Cultural Competency Tool Kits

The Multicultural, Diversity, and Inclusion (MDI) Network is a network of independent groups of various diverse identity and affiliations based on race/ethnicity; disability; sexual orientation; and religious affiliation that collectively support the increase of diversity and inclusion in occupational therapy. The seven MDI Tool Kits below provide resources to understanding the specific values, norms, beliefs, attitudes, and behaviors associated with different cultural groups.

Why We Need Multicultural Competency

Demographics: The population of the United States in 2013 is reported at 316,128,839 (U.S. Census Bureau, 2014). Demographic distribution based on race/ethnicity is as follows: White 77.7%; Hispanic Latino 17.1%; Black or African American 13.2%; Asian 5.3%; two or more races 2.4%; American Indian and Alaska Native 1.2%; Native Hawaiian and Pacific Islander 0.2%.

In the next 50 years, the U.S. is projected to be a plurality nation, where the non-Hispanic white population will be the largest single group, but no group will be in the majority.

Health inequities: The prevalence and distribution of illness, premature death, and disability is disproportionately represented in certain populations that are considered vulnerable on the basis of race/ethnicity, socioeconomic status, geography, gender, age, disability status, sexual orientation, and primary language. Factors that contribute to health, also known as health determinants are genes and biology, health services, health behaviors, physical environment, and social environment (Centers for Disease Control and Prevention [CDC], 2014). The contribution of biology and health behaviors to health is approximately 25%, and access to health care (or lack thereof) is no more than 20% (CDC, 2014). The root causes of health inequities are the consequence of complex interactions of these health determinants.

Attitudinal barriers: Attitudes are cultural products and influence how we think, feel, and behave toward others who are different. Social attitude is an environmental factor that impacts health, well-being, and ability to participate in social situations (World Health Organization, 2002). Practitioners’ cultural identity influences their attitudes and behaviors towards their clients. In a landmark publication, the unconscious bias and stereotypes held by providers was identified as the cause of differential treatment and quality of care provided to minorities and non-minorities with equal access to care and no differences in their needs and preferences for treatment (Institutes of Medicine, 2001).

Social exclusion impacts health negatively; people want to belong and feel accepted. Transcending differences and recognizing the common humanity we share helps create a socially-inclusive society.

Cultural competency education is expected to improve health outcomes by enhancing the provider’s knowledge, skills, and attitudes toward diverse clients and enhancing the ability to provide culturally responsive and effective services.

What is Multicultural Competency?

Multicultural competency means having the ability to function effectively in cross-cultural interactions with clients who are from a different cultural group. A critique of cultural “competency” has been that it implies that there exists an end-point at which one becomes competent (Gupta, 2008). However, given the complexity of both culture and human behaviors, it is important to recognize that acquiring cultural competency is a life-long process. Some alternate terminologies associated with the idea of cultural effectiveness are represented in the table below.


Definitions & key reference

Cultural Competence

“Cultural competence is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations” (Cross, Bazron, Dennis, & Isaacs, 1989, p. 13).

Cultural Responsiveness

Cultural responsiveness is about reciprocity and mutuality. The process involves exploring differences, being open to valuing clients’ knowledge and expertise, and recognizing the unique cultural identity of each individual client (Munoz, 2007). 

Cultural Humility

Cultural humility is an attitude and process by which providers strive to address issues of power differences between professionals and clients, value and respect clients by continuous engagement in self-reflection, and self-critique as life-long learners and reflective practitioners (Tervalon & Murray-Garcia, 1998).

Cultural Intelligence

Cultural intelligence is the ability to interact effectively with culturally different clients, and it relies on cultural metacognition—knowledge of your own attitudes, values, and skills, and those of the clients, makes for an effective encounter (Thomas et al., 2008).

Cultural Safety

Cultural safety is a sociopolitical idea about the unconscious and unspoken assumptions of power held by health providers of particular groups that have been historically marginalized. It is about the trust and safety a client experiences when treated with respect and understanding, and is included in the decision-making process. Providers recognize their own culture, beliefs, and attitudes, recognizing that building trust and empowering clients requires power sharing (Canadian Association of Occupational Therapists, 2011).

Influential Theories Relevant to Culture

The familiar image of culture as an iceberg shows that most important and deeper meanings of culture are hidden from view. Culture shapes our beliefs and world view. Values are at the core of differences in cultural beliefs, attitudes, and behaviors. The following are some dominant and influential theories.

  • Schwartz’s Theory of Basic Values identifies ten core universal values that are common to all cultures, with defining goals and behaviors that are essential for human survival and existence as socially organized groups (Schwartz, 2012). The differences between cultures lie in how these values are prioritized and the behaviors they elicit.
  • Hofstede’s Cultural Dimensions Theory (2001) provides a systematic framework for five cultural dimensions shared by all cultures: Power Distance (equality versus hierarchy), Individualism (individual freedoms versus collective responsibilities), Uncertainty Avoidance (informal versus formal), Masculinity (competition versus collaboration), and Time Orientation (short-term versus long-term).
  • Hall (1976) classified cultures on the basis of communication as high-context (HC) cultures and low-context (LC) cultures. The communication style of HC culture is indirect and meaning is implicit. Communication in LC culture is direct and explicit. The U.S. is a low context culture.

It is best to view these cultural characteristics as lying along a continuum rather than as polar opposites. For example, it is the relative degrees of individualism versus collectivism that differentiates cultural groups. Individuals from a collectivist culture are still individuals, but the degree to which they factor others into their decisions is different from those from a strong individualistic perspective.

Culture and Individual Identity

Client-centered practice dictates that we treat each client as a unique being. Some important ideas to keep in mind in cross-cultural interactions are the following:

  • Culture is dynamic and complex and is influenced by outside forces such as technology and globalization.
  • Cultural influences one’s identity, but identity is multilayered and is derived from multiple sources. A client typically holds multiple identities based on life circumstances and experiences. These identities stem from affiliations to family, community, profession, religion, nation, and others.
  • A client’s identity is a product of intersections of race/ethnicity, education, socioeconomic class, sex, age, sexual orientation, (dis)ability, religion, etc.

Implications for Practice

How do we use our knowledge, skills, and attitudes to provide culturally responsive and culturally effective care? Knowledge about key cultural characteristics is helpful, but it is important to know that over time people are acculturated and socialized to the larger context and dominant ways of doing and being. Acculturation is a process in which members of one cultural group adopt the beliefs and behaviors of another group (Berry, 1997). The extent to which individuals become acculturated varies; social integration requires a certain degree of acculturation from diverse cultural groups as well as an inclusive attitude by the dominant social groups.


Berry, J. W. (1997). Immigration, acculturation and adaptation. Applied Psychology: An International Review, 46, 5–68.

Canadian Association of Occupational Therapists. (2011). CAOT Position Statement: Occupational therapy and cultural safety. Retrieved from

Centers for Disease Control and Prevention (2014). Social determinants of health. Retrieved from 

Cross, T., Bazron, B., Dennis, K., & Isaacs, M. (1989). Towards a culturally competent system of care (Vol. 1). Washington, DC: Georgetown Center. Retrieved from 

Gupta, J. (2008, September). Reflections of one educator on teaching cultural competence. Education Special Interest Section Quarterly, 18(3), 3–4.

Hall, E. T. (1976). Beyond culture. New York: Anchor Books.

Hofstede, G. (2001). Culture’s consequences: Comparing values, behaviors, institutions, and organizations across nations. Thousand Oaks, CA: Sage.

Institutes of Medicine. (2001). Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, DC: National Academies Press.

Munoz, J. P. (2007). Culturally responsive caring in occupational therapy. Occupational Therapy International, 14(4), 256–280. 10.1002/oti.238

Schwartz, S. H. (2012). An overview of Schwartz theory of basic values. Online Readings in Psychology & Culture, 2(1).

Tervalon, M., &Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 17–25.

Thomas, D. C., Elron, E., Stahl, G., Ekelund, B. Z., Ravlin, E. C., Cerdin, J-L.,… Lazarova, M.B.  (2008). Cultural intelligence: Domain and assessment. International Journal of Cross Cultural Management, 8, 123–143. 

U.S. Census Bureau. (2014). U.S. state and country quick facts. Retrieved from

World Health Organization. (2002). International classification of functioning, disability and health. Retrieved from