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Cultural competence: Development of a conceptual framework

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Disability and Rehabilitation, 2009; 31(14): 1153–1160

RESEARCH PAPER

Cultural competence: Development of a conceptual framework

FABRICIO E. BALCAZAR, YOLANDA SUAREZ-BALCAZAR & TINA TAYLOR-RITZLER

Department of Disability and Human Development, University of Illinois, Chicago, Illinois, USA

Abstract
Purpose. To describe the development of a conceptual framework for cultural competence that could help and guide the
training of rehabilitation practitioners, students and researchers.
Method. A systematic review of the literature yielded 259 usable documents that were further reviewed by two independent
readers to identify 32 publications that described cultural competence conceptual models.
Results. After eliminating redundancy, 18 unique cultural competence models were identified. A synthesis model was first
developed which included four components. After an empirical validation of the model, a new model with only three
components emerged.
Conclusion. The empirically validated conceptual framework is a promising tool for training and evaluation of cultural
competence.

Keywords: Cultural competence, conceptual framework, ethnic minorities

Introduction tioners understand and appreciate differences in

The construct of cultural competence has received
much attention in the psychological [1,2]; rehabilita-
tion [3–5]; nursing [6–8]; and public health, educa-
tional and health professions literature [9,10], due in
part to the increased diversity of the population in
developed countries. In the USA, the most recent
census figures suggest that about 30% of the
population is of non-European Caucasian descent
and that people of colour are becoming numerical
majorities in some of the largest cities [11]. Practi-
tioners like nurses, doctors, psychological and voca-
tional rehabilitation counsellors and physical and
occupational therapists are more likely than ever
before to encounter individuals from diverse ethnic
backgrounds in their practice.
Despite the vast literature on cultural competence,
researchers have struggled with its definition and
measurement. One of the most commonly accepted
definitions of cultural competence in the healthcare
field was developed by Camphinha-Bacote [12] in
the nursing profession. According to this definition,
cultural competence is demonstrated when practi-
health beliefs and behaviours, recognise and respect
variations that occur within cultural groups, and are
able to adjust their practice to provide effective
interventions for people from various cultures [12].
Suarez-Balcazar and Rodakowski [13] assert that
‘becoming culturally competent is an on-going
contextual, developmental and experiential process
of personal growth that results in professional
understanding and ability to adequately serve in-
dividuals who look, think and behave differently from
us’ (p 15). The process of becoming culturally
competent can happen through repetitive engage-
ments with diverse groups, by increasing one’s
critical awareness and knowledge, and/or by having
opportunities for reflection and analysis about one’s
professional performance.
One of the shortcomings in the current cultural
competence literature is the limited number of
available validated conceptual frameworks and mea-
sures. The authors conducted a systematic review of
the literature to identify the most prevalent models
and measures utilised to train and/or evaluate
cultural competence.

Correspondence: Fabricio E. Balcazar, Professor, Department of Disability and Human Development (M/C 626), University of Illinois at Chicago, 1640 West
Roosevelt Rd, Chicago IL 60608, USA. E-mail: fabricio@uic.edu
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa UK Ltd.
DOI: 10.1080/09638280902773752
1154 F. E. Balcazar et al.
Cultural competence literature review
We conducted a search of databases in the social
sciences (PsychINFO), education (ERIC) and health
(PubMed), as well as Google Scholar for all English-
language journal articles and books published from
1991 to 2006 using the following search terms:
cultural competence models, cultural knowledge,
cultural awareness, cultural competency research,
multiculturalism, minorities and cross-cultural ser-
vices/care. From these searches, we identified 259
peer reviewed articles and/or book chapters, exclud-
ing dissertations, technical reports and conference
presentations. Two independent reviewers examined
the abstracts of these documents and identified 32
publications that refer to cultural competence
models. After reviewing the full manuscripts, we
identified 18 articles representing unique cultural
competence models. We excluded nine articles that
offered professional guidelines for displaying cultu-
rally sensitive behaviours, but did not attempt to
provide a conceptual framework for explaining
cultural competence. We also excluded five articles
that illustrate factors that impact cultural diversity. A
complete list of the main components, their intended
utilisation and field of application can be found in
Balcazar et al. [14].
All of the models include cognitive and behaviour-
al components, with few attending to contextual
elements. The cognitive components emphasise
awareness and knowledge acquisition. The beha-
vioural components emphasise skills development –
such as being able to engage culturally diverse clients
in a genuine accepting manner [15]. Only five of the
models explicitly address learning about the context
of the people they are trying to serve [16–20]. In
addition, Poole [17] considered the need to examine
organisational policies to allow the agencies to hire
staff members (outreach) from the target community
and allow staff members to engage in the community
(e.g. attending evening and/or weekend events with
community members and/or agency clients). This is
a theme that would become a central component of
the U.S. Office of Minority Health (OMH) recom-
mendations [21].
Although the main focus of all of the models is
changing the behaviours of the professional practi-
tioners and/or changing their interactions with
people who are culturally different from them, only
four of the frameworks have developed assessment
instruments to evaluate their models. Camphina-
Bacote [12] developed and tested an inventory to
assess the process of acquiring cultural competence
with a sample of health care professionals. She later
replicated the study with a sample of rehabilitation
professionals serving people with disabilities [6].
Doorenbos and Schim [22] tested their model with a
sample of 113 hospice employees. Harris-Davis and
Haughton [23] also evaluated their model with a
sample of nutrition counsellors. Finally, Kim-God-
win et al. [24] tested their model with a convenience
sample of 192 nursing students. A systematic review
of the studies that evaluated interventions designed
to improve the cultural competence of health
professionals [25], indicated that training improves
the attitudes, knowledge and skills of trainees, and
that the training can impact patient satisfaction.
However, no studies have evaluated patient health
status outcomes resulting from cultural competence
training.
Finally, the majority of the models are in the field
of nursing or health care (72%), followed by
counselling (22%) and social work (6%). These are
occupations that involve a great deal of direct contact
between professionals and individuals from different
cultural backgrounds. In fact, many professional
organisations such as rehabilitation counselling [26]
and psychology [27] have revised their code of ethics
to include respect for cultural diversity as part of the
professional standards for education, training, re-
search and practice. For example, one of the guiding
principles for psychologists is to ‘recognise that, as
cultural beings, they may hold attitudes and beliefs
that can detrimentally influence their perceptions of
and interactions with individuals who are ethnically
and racially different from themselves’ [27, p 382].
In health care, the U.S. OMH is promoting national
standards for culturally and linguistically appropriate
services (CLAS) in all states.
A proposed model of cultural competence
On the basis of our review of the cultural competence
literature, we developed a synthesis model that
incorporates the most common elements identified
in the literature. Our model has four components.
The components reflect the iterative process (on-
going) of becoming culturally competent, which
suggests that as service providers become familiar
or comfortable working with a particular group of
people, they may be challenged by the emergence of
a different group and so on. A pre-condition of the
process is desire to engage, which reflects the
assumption that service providers seeking cultural
competence training must be willing to engage in the
process. Feist-Price and Ford-Harris [28] pointed
out that multicultural rehabilitation counselling is
especially critical for Anglo American counsellors
who often are poorly or inadequately trained in
understanding the cultural dynamics of consumers of
colour. However, service providers from any race or
ethnic group are likely to face similar challenges
when dealing with consumers from other races

and/or those who speak a different language than
English. In fact, Jones [29] argued that human
beings of any race or ethnicity share both similarities
and differences with each other. They are neither
different nor similar from each other, they are both.
This assertion helps explain why service providers
from one ethnic group may not necessarily attain
better results with consumers from the same group.
The following is a brief description of the model
components.
First, critical awareness reflects an understanding
of our personal biases towards people who are in any
way different from us, and a critical examination of
our own position of privilege in society, including
class differences and experiences of oppression. The
process of self-reflection allows professionals to
examine their personal attitudes toward others, and
to foster views about acceptance, inclusion, and
consideration of the rights of others. Leininger [30]
argued that without critical awareness, researchers
and service providers tend to impose their beliefs,
values and patterns of behaviour upon cultures other
than their own, making it harder to recruit and
sustain the participation of minorities in research and
service use.
Second, cultural knowledge leads to familiarisa-
tion with others’ cultural characteristics, history,
values, belief systems and behaviours. Several
researchers (e.g. [8]) have conducted detailed re-
views of the complex cultural characteristics of
multiple ethnic or national groups, particularly
regarding health-related practices, rituals associates
with birth and death and nutritional practices. This
information is becoming increasingly available with
the advent of the internet. Sawyer et al. [31] defined
cultural knowledge as the practitioner’s understand-
ing of integrated systems of learned behavioural
patterns in a cultural group including the ways in
which members of this group talk, think and behave
and their feelings, attitudes and values. We argue
that a critical way to know about others is to
understand the factors that influence diversity. On
the basis of our review of the literature, we identified
several factors that are primarily responsible for
determining cultural diversity – establishing our
similarities and/or differences with one another.
There are both observable and non-observable
factors that contribute to diversity. Any one of the
observable factors (i.e. race/ethnicity, age, gender,
disability and attractiveness) is among the first things
that people notice about a person, which may trigger
differential responses. Research evidence suggests
that race plays a central role in predicting poor or
limited outcomes – in the case of minority groups –
for employment, education, rehabilitation and/or
health outcomes, particularly when associated with
other factors like low-socioeconomic status, limited
Cultural competence 1155
levels of education and/or immigration status (e.g.
[32,33]). The non-observable factors (i.e. socio-
economic status, experience of oppression, educa-
tion, religious affiliation, level of acculturation, etc)
reflect the complexity of the individuals that interact
with a service provider in a given time.
Third, skills development refers to the ability of
the professional to communicate effectively and
empathically with the consumer, being able to
incorporate the consumer’s beliefs, values, experi-
ences and aspirations into the provision and planning
of the services [34]. The process requires multiple
skills like problem solving [35]; understanding the
dynamics of oppression, racism, sexism, classism and
other forms of discrimination [15]; understanding
the complexity of the service delivery systems
[16,18]; increased awareness of personal biases
[22,36–38]; having knowledge of the context that
influence the behaviours of individuals and families
[17]; and utilising a process of questioning that
recognises individuals as the experts of their own
experience [39]. We also argue that, to be able to
better understand and interact with their clients,
service providers need to develop communication
skills that would allow them to identify the non-
observable factors mentioned earlier and recognise
how the external and internal factors play out in the
cultural encounter.
Fourth, practice/application refers to the process
of applying all of the previous components in a
particular context. Perhaps, the most difficult part of
addressing cultural competence is implementing
individual and organisational practices that will
improve professionals’ ability to deliver care in a
culturally competent way. In the USA, the OMH of
the Department of Human Services has proposed
standards for CLAS in health care [21]. These
standards are intended to influence professional
practice in all health-related areas and are guiding
most professional practice in the human services
area.
A validated model of cultural competence
One of the shortcomings in the current cultural
competence research literature is the limited number
of validated measures available to assess cultural
competence and the very limited number of validated
conceptual frameworks. Suarez-Balcazar et al. [40]
reviewed the literature on scales and cultural
competence assessment instruments and identified
13 scales, nine of which included psychometric
properties and were validated – three with practi-
tioners samples, three with mixed samples of
practitioners and students and three with student
populations only. Examples of such scales include
1156 F. E. Balcazar et al.
Campinha-Bacote [12], who validated her scale with
licensed nurses and nursing students and measured
four factors: cultural awareness, cultural knowledge,
cultural skills and cultural encounters. Another scale
often used in the counselling psychology literature is
the multicultural awareness, knowledge and skills
survey, developed by Kim et al. [41] which measures
three components: cultural awareness, knowledge
and skills. A third scale often used to measure
cultural competence in the context of psychological
counselling is the multicultural counselling inventory
developed by Sodowsky [42] and designed to
measure multicultural counselling skills, awareness,
multicultural relationships and knowledge.
The most common domains measured in the 13
scales we found in the psychology, social science and
health literatures included cultural awareness,
knowledge and skills. Although these are essential
components for understanding, conceptualising and
measuring cultural competence, recent studies have
found the importance of environmental and con-
textual features in promoting cultural competence
among practitioners [43]. The only measure to
include contextual and setting-related items is
Goode’s [44] cultural competency self-assessment
checklist, which includes a subscale on character-
istics of the practitioner’s office physical environ-
ment, materials and resources. However, Goode
does not mention psychometric or validation data of
her checklist. Therefore, the need to develop and
validate an instrument to assess cultural competence
among practitioners that includes specific items
related to contextual factors such as an organisation’s
support for engaging in behaviours that support
cultural competence remains.
Suarez-Balcazar et al. [40] developed and vali-
dated the cultural competence assessment instru-
ment – University of Illinois at Chicago (CCAI-UIC)
with a sample of 477 occupational therapy practi-
tioners. The CCAI-UIC is a self-report instrument
that does not directly measure cultural competence
behaviours or performance. The original instrument
was developed on the basis of previous studies and
our own experiences and included 49 items that
measured four components: awareness, knowledge,
skills and practice/application of cultural competence
(a detailed description of the development and
validation of the CCAI-UIC, including psychometric
data, can be found in Suarez-Balcazar et al. [40]). A
factor analysis confirmed the presence of three of the
four original components – the two components of
critical awareness and cultural knowledge were
combined into one cognitive factor, the behavioural
factor was retained and a new contextual factor was
identified. The resulting instrument has 24-items
(see a copy in Table I). The CCAI-UIC assesses
cultural awareness/knowledge (Eight items, Cron-
bach’s a ¼ 0.76); skills (Eight items, Cronbach’s
a ¼ 0.82); and organisational support (Eight items,
Cronbach’s a ¼ 0.80). All CCAI-UIC survey ques-
tions were rated using a four-point scale in which
four was strongly agree and one was strongly
disagree1.
The resulting conceptual model is depicted in
Figure 1. The model assumes the professional’s
desire to engage individuals of diverse cultural/ethnic
backgrounds. The cognitive factor refers to the
appreciation and understanding of different cultures
and acknowledgement of one’s potential biases
towards other cultures. The skills factor assesses
the degree to which one possesses the necessary
abilities to adjust professional practice to address the
needs of multicultural populations. The new con-
textual factor – organisational support for multi-
cultural practice – assesses the institutional or work
setting value placed in the promotion of other
cultures and the contextual opportunities to become
culturally competent. The degree of organisational
support for engaging in culturally competent prac-
tices is important because employees may be knowl-
edgeable and critically aware of diversity issues with
their consumer population but the agency may have
policies that discourage ethnically diverse individuals
from seeking services there. For instance, staff
members may need flexibility in serving clients who
do not make prior appointments but show up for
services; or staff may have to be available in the
evenings or on weekends to serve clients who can not
take time off from work during the regular week
schedule. Availability of translators and/or informa-
tional materials in languages other than English that
reflect the target community demographics are
important and often require institutional investment.
Similarly, having a diverse staff enhances the cred-
ibility and visibility of the agency among diverse
groups in the target community. Half of the U.S.
Department of Health and Human Services OMH
standards for CLAS [21] are directly related to
organisational supports for cultural competence
(Standards 8–14). For example, Standard 11 says,
‘Health care organisations should maintain a current
demographic, cultural and epidemiological profile of
the community as well as a needs assessment to
accurately plan for and implement services that
respond to the cultural and linguistic characteristics
of the service area’. Agencies serving individuals with
disabilities in the US are being encouraged to follow
these standards. We were please to find that this
emphasis on organisational support for cultural
competence is consistent with the findings from
our study.
The center on capacity building for minorities with
disabilities research at the University of Illinois at
Chicago has developed a series of training workshops
 Cultural competence 1157

Table I. Cultural competence assessment instrument (CCAI – UIC).

Strongly Strongly
Considering your work over the past year agree Agree Disagree disagree

I feel that I can learn from my ethnic minority clients 4 3 2 1

It is hard adjusting my therapeutic strategies with ethnic minority clients 4 3 2 1
I am effective in my verbal communication with clients whose culture is different from mine 4 3 2 1
My organisation does not provide ongoing training on cultural competence 4 3 2 1
I do not consider the cultural backgrounds of my clients when food is involved 4 3 2 1
I receive feedback from supervisors on how to improve my practice skills with clients from 4 3 2 1
different ethnic minority backgrounds
At work, pictures, posters, printed materials and toys reflect the culture and ethnic 4 3 2 1
backgrounds of ethnic minority clients
I feel confident that I can learn about my clients’ cultural background 4 3 2 1
Cultural competence is included in my work place’s mission statement, policies and 4 3 2 1
procedures
I am effective in my nonverbal communication with clients whose culture is different from 4 3 2 1
mine
The way services are structured in my setting makes it difficult to identify the cultural values 4 3 2 1
of my clients
I feel that I have limited experience working with ethnic minority clients 4 3 2 1
It is difficult to practice skills related to cultural competence 4 3 2 1
I am sensitive to valuing and respecting differences between my cultural background and 4 3 2 1
my clients’ cultural heritage
My workplace does not support using resources to promote cultural competence 4 3 2 1
I have opportunities to learn culturally responsive behaviours from peers 4 3 2 1
I do not feel that I have the skills to provide services to ethnic minority clients 4 3 2 1
I examine my own biases related to race and culture that may influence my behaviour as a 4 3 2 1
service provider
I actively strive for an atmosphere that promotes risk-taking and self-exploration 4 3 2 1
My work place does not support my participation in cultural celebrations of my clients 4 3 2 1
I would find it easy to work competently with ethnic minority clients 4 3 2 1
I openly discuss with others issues I may have in developing multicultural awareness 4 3 2 1
I learn about different ethnic cultures through educational methods and/or life experiences 4 3 2 1
It is difficult for me to accept that religious beliefs may influence how ethnic minorities 4 3 2 1
respond to illness and disability

that typically last 6–9 h and include lectures, group
activities and discussions. To date, Center staff has
conducted 35 trainings between 2005 and 2008,
involving over 1000 staff from 68 disability-related
organisations. Training participants have been very
satisfied with the trainings (Mean rating ¼ 4.83, on
a 1–5 scale). A unique feature of our trainings is
that we invite staff members to set goals they believe
will improve some aspect of cultural competence in
their respective organisation. Thus, our workshops
become an opportunity to engage in a process of
organisational change. Participants are free to
choose the direction and extent of the process.
Many participants are actually surprised to learn
that we are willing to provide free technical
assistance for upto 6-months following the training.
The reason is that real change can not take place
after a one-time workshop and the funding agency
(the National Institutive on Disability and Rehabi-
litation Research) supports our vision. We have
provided follow-along consultation and technical
assistance to 48 organisations (70% of the total
number participating) that elected to set goals (a
total of 328 goals were set during the training
workshops). We have successfully completed be-
tween 1 and 3 follow-up interviews with 120
departments/offices within those organisations. We
are currently analysing those findings and hope to
publish them in the near future. We are also
engaged in the process of developing a 2-h web-
based version of the training that could be used to
introduce service providers to the basic components
of our cultural competence conceptual model2.
Discussion
As suggested by the proposed conceptual model of
cultural competence, the process starts with personal
desire to engage other cultures, developing knowl-
edge of different cultures and a critical under-
standing of our personal biases, developing skills
that would allow us to effectively engage people from
diverse cultures and the degree of organisational
1158 F. E. Balcazar et al.
Figure 1. Revised cultural competence conceptual framework after empirical validation.
support for engaging in culturally competent prac-
tices. Cultural competence is attained gradually and
the skills involved require knowledge of the state-of-
the art in care and service delivery. But the
application of cultural competence involves organi-
sational and systemic changes. Service providers do
not function in a vacuum. Their efforts and practices
are often a function of the policies and guidelines of
the agency where they work. We concluded that one
of the reasons the organisational factor did not come
out in the original model is because the research
literature is strongly influenced by a clinical model
that emphasises individual knowledge, awareness
and skills change. In fact, a practitioner might have
the best intentions of developing cultural compe-
tence herself but if her work place is not supported of
her taking workshops, addressing issues with multi-
cultural populations, trying to change her work
schedule to be more accessible or conducting
outreach activities in the community, she might not
be successful in her efforts. Therefore, organisational
support seems to be a very important factor in
determining the capacity of individual practitioners
to deliver culturally competent services.
This conceptual framework has been used to train
many rehabilitation professionals (over 1000 thus
far) in the State of Illinois and the Midwest region of
the US. Our training efforts are about to increase
exponentially, as we have recently secured a contract
to develop a web-based training version of the model
to train state employees from a large social service
agency (Department of Human Services), which has
over 14 000 employees in all areas of disability and
social services.
Culture is always evolving and the amount of
knowledge necessary to understand different cul-
tures is vast and our very being in the contempor-
ary, interconnected world requires cultural
understanding as never before. Attending to cultur-
al variations and developing sensitivity and aware-
ness of the cultures in our social contexts are
necessary to help us achieve cultural competence
[2,5]. Becoming culturally competent is an inten-
tional endeavor, a journey and a life-long process
[13,14]. The development of cultural competence
means our willingness to engage in a series of
activities such as examining the institutional biases
of traditional practices and services of the agencies
we work for; being open and willing to accept
individuals from other cultures; trying non-tradi-
tional interventions or changing standard proce-
dures to better address individual needs; and
challenging racist practices, discrimination and
oppression when observed.

Acknowledgements
This project was supported in part by a grant from
the National Institute on Disability and Rehabilita-
tion Research (NIDRR) of the U.S. Department of
Education to the Center for Capacity Building on
Minorities with Disabilities Research, award no.
H1333A040007. The opinions expressed here are
ours and not necessarily those of NIDRR.
Notes
1. Copies of the instrument are available from the first author
upon request.
2. For information about the web-based training, please visit our
website: http://www.disabilityempowerment.org/.
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