The World Health Organization (WHO) emphasizes the importance of international collaboration between governments, community organizations, foundations, and researchers to save lives and improve health at national and global levels. International collaboration is mutually beneficial to all collaborators and allows for the exchange of knowledge and expertise, which can lead to new insights, innovative solutions, sustainable capacity building, and more effective strategies for promoting health and preventing disease 1.

International collaboration enriches the human experience for all stakeholders through the interaction that takes place between teams of diverse cultural backgrounds that leads to growth, promotes global solidarity, and supports progress for all 2. However, significant challenges face those engaged in international collaborations. Language barriers, cultural differences, different rules and regulations, and limited resources are some of the familiar challenges that occur during international collaboration. Language barriers necessitate the use of interpretation, ideally by team members who are multilingual. Cultural differences can be addressed via many innovative strategies. A good start is recruiting multicultural team members who can serve as cultural brokers and facilitate intercultural dialogue. Different rules and regulations between the collaborating stakeholders can be multifaceted and complex; therefore, learning about country-specific rules and regulations early in the planning phase of collaboration is necessary to ensure compliance. Finally, limited resources among collaborators often require team members to be flexible and innovative to overcome delays caused by the inadequacy of resources 3.

This paper is discussing the use of cultural humility theory to support an international collaboration between stakeholders from different countries with diverse cultural backgrounds working together to optimize a novel middle and high school curriculum intended to promote peaceful coexistence and anti-extremism in Bahrain. We use the attributes of cultural humility as a framework to reflect on the lessons learned regarding how we navigated cultural differences, and we conclude by recommending the use of this framework during international collaborations. Accordingly, all teams had representatives serving as authors for this paper. We believe that cultural humility is a valuable approach that not only values differences but also teaches us how to interact with diverse cultures effectively which could lead to improving the practice of public health.

Cultural humility can overcome cultural differences faced by those who are engaged in international collaborations 4. The concept of cultural humility originated in the healthcare field, but it has since been adopted by many other fields including education, social work, and business. Cultural humility is the ongoing process of self-awareness, learning, and respectful engagement with people from diverse backgrounds 5, in contrast to the static notion of cultural competence 6. Adopting cultural humility as a framework in international collaboration cultivates the establishment of mutually beneficial, successful, and supportive interactions between stakeholders 7. We echo Gottlieb in her article of 2021 advocating for using cultural humility as a recommended framework for all relationships 8. Additionally, cultural humility uniquely addresses power differences at individual and institutional levels 9. Cultural humility is a process of critical self-reflection and lifelong learning, resulting in mutually positive outcomes 10.

Overall, the purpose of this paper is to use cultural humility theory as a framework for international collaboration. We also share our lessons learned navigating cultural differences during our current international collaboration guided by the attributes of cultural humility to achieve a successful partnership. Moreover, we provide practical examples of how to translate, enact, and operationalize the attributes of cultural humility into communication strategies and practical tools that inform current and future international collaborations.

The international collaboration that is the context for this manuscript involved a study intended to optimize a novel middle and high school curriculum that promotes peaceful coexistence and anti-extremism. The study is using the innovative Multiphase Optimization Strategy (MOST) 11 to optimize the Drug Abuse Resistance Education (DARE) Bahrain peaceful coexistence and anti-extremism intervention. Prevention Strategies, a spinoff of the University of North Carolina Greensboro (UNCG) oversees the application of MOST.

MOST is a flexible framework for developing and optimizing complex interventions first introduced by Collins et al. in 2005. MOST enables researchers and practitioners to develop effective interventions efficiently and systematically, while minimizing resource waste and maximizing the potential for success. MOST involves several key phases:

1. Preparation involves defining the intervention and identifying its key components.

2. Optimization involves systematically testing the effectiveness of each component of the intervention using a factorial design.

3. Evaluation involves testing the optimized intervention in a randomized controlled trial to determine its effectiveness in a real-world setting.

The study team members are DARE America 12, the Kingdom of Bahrain Ministry of Interior’s, DARE program (DARE Bahrain), and Prevention Strategies. DARE Bahrain contracted DARE America and Prevention Strategies to optimize and evaluate their curriculum. In this paper we refer to Dare Bahrain as the Bahrain team while all other stakeholders are referred to as the American team.

DARE America is a prevention program that provides youth with the knowledge and skills they need to make healthy and safe choices. The program was developed in the United States in 1983 and has since been implemented in over 50 countries around the world. The DARE program is typically delivered in elementary, middle, and high schools by specially trained police officers. The program uses a combination of classroom lessons, interactive activities, and role-playing exercises and covers a wide range of topics including drug and alcohol abuse, violence prevention, bullying, internet safety, and responsible decision-making.

DARE Bahrain is based in the Kingdom of Bahrain, an island in the Persian Gulf. It is located east of Saudi Arabia and north of Qatar. Although it is only 3.5 times the size of Washington, DC, it has an ethnically and religiously diverse population of 1.5 million people. The main language in Bahrain is Arabic and the predominant religion is Islam. Bahrain is known for its rich history and culture dating back to ancient times and is today a modern, cosmopolitan country with a diverse population and a thriving economy 13.

In 2011, DARE Bahrain was launched by the Ministry of Interior in the Kingdom of Bahrain. The program is named Ma’an, which in Arabic means “together.” It incorporates Arabic and Islamic values and seeks to prepare youth to resist addictive substances and violent responses to life challenges 14. In 2019, DARE Bahrain launched a new initiative to create a peaceful coexistence intervention that expands the knowledge and skills of youth and gives them the tools needed to avoid radicalization and extremism. The peaceful coexistence intervention uses face-to-face lessons that engage youth in classroom discussions and activities. It is delivered by DARE Officers over 8 weeks. The middle school curriculum is focused on intolerance and includes lessons related to 1 intolerance, 2 intolerance and social media, 3 intolerance and video games, and 4 religious intolerance. The high school curriculum is focused on anti-extremism and includes lessons related to 1 extremism, 2 social extremism, 3 political extremism, and 4 religious extremism 15.

Therefore, we felt compelled to share our experience navigating cultural differences during this collaborative using cultural humility theory hoping to fill a gap in literature on how to navigate cultural differences during international collaboration.

The purpose of this section is to describe the lessons learned during our international collaboration. We use the attributes of cultural humility to guide our synthesis. Additionally, we provide examples of how to translate and operationalize the attributes of cultural humility into communication strategies and practical tools that could inform interactions when working with diverse teams.

Foronda et al. in 2016 16 conducted a concept analysis of the term cultural humility. The authors uncovered and defined the antecedents, attributes, and consequences of cultural humility. The antecedents of cultural humility were diversity and power imbalance. The attributes of cultural humility were openness, self-awareness, egoless, supportive interactions, and self-reflection and critique. In the following section, we will share examples of how our team translated the five attributes of cultural humility into actions and attitudes. The examples are organized based on the attributes of cultural humility so that the readers have examples of how the attributes can be translated into actions.

Openness is defined as having an attitude willing to explore new ideas 16. In our collaboration, both teams changed timelines as well as the wording of evaluation instruments, their structure, and mode of delivery to align with cultural values and community rules. Both teams allocated time and efforts to learn about the American and Bahrain cultures through scheduling of field visits to the US and Bahrain that not only included work meetings but also sightseeing and learning about the culture by attending local events.

In this project, teams demonstrated openness while developing the curriculum and planning the evaluation. Despite the complexity of the evaluation process, the Bahrain team was open to learn and implement MOST. In addition, they approved and adopted the curricular changes that were proposed by the American team that resulted from using MOST.

Both teams showed openness to adjust timelines during the COVID-19 pandemic. There is no doubt that COVID-19 complicated the implementation of the study. Accordingly, the American team changed the survey mode of delivery and changed timelines. Lastly, we had to deliver the curriculum using hybrid instructional scenarios (virtual and in-person). Although DARE considers in-person delivery of curricula essential for promoting student engagement, the American team accommodated this new mode of delivery as did everybody else during the pandemic.

Both teams showed openness to learn about new cultures. This project was the first time that the American team worked in an Arabic and Islamic cultural context. The American team took the time to visit important historic and touristic places in Bahrain (e.g., the Grand Mosque, the national museum, historical markers, and buildings, etc.). We realized that one way of learning how to be open-minded is by being genuinely curious about unfamiliar cultural backgrounds and beliefs and being able to see the value of diversity in enriching human experience. There is a quote mentioned by the Bahraini King expressing the value of diversity. The King said, “The greatest source of wealth in Bahrain is our diversity.” This is a powerful example of openness and humility.

To summarize our lessons learned on how to achieve the cultural humility attribute of openness during international collaboration, we would advise others to be flexible and open to adapt protocols and plans based on feedback from different team members specifically regarding suggestions that are culturally driven. Accommodating cultural preferences whenever possible will empower team members of diverse cultural backgrounds. Attempting to be genuinely curious and seeking to understand the diverse cultural and religious beliefs that influence decisions related to any component of the collaboration is helpful. And lastly, seek to be open to different ideas and comfortable with novelty and unfamiliarity.

Self-awareness is defined as being aware of one’s strengths, limitations, values, beliefs, behavior, and appearance to others 16. We learned that trusting each other and co-leadership was necessary to navigate the remote implementation. Additionally, sharing the power of decision making led to a mutually beneficial partnership. At the beginning of the current international collaboration, teams were not fully aware of their collective strengths and limitations. It took time and intentional efforts for both teams to get to know each other and build a trusting relationship.

The American team was not able to do cognitive interviewing or administer surveys in Bahrain schools due to regulations set by the DARE Bahrain. Because the American team trusted the ability of the Bahrain team to be the research associates on the ground, DARE mentors were trained to conduct cognitive interviews about the surveys with the students. To help with survey administration, the American team developed strict protocols for survey administration in schools and DARE mentors were trained by the American team to train DARE officers to administer the surveys. This process of empowering the Bahrain team through trusting their ability to follow the strict implementation guidelines led to successful survey administration.

Our lesson learned about self-awareness relates to the importance of empowering partners and treating them as collaborators, not as clients. It is crucial to adopt a strength-based approach when collaborating with partners from diverse cultural backgrounds. Assessing the assets as well as the needs of all stakeholders is a crucial step in being self-aware.

Egolessness is defined as the attitude of being humble and seeing the worth of all individuals 16. This might be one of the most challenging attitudes to acquire because we are trained to be experts in our own fields. However, the American team exhibited egolessness by trying to understand the Bahrain culture and how it influences the collaborative. In addition, everyone was willing to adapt their plans and protocols when needed.

In this collaboration, language barriers sometimes slowed the pace of the project. Both teams benefited from using interpreters and translators. The American team also recruited a Graduate Assistant (GA) who is bilingual (speaks Arabic and English fluently) who was an important asset in helping the team navigate cultural differences as well as adapting the Arabic translation of the surveys to make them culturally appropriate. The American team also took the time to discuss with their team how to communicate effectively with the Bahrain team in culturally appropriate ways that are tailored to age, gender, educational background, and personal characteristics.

Egolessness in this collaboration was also exhibited by the American team through their willingness to conduct the research in a way that was most convenient for the Bahrain team. There were several instances when protocols were not followed and there was never any hesitation from the Bahrain team to reach out and inform the American team so that together both teams could figure out what needed to be done (if anything) to remedy the situation. We agreed to run the first pilot test using the Bahrain version of the curricula before the American team would make recommendations for edits based on prevention science.

Our lesson learned about egolessness is to anticipate delays, changes, and sometimes misunderstandings and to be ready to apologize and continue learning about what works best for all stakeholders. Sharing decision-making and co-leadership take advantage of the unique strengths of individual team members and promotes effective problem-solving.

Supportive interactions are defined as intersections of existence among individuals that result in positive human exchanges 16. Supportive interaction is a form of caring for others. We learned that being supportive and caring for each other was crucial in overcoming many challenges and enabled connections at the human level that made the experience enjoyable and empowering.

In this project, teams had many formal and nonformal opportunities to interact personally, culturally, and professionally. Some of the notable events that facilitated the American team’s understanding of the Bahrain cultural context was visiting schools that served as implementation sites. Visiting schools enabled the American team to learn about the culture, implementation setting, as well as provided opportunities to interact with participants. Likewise, the Bahrain team visited the U.S. and spent professional and personal time to get to know the personnel at Prevention Strategies and DARE America.

Our lesson learned about supportive interactions relates to the need to be patient with communication delays, investigate the reasons behind the delay, and react with instructions and communications that are clear and easy to understand. Recruiting team members who have effective communication skills will support the ease and clarity of communication. Also, recruiting multilingual multicultural team members would help in bridging the gap of knowing and working with diverse cultures.

Self-reflection and critique 16 are defined as a critical process of reflecting on one’s thoughts, feelings, and actions. In this project, self-reflection and critique led to faster, more efficient communication, procedural adaptation, and enhancement of professional and interpersonal relationships. Self-reflection was exhibited by daily debriefing meetings during field visits. The debriefing included conversations about the project and interactions, mistakes, and improvements to be made for the next day.

Field visits were crucial for both teams and provided first-hand experience of learning about the values, feelings, and behaviors of team members from diverse cultures. The American team when visiting Bahrain did lots of reflection on their in-person interactions which helped them learn how to best work with the Bahrain team. These reflections resulted in a greater understanding of how to best facilitate implementation and maximize the use of shared assets and talents. Planning and engaging in self-reflection are important strategies of cultural humility. Self-reflections helped both teams better navigate their biases and stereotypes, deepened understanding of how best to interact with each other, and facilitated appreciation of cultural differences.

Our lesson learned about self-reflection and critique is to be intentional about planning and engaging in self-reflection and self-critique regularly. Making self-reflection and critique a daily practice enhances communication and cultivates mutual understanding among stakeholders.

In summary, we realized that effective international collaboration in public health requires not only a deep understanding of cultural, political, and logistical factors but also a commitment to building strong partnerships to creatively overcome challenges. International collaboration creates an opportunity to achieve global prosperity. However, significant challenges face those who are engaged in international collaboration because multicultural interaction often entails diversity and power imbalances. We echo the call to action of Alvarez 6 to move beyond cultural competence as a fixed skill and engage in ongoing self-reflection about our own cultural assumptions, biases, and positionality to co-create knowledge with international partners, honoring their expertise and lived experiences. We strongly recommend cultural humility as an approach for working with diverse and multicultural teams attempting to eliminate disparities, achieve social justice, and promote global public health 16.

We also call for delivering training to all stakeholders engaged in international collaboration on cultural humility attributes prior to implementation. “Incorporating attributes of cultural humility into the training highlights their importance and impels providers to integrate such concepts into their professional and personal lives” 8. Our experience suggests that applying cultural humility will facilitate the achievement of mutual empowerment, partnerships, respect, care, and lifelong learning.

Ministry of Interior, Kingdom of Bahrain