintain the authenticity and significance of the research, preventing any loss of voice or meaning. JF and AK are white females from another continent and outsiders to the research setting. They acknowledged their limitations in understanding participants\u0026rsquo; lived realities. They approach research from constructivist lenses and from this position they asked questions about scientific rigour, collection and interpretation of data and applicability.\u003c/p\u003e \u003cp\u003e After interviews, participants were invited to share feedback on their interview experience. Their reflections along with audio recordings, transcriptions, data-analysis frameworks and interpretations were shared amongst and discussed in the research team. The study engaged critical readers encompassing diverse backgrounds in terms of race, gender and age, who provided invaluable input.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eParticipants:\u003c/h2\u003e \u003cp\u003eUndergraduate medical students were invited to partake in the study. To capture varied perspectives on interactions with others, the aim was to ensure diversity in recruitment, encompassing factors such as race, gender and academic year level. All students who agreed to participate were provided with an explanation of the research and the option to withdraw at any point. Participants were asked to provide consent to be interviewed and recorded and were ensured anonymity.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection:\u003c/h2\u003e \u003cp\u003eSemi-structured individual interviews were employed to delve deeply into student perspectives, attaining a comprehensive understanding of the topic while creating a safe environment for sharing of opinions about interactions. Virtual interviews were conducted using unique participant codes for login, ensuring privacy. A total of 17 participants from academic year levels 1\u0026ndash;6 and a diversity of racial and gender backgrounds were interviewed with an average interview length of 52 minutes. The interview guide\u0026rsquo;s questions and prompts were developed based on CH literature, aiming to address the research question. Three short vignettes were created based on experiences students previously shared during a diversity elective. The aim of the vignettes was to prompt participants\u0026rsquo; thinking. Interviews were conducted by three interviewers of different race (including GB), however, not all interviews were conducted by a same race interviewer. The interviewers conducted pilot interviews with colleagues representing different racial and gender backgrounds. Transcription was executed verbatim.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis:\u003c/h2\u003e \u003cp\u003eThematic analysis was employed to discern, analyse and present patterns within the data. Initial analysis involved open coding of each interview transcript. Subsequently, data codes were amalgamated in a second analysis phase, followed by recurrent categorization aligned with the research questions. This cyclic process of classifying and re-classifying codes into categories persisted until complete data analysis and happened through collaborative meetings of the research team. In the third and concluding analysis stage, categories were clustered into four overarching themes that extended beyond the research questions. Transcripts, analysis coding frameworks and key findings were shared within the research team, and collaborative discussions refined the process iteratively. Specific attention by MM was given to ensure that the quotes presented in the results reflected participants\u0026rsquo; intended meaning and authenticity.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study investigated how interactions between student-peer, student-teacher, student-patient and student-system encounters enhance or inhibit the development of CH and its component parts. It was found that actor interactions dynamically influenced the progression of supportive relations, self-awareness, open-mindedness, and egolessness in multi-directional and layered ways. The findings revealed participants chartered their unique CH journey at their individual pace. The findings were classified into four themes, with two questions remaining unanswered for participants.\u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eJourneying from feeling like an outsider to embracing interactions:\u003c/h2\u003e \u003cp\u003eParticipants reflected on their early life contexts as quite segregated and exclusionary. Through influences from parents, schooling, religion, community, and traditions, participants cultivated strong mind-sets about others, which shaped how they comprehended and navigated difference. They for example \u003cem\u003e\u0026lsquo;learnt from high school about difference in terms of sexualities, but there were no different races\u0026rsquo; (CH10), \u0026lsquo;so coming here you have these pre-setup ideas about how people are\u0026rsquo; (CH3).\u003c/em\u003e Entering the institution was therefore akin to a \u003cem\u003e\u0026lsquo;culture shock\u0026rsquo; (CH1)\u003c/em\u003e, with students hailing from \u0026lsquo;\u003cem\u003eevery corner of the country\u0026rsquo; (CH7)\u003c/em\u003e and having varying \u003cem\u003e\u0026lsquo;cultural, moral and religious backgrounds\u0026rsquo; (CH1).\u003c/em\u003e However, this phenomenon also differs from individual to individual as illustrated by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;We do have different races like Indians, Black and White people and some are rich, some are not rich, the cultures in general there is some kind of segregation there but when it comes to black people who are from other countries there\u0026rsquo;s no problem mixing with the black people\u0026rsquo; (CH13)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn general, participants felt ill-equipped to deal with diversity because \u0026lsquo;\u003cem\u003ethe way each one of us grows up is very different to the person you may sit next to on your very first day (CH7)\u003c/em\u003e. Some students indicated they needed a mediator to introduce them to others as demonstrated by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;When I was a first year last year I was standing alone at registration and then these other ladies were coming and asking \u0026lsquo;which course are you doing?\u0026rsquo; And then they came with a white lady to me and said \u0026lsquo;you can be friends\u0026rsquo; and all that and then we started talking. So that one was very kind. She's kind and she's open. So I talked to her and we found we have things in common\u0026rsquo; (CH11)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e Some participants acknowledged and respected diversity, while others navigated it by considering individuals based on their qualities. Moreover, instances arose where participants felt \u003cem\u003e\u0026lsquo;excluded from conversations\u0026rsquo; (CH8).\u003c/em\u003e This could stem from unkindness or exclusionary behaviours by peers, or personal apprehension in approaching new groups. Most attributed such exclusivity to a tendency for people to gravitate toward those of their own race or culture for a sense of familiarity and security because \u0026lsquo;\u003cem\u003ethat\u0026rsquo;s what they know and that\u0026rsquo;s where they feel safe\u0026rsquo; (CH4).\u003c/em\u003e\u003c/p\u003e \u003cp\u003eIn general, inadequacy in skills, knowledge, experience and confidence hindered participants\u0026rsquo; capacity to engage with others. Despite a sincere desire for interaction, many expressed apprehensions due to the \u0026lsquo;\u003cem\u003efear of offending each other\u0026rsquo; (CH2).\u003c/em\u003e Forced group work seemed to have assisted many students in overcoming strangeness as illustrated:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;One thing that I do think actually helps them with the integration is the dividing of the clinical groups as well as the division for chemistry and physics in first year. During our physics practical\u0026rsquo;s \u0026hellip; my group, we were ten but we were Tswana, we were Hindu, we were Muslim, White, Black. Everyone was mixed together and we were all kind of forced to work together, that really helps us to communicate with other students and to get to know other students. For me personally, I know that helps quite a lot\u0026rsquo; (CH4)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, for some participants, interactions between different groups often remained confined to \u0026lsquo;\u003cem\u003eschool related\u0026rsquo; (CH10)\u003c/em\u003e contexts, with some admitting they had never engaged with their peers beyond classroom settings even halfway through their course. Although forced group work facilitated situation-specific professional collaboration, its impact was largely constrained, e.g.:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;it depends on the setting where you are meeting for example in terms of the LGBTQ community we are expected to do group work and in such a setting we communicate well and understand each other but it might be different if we are meeting at a cafeteria or party because there you are not obliged to speak to them\u0026rsquo; (CH6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eUnderstanding another culture\u0026rsquo;s practices proved challenging, as interactions across cultural groups demanded stepping out of comfort zones. These interactions necessitate risk-taking \u003cem\u003e\u0026lsquo;in spite of being scared\u0026rsquo;\u003c/em\u003e (CH4), compelling participants to communicate and connect with others. Some interactions remained surface-level, such as \u003cem\u003e\u0026lsquo;the only time I've experienced any contact with a homosexual person was in third year (CH3)\u003c/em\u003e. A number of participants were propelled by personal narratives, like a fellow student\u0026rsquo;s candid sharing.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;we had a girl in our group, she was very open and willing to tell her story which I think made a few people uncomfortable, but I personally learned a lot from this lady and also how different her life is from mine, at home she had a lot of problems, but to my surprize the girl was able to compete with me head to head academically, socially and she was a very good person to be around with\u0026rsquo; (CH1)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eEmbracing openness to new experiences was commonly perceived as empowering, exemplified by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;[t]he more that you open yourself to these experiences and actually go to other people from different groups, you in the first place are very welcome, it\u0026rsquo;s very rarely that someone is being rude or outright miserable to you and in the second place you learn a lot, so it is welcoming and it\u0026rsquo;s very educational\u0026rsquo; (CH3)\u003c/em\u003e.\u003c/p\u003e \u003cp\u003eInformal encounters on campus, including sport events, led to positive interactions akin to reuniting with old acquaintances from class, fostering conversations and connections. It seemed participants valued the development of personal friendship relationships as a hallmark for developing cultural humility as exampled by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;On campus because as an Indian, because our race group isn't as big as the African race group, I did feel at first that people did not approach me as they approached other black people, so at the beginning I had one or two Indian friends, and we mostly study together and then only around July or about half year then I had more black friends and more white friends\u0026rsquo; (CH16)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eHowever, participants contended that social relationships hinged on factors like living arrangements, personality, the freedom to associate and opportunity. However, they also cautioned against presuming discomfort in professional collaborations due to personal associations, asserting that others should not judge their beliefs without knowing them.\u003c/p\u003e \u003cp\u003e Some participants noted that the depth and quality of interactions improved gradually over time e.g.:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;We started off just knowing each other's name and then it happened that we ended up in the same clinical group year after year, you get to know a person, you build the relationship on a personal level, and eventually it formed into a friendship with honest and open conversations, and I can tell her, \u0026lsquo;I think you're wrong\u0026rsquo; because that's just the relationship we've grown over the years and she can tell me she thinks I'm wrong without me getting angry\u0026rsquo; (CH7).\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eJourneying from the absolute truth to questioning perceptions\u003c/h2\u003e \u003cp\u003eBias was described as a latent element that everyone carries, but may struggle to identify. This perspective deemed bias as \u0026lsquo;\u003cem\u003ea very bad thing\u0026rsquo; (CH7)\u003c/em\u003e, capable of being directed against one\u0026rsquo;s own group or formed about others even before becoming acquainted with them. Participants became cognizant of their inclination to perceive their viewpoints as the absolute truth. They willingly question whether their perceptions about others might be incorrect or whether they regarded others as inferior. Informal social interactions played a role in unveiling subtle and overt biases and motivated efforts to correct them, as illustrated by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;until I got a chance to interact with them and realise that I was just biased, it's not true, it was just all in my head\u0026rsquo; (CH6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eand\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;It is up to us to realise that in certain social settings we must always be aware of the off putting things that we say, it is something as small as asking an Afrikaans guy why he arrived without the biltong, so it\u0026rsquo;s up to us to come to the understanding that listen, every Indian guy doesn't love hot curry the same way every Black person doesn\u0026rsquo;t speak nine official languages, so it's important to rather ask questions than to automatically assume\u0026rsquo; (CH5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eModesty\u0026rsquo;s acquisition was tied to teamwork and leadership. Some recognised their role as societal leaders, therefore the \u003cem\u003e\u0026lsquo;need to be impartial, to understand, to not judge\u0026rsquo; (CH1).\u003c/em\u003e Elected leaders emphasized the imperative to \u003cem\u003e\u0026lsquo;be neutral, to identify with all\u0026rsquo; (CH12).\u003c/em\u003e Team participation highlighted how \u003cem\u003e\u0026lsquo;others fit into the team even if you differ in leadership style\u0026rsquo; (CH15).\u003c/em\u003e For many leaders, learning from mistakes, such as addressing people improperly, prompted self-reflection and change.\u003c/p\u003e \u003cp\u003eParticipants acknowledged that medical students should \u003cem\u003e\u0026lsquo;adapt to new situations, understand that now I am meeting different people, many different beliefs, different ways of life, we should be curious about such things\u0026rsquo;\u003c/em\u003e (CH1). Many participants acknowledged that being admitted to the institution, immersed into a diverse mix of individuals, having been introduced to an indigenous language course and forced to work in diverse groups served as a transformative experience. The majority of participants concurred that change yielded rewards, describing the journey as \u0026lsquo;\u003cem\u003ereally interesting\u0026rsquo;\u003c/em\u003e and \u003cem\u003e\u0026lsquo;amazing\u0026rsquo; (CH6)\u003c/em\u003e, or attributing a sense of independence from parents\u0026rsquo; viewpoints.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eJourneying within power imbalance\u003c/h2\u003e \u003cp\u003eEncounters involving power imbalances were deemed significant challenges as participants lacked a suitable forum for discussing these issues openly. Participants conveyed their comprehension of gender-associated power dynamics, noting that traditional notions of males holding more power than females persist, evident in interactions like patient consultations or lecturer-student exchanges. However, participants also highlighted concerns about power imbalances between students and teachers, irrespective of gender, as illustrated:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I did not want to voice my opinion against the Prof because I am sure that I would face repercussions because I will be called a rude student, and you also think of your career on the line, should you report this person? What if no one believes you? And what if for now the whole department is turning against you, because you reported that\u0026rsquo; (CH6)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eParticipants identified interactions with peers as potentially unequal, stressing the significance of discerning individuals to approach with caution as exemplified by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;people who are politically connected either to the SRC or to the governing party kind of throw their weight around and they think they can tell you what to do, and then when you stand up to them you are told you are being rude, you are being disrespectful and we are scared to stand up to them because they have a certain pull, which is something that has encouraged me to learn more about politics on campus because then you know who has genuine pull, who is genuine a threat to you\u0026rsquo; (CH4).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eA hindering aspect was the use of language that excluded others, with its implications tied to perceptions of privilege as seen in:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;I can cross that line and maybe communicate with languages that I know black people only can understand, as with the white people in my group it is a bit more challenging, because we think they will understand or they already have the message, things like that\u0026rsquo; (CH12)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eOne participant expressed frustration when a peer assumed authority without consensus \u003cem\u003e\u0026lsquo;taking charge without even allowing people to vote for who should be the group leader\u0026rsquo; (CH11)\u003c/em\u003e prompting recourse to communication strategies to address decision-making concerns. Nonetheless, disagreement surfaced, with some participants feeling restrained from discussing issues openly. Several participants repeatedly underscored the central concern as race prejudice, exemplified by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;the current group of white students are intimidated to say what if I talk about this, it will be taken wrongly, for instance if as a black person I do something wrong, and now they complain that might be seen as an act of racism even though it has got nothing to do with race\u0026rsquo; (CH2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;[the institution] is like a microcosm of South Africa; there\u0026rsquo;s a lot of issues that haven\u0026rsquo;t been dealt with and from time to time they spring up, and we still don\u0026rsquo;t deal with them and, you know, you just try and live with the negatives and positives as opposed to really do hard work on the social side, specifically the race prejudice. It\u0026rsquo;s a huge, huge, huge one that has not been dealt with and continues to be overlooked\u0026rsquo; (CH5)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eIn spite of challenges, one participant reported that interactions with peers, teachers and patients were mostly empowering as he \u0026lsquo;\u003cem\u003edidn\u0026rsquo;t feel that stigma; that tension anymore\u0026rsquo; (CH8).\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEmbracing future roles through introspection\u003c/h2\u003e \u003cp\u003eParticipants realised that they will need to navigate engagement with different others \u003cem\u003e\u0026lsquo;so you can understand your patients better one day\u0026rsquo; (CH4)\u003c/em\u003e. Participants emphasised the significance of introspection from early stages of the curriculum as seen in:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;during first year I realised it was up to me to treat the patient with respect, and even though they weren't the same race as me, even though they weren\u0026rsquo;t the same religion as me, it was an ah-ha moment because I was given the responsibility and it taught me no matter who the patient is across me, I have to treat everyone equally\u0026rsquo; (CH16).\u003c/em\u003e \u003c/p\u003e \u003cp\u003eInteractions within the health care system held notable significance for participants who identified as privileged. They recognised how their attempts to address disparities might have been perceived by others, as illustrated by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;if I express it coming from my point of view, because I do come from a more privileged background, it might be that they (clinic staff) see me as entitled and will laugh me out, so I should be sensitive to the circumstances that they have been used to for so many years\u0026rsquo; (CH7)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eConversely, participants from less privileged backgrounds faced the unsettling realization that transitioning from a low power group (rural patient) to a high power group (medical student) could reshape their perceptions of care, exemplified by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026lsquo;So it's just that I am mostly here most of the time now as a student rather than going there as a patient; here we see everything like it\u0026rsquo;s normal; and you don\u0026rsquo;t have time to check the difficulties, the bad experiences that patients go through\u0026rsquo; (CH2)\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe majority of participants contemplated their role as future doctors and deliberated upon the potential benefits of cultivating an internal locus of control, as exemplified by:\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;If you know there is a lot of inequalities at your hospital, you first have to introspect and ask yourself, \"what do I feel and what are the things I see, what is my own bias, how do I treat others?\", from that you have to fix yourself, only after that you can address the issues in the system\u0026rdquo; (CH15)\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eResearcher impact\u003c/h2\u003e \u003cp\u003e Participants indicated that interviewer difference may have impacted on responses. One participant felt \u003cem\u003e\u0026lsquo;it could possibly be more difficult for a student who is not white and not female to be as open as I have tried to be\u0026rsquo;\u003c/em\u003e, however, they also indicated that they were honest in sharing their opinions because \u003cem\u003e\u0026lsquo;the questions you are asking are pressing and should be dealt with\u003c/em\u003e\u0026rsquo; (anonymised).\u003c/p\u003e \u003cp\u003eParticipants with different race interviewers \u0026lsquo;\u003cem\u003ebelieved\u0026rsquo;\u003c/em\u003e that the\u003cem\u003ey \u0026lsquo;should only give honest and accurate answers\u0026rsquo;\u003c/em\u003e because \u0026lsquo;\u003cem\u003eyou need to report your findings as accurately as possible otherwise it is not going to help at all\u0026rsquo;\u003c/em\u003e (anonymised). One participant felt \u003cem\u003e\u0026lsquo;ideological perspectives\u0026rsquo;\u003c/em\u003e may differ and \u003cem\u003e\u0026lsquo;will sub-consciously affect\u0026rsquo;\u003c/em\u003e responses, but \u003cem\u003e\u0026lsquo;for today\u0026rsquo;s interview I spoke from my heart because these are some of the things that are very close to me\u0026rsquo;\u003c/em\u003e (anonymised). One participant pointed out that the differences made him cautious, yet prompted him to look at issues from a different angle, as seen in:\u003c/p\u003e \u003cp\u003e\u003cem\u003e\u0026lsquo;it does affect, all the differences that we have, how we interact, for instance the fact that you are older I need to treat you with more respect and maybe not in this session, but if I come to your department I want to ask something, I need to be careful with words because I don\u0026rsquo;t really know how you going to take it, more especially the racial difference, but of course we cannot really shy away from those differences, because we really can't change, we are different that's a fact; but for this research rather than being less honest, it helped me in such a way that I needed to think on more sides, it felt like I tried to make my mind wider\u003c/em\u003e\u0026rsquo; (anonymised).\u003c/p\u003e \u003cp\u003e From the above it became clear participants entered the institution from hugely different and segregated contexts with a diverse set of needs and they embarked on their distinct CH journeys at their own pace in unique and multi-directional and layered ways as various interactions with a host of actors affected their interpretation of situations, emotional navigation, and responses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDeveloping CH during medical training is a multifaceted process encompassing both planned and opportunistic learning. Its development is paradoxically enhanced and inhibited by interactions with peers, teachers, patients, the \u0026lsquo;system\u0026rsquo; and even researchers. In seeking to elucidate these findings, we delve into the concepts around cultural plunge, wayfinding, transculturation theory and intergroup contact theory as potential explanatory frameworks in order to expand on explaining \u003cem\u003ethe how\u003c/em\u003e in facilitating the development of CH in societies with extreme inequity and power imbalance.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eThe question of social relationships\u003c/h2\u003e \u003cp\u003eOur findings underscore the value of learning from and with others in diverse groups. Engaging with individuals from diverse cultural backgrounds on an equal plane in work and learning spaces was viewed as essential for professional practice. However, interactions conducive to intergroup friendships were influenced by factors like time, opportunity, and personality and were less frequently observed. The extent to which one needs to immerse oneself in friendships remained an open question, given some participants valuing it while others do not. This contemplation invites further exploration, which can be informed by literature on \u0026lsquo;cultural plunges\u0026rsquo; [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]\u003csup\u003e,\u003c/sup\u003e intergroup contact [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and transculturation [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCultural plunges entail direct interaction with culturally diverse individuals or groups in real-life settings beyond one\u0026rsquo;s own group, aiming to illuminate personal biases and values [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Our study suggests that participants experienced a cultural plunge to some extent, as coming to the institution propelled them into a hugely diverse student community, which in turn, coupled with prolonged contact, compelled them to confront bias and prejudice and cultivate empathy. Indeed, contact theory research reveals that successful, repeated, meaningful, face-to-face interactions tend to decrease prejudice across diverse contexts, age groups, and various characteristics such as race, ethnicity, nationality and sexual orientation [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInitially, our participants exhibited reluctance and apprehension towards others, doubting the feasibility of positive exchanges and preferring to stay within their own cultural groups \u0026lsquo;\u003cem\u003esticking together\u0026rsquo;\u003c/em\u003e. In literature, \u003cem\u003eWayfinding\u003c/em\u003e is described as a process whereby minority group students navigate power imbalances in order to find voice and agency [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. In contexts where power imbalance is perceived to exist, literature underscores the importance of allowing minority group students to maintain their cultural identity to foster belonging and reduce isolation [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Our findings did confirm that some students seem to seek friendships and academic support within an own group; however, their tenure at the institution mostly led to the development of supportive professional relationships, self-awareness and open-mindedness. As such, transculturation theory delineates a four-stage process starting with alienation, where students feel they are outsiders but then could progress to self-discovery, realignment, and participation [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. However, some students may progress through a trajectory of disillusionment and emotional rejection to disengagement. The two opposite trajectories highlight the complexities of cultural adaptation [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. Our findings demonstrate interactions unfolded multi-dimensionally and over successive layers, with numerous participants describing it as transformative and life-altering experiences, and although seemingly complex, most participants generally managed to fully participate in learning events and team work.\u003c/p\u003e \u003cp\u003eWhile contact theory suggests a reduction in prejudice, research points to cross-group friendships remaining scarce in South Africa, with self-segregation persisting [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Friendship formation typically involves shared neighbourhoods, schools, or work places, while intergroup distrust is linked to residential segregation rather than diversity [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Our findings affirm the impact of structural barriers to contact shaped by participants\u0026rsquo; upbringing, especially in cases where strict segregation still prevailed. Participants further pointed out limited opportunities for social engagements at the institution as a problem. While the majority of senior students seemingly succeeded in developing out-of-class acquaintances, not all participants managed to foster cross-cultural friendships, warranting interventions to facilitate opportunities for intergroup living and socialising spaces such as debate, sport, art, music etc.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eThe question of power and conflict resolution\u003c/h2\u003e \u003cp\u003eOur findings unveiled a quandary: minority group students, formerly considered part of a high-power group, struggled to assimilate into a majority local culture that had long remained unfamiliar to them. They faced a healthcare system characterised by profound disparity, which they perceived blame them, while simultaneously feeling powerless to effect change and voice their concerns. In contrast, majority group students, assumed to possess political power, grappled with engaging cultures they had little exposure to, which engendered mistrust due to historical context and perceived enduring privilege and proximity.\u003c/p\u003e \u003cp\u003eAs literature emphasizes, systems possess distinctive cultures, and individual behaviours and beliefs are influenced by context [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. As low and middle income countries in general and South Africa in particular have undergone substantial socio-political and economic transformations over the past decades [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e] it seems pertinent that institutions engage in critical conversations about intercultural pain and misunderstanding [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. While intergroup relations encompass both individual discomfort and perceived threats, these threats can be realistic (political, economic power) or symbolic (values, beliefs) [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Effective contact necessitates equal status, intergroup cooperation; shared goals; and authority sanction to reduce conflict [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Unequal status may lead to negative outcomes, urging contact interventions to address such challenges [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Conflict often arises, triggering feelings of insecurity, devaluation, and disrespect within the groups. Such conflicts lead to considerable distress, necessitating difficult, honest and courageous interventions to alter values, attitudes, norms, behaviours and interactions [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. While intergroup contact theorized mitigation of intergroup anxiety, bias, and prejudice [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e], our study highlights overlooked curriculum opportunities in addressing students\u0026rsquo; concerns and promoting essential critical dialogues to understand their lived experiences and realities as well as the actions that need to be taken in addressing structural disparities. These findings furthermore bring to mind the importance of Freire\u0026rsquo;s pedagogical approach where people are brought together in dialogue in order to gain knowledge and reflect upon their realities to further act together to transform such realities [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. It points to developing an approach to others at multiple levels, across varying contexts [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]; and to being a critical attribute, embedding its core values in the individual, ultimately providing an internal lens for responsive practice [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this country of extreme inequity, actors may identify with both high power (politically) and low power (economically) groups or vice versa (low power politically / high power economically). To fully develop CH as a fundamental attribute and internal perspective for medical students, exposure to all combinations of high-power: low-power actors and groups in their lived contexts will be essential. Actor interactions (student-peer, student-teacher, student-patient, student-health care professional/manager, student-researcher) should occur within a secure and inclusive environment, accommodating all actors regardless ideological, socio-economic or other backgrounds during deliberate facilitation of courageous, honest and respectful dialogues by sensitized and mindful role-models across the entire six-year long curriculum. If developing CH for medical students in South Africa is to live up to its expected outcomes (\u003cem\u003emutual empowerment and non-paternalistic clinical and advocacy partnerships\u003c/em\u003e) this approach seems essential for promoting developing humility for all actors (students, teachers, researchers, health care professionals and clinical managers) and for addressing health disparities in all clinical contexts, if not, CH will remain a nice ideal on paper with no real practical value.\u003c/p\u003e \u003cp\u003eOur study contributes the understanding that theoretical models for \u003cem\u003ethe how\u003c/em\u003e of CH\u0026rsquo;s development should incorporate lessons from contact and transcultural theory, as well as lessons from wayfinding and cultural plunge, and that individuals will always develop at their own pace at their own time, especially given the contexts against which they were raised. In illuminating \u003cem\u003ethe how\u003c/em\u003e of developing CH during medical training our study emphasises that it should be seen as multifaceted process significantly influenced by interactions with various peers, teachers, patients, the healthcare and educational system, and even researchers, both formally and informally. Actor interactions dynamically influence the development of CH during a distinct and individual journey, where supportive relations, self-awareness and -critique, open-mindedness, and egolessness progress in multi-directional and layered ways, and not always as planned.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe profile of the single institution, with a focus on students from only one professional undergraduate programme, could be a limitation in terms of the generalisability of the study to all health professions and all institutions in the country. The most salient social identity groups the main author identifies with are white, female and Afrikaans. Also, take note that this specific status might have led to some bias in interpretation in this study, however involving multiple researchers and critical readers addressed such concerns. Furthermore, responses of participants could have been influenced by their desire to please interviewers. This paper sounds a pervasive, dominant and optimistic note in its emphasis that intergroup contact along with instituting deliberate positive interactions through critical dialogue among a diversity of actors across a prolonged period of time and varied settings, as well as addressing power dynamics, will likely foster the development of CH and its component parts.\u003c/p\u003e \u003cp\u003eThe question of personal relations and systemic power dynamics need to be further explored through research. In, addition there is a need for future research to explore longitudinal and multilevel processes, assessing the effects of interactions among diverse actors in challenging and suboptimal medical education and health care environments.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding Information\u003c/h2\u003e \u003cp\u003eSefako Makgatho Health Sciences University\u003csup\u003e1\u003c/sup\u003e (SMU) \u0026ndash; Research Directorate, through the University Capacity Development Grant, provided for by the Department of Higher Education and Training in South Africa; registration fees for protocol development workshop and for registration of PHD study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAll authors (G.B; J.F; A.K and M.M) contributed to protocol development, literature review, listening to auto-recordings and reading verbatim transcripts of data collected, data analysis and interpretation, finalizing frameworks for analysis and to writing, structuring and editing of the manuscript for language, scientific rigour etc. G.B. was to address technical and communication processes during application for ethics clearance, as well as data collection \u0026ndash; recruitment of participants, interviewing and management of consent forms\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThe authors would like to thank Dr Zikalala and Dr Sukrajh for interviewing participants, and Prof Moodley, Prof Mabuza and Prof Mawela for encouragement and as critical readers for most valuable comments on this study and manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLudwig S, Gruber C, Ehlers JP, Ramspott S. 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Journal of Professional Nursing. 2020 Jan 1;36(1):28-33.\u003c/li\u003e\n\u003cli\u003eDanhoundo G, Nasiri K, Wiktorowicz ME. Improving social accountability processes in the health sector in sub-Saharan Africa: a systematic review. BMC public health. 2018 Dec;18:1-8.\u003c/li\u003e\n\u003cli\u003eOleribe Oleribe OO, Momoh J, Uzochukwu BS, Mbofana F, Adebiyi A, Barbera T, Williams R, Taylor-Robinson SD. Identifying key challenges facing healthcare systems in Africa and potential solutions. International journal of general medicine. 2019;12:395 https://doi.org/10.2147/IJGM.S22388\u003c/li\u003e\n\u003cli\u003eHewstone M, Lolliot S, Swart H, Myers E, Voci A, Al Ramiah A, Cairns E. Intergroup contact and intergroup conflict. Peace and Conflict: Journal of Peace Psychology. 2014 Feb;20(1):39.\u003c/li\u003e\n\u003cli\u003eAl Ramiah A, Hewstone M. Intergroup contact as a tool for reducing, resolving, and preventing intergroup conflict: evidence, limitations, and potential. American Psychologist. 2013 Oct;68(7):527.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4305371/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4305371/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e Cultural humility (CH) is a vital journey for addressing diversity, but its application remains elusive. While existing literature covers cultural humility’s \u003cem\u003ewhy \u003c/em\u003eand \u003cem\u003ewhat \u003c/em\u003emainly in the context of western countries\u003cem\u003e,\u003c/em\u003e the holistic development of its parts during medical training remains underexplored. Given the foundational role of interactions in cultural humility, this study explores its development during various interactions with peers, teachers, patients and researchers across a diversity of education and clinical health care settings marked by inherent power imbalance and inequity.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e:\u003c/strong\u003e An interpretivist qualitative case study approach was employed, involving purposive sampling of diverse medical students from one medical school in a country with one of the highest inequity coefficients in the world. Data collection was through semi-structured interviews and analysed using thematic analysis. Ethical clearance and participant consent was obtained.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eInteractions between actors unfolded in multiple dimensions and layers. Findings were classified into four themes i.e. journeying from feeling like an outsider to embracing interactions, from absolute truth to questioning perceptions, journeying within power imbalance; and embracing future roles through introspection. For participants two fundamental dilemmas remained, i.e. \u0026nbsp;whether to navigate social relations and how to navigate intergroup conflict.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e\u003c/em\u003e\u003cstrong\u003e \u003c/strong\u003eThis study argues that the development of CH is context based and dynamic; however, it’s development should not be assumed but should be considered as multifaceted and layered, where the individual process is significantly influenced by past contexts as well as enhancing interactions with peers, teachers, patients and researchers both formally and informally.\u003c/p\u003e","manuscriptTitle":"Medical students’ journey towards Cultural Humility – navigating diverse others and systems with extreme inequity","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-25 16:32:32","doi":"10.21203/rs.3.rs-4305371/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"29152bdc-0c78-4227-bbb5-142a820a0418","owner":[],"postedDate":"April 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-06-30T14:53:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-25 16:32:32","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4305371","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4305371","identity":"rs-4305371","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}