Introduction: Telehealth allows behavioral health care and specialty services to be extended to rural residents. Telehealth is an important resource for the Alaskan healthcare system, which is tasked with providing services to culturally diverse populations living in remote areas. Training competent providers to deliver telehealth services is vital for the implementation of successful telehealth programs. Yet, the literature is lacking in the area of provider behavioral telehealth competency training. Methods: This study assessed the impact of a Behavioral Telehealth Ethical Competencies Training program on 16 behavioral health providers' development of behavioral telehealth competency. A total of 14 competencies were developed, which required participants to understand the roles and responsibilities of a behavioral telehealth coordinator working at the distal site as well as the roles and responsibilities of the therapist. Video vignettes evaluating the 14 competencies, self-reported competence surveys and follow-up surveys of progress on telehealth goals were utilized to assess effects of the training. Results: Results indicated participants' behavioral telehealth competencies increased following training. Participants reported positive perceptions regarding their competency, and achieved progress on the majority of behavioral telehealth goals set during the training. Conclusions: This study provides a baseline for developing a best practice model for behavioral telehealth service delivery by identifying specific provider competencies for administering effective behavioral telehealth services. A unique continuing education training model, led by content experts including university professors and Alaska Native Elders, incorporating behavioral telehealth, rural ethics, cultural competency and vicarious trauma training is described. Lastly, this study details the use of an innovative video vignette assessment instrument for evaluating the effectiveness of continuing education training.

Cultural competence serves as resource for social workers and other helping professionals to improve service delivery by using approaches that are compatible with the client’s cultural values and beliefs. As the Latino population continues to grow, understanding the culture has important implications for social work practice, advocacy and research. There is a dearth of cultural competence training and educational programs that seek to effectively identify, address and meet the unique cultural and linguistic needs of Latinos. With the growing population and a lack of culturally responsive services, clinicians familiar with the Latino culture and Latino cultural competency training and education programs, disparities among Latinos will continue to steadily rise. It is important for social work students and clinicians to receive advanced training in understanding the diverse needs of Latino populations. The purpose of this thesis is to review the existing literature to identify culturally competent practice methods and examine efforts to prepare social work students and clinicians to work with the Latino population. A search was conducted using PsychINFO, PubMed, Education Resources Information Center (ERIC) and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases. Key terms used in the searches were“cultural competency training”, “cultural competency education” and/or “social work/clinician” coupled with terms Hispanic or Latino. This thesis concludes with some considerations for integrating Latino cultural competency into the social work curriculum.

Syftet med denna studie är att undersöka vilken innebörd begreppet ”kulturkompetens” ges i litteraturen samt utifrån detta problematisera dess applicering på praktiken. Begreppet ”kulturkompetens” saknar en enhetlig definition, något som initierat skrivandet av denna uppsats. Studien bygger på en litteraturstudie i form av en kvalitativ textanalys. I vår kritiska granskning av litteraturen kunde vi bland annat finna begrepp, såsom ”ethnic-sensitivity” och ”cultural awareness”, som på liknande sätt berör strategier för att uppnå ”kulturkompetens”. Självinsikt hos socialarbetaren och öppenhet inför kulturella skillnader är viktiga egenskaper hos en ”kulturkompetent” socialarbetare enligt handböckerna. Genom en granskning av de begrepp vi funnit i litteraturen var för sig, men även genom jämförelse av dem, har vi bland annat funnit att kultur nästan genomgående kopplas till etnicitet i diskussionerna kring ”kulturkompetens”. I problematiseringen av begreppet har vi pekat på hur mötet mellan socialarbetaren och klienten kan komma att påverkas då socialarbetaren utgår från tankar kring ett ”kulturkompetent” bemötande. / The purpose of this study is to investigate what meaning the concept "cultural competence" is given in the literature and from this problematize its application to practice. The concept "cultural competence" has no uniform definition, which initiated the writing of this essay. The study is based on a literature review in the form of a qualitative text analysis. In our critical review of the literature we could find, among other concepts, "ethnic-sensitivity" and "cultural awareness", which is similarly related to strategies for achieving "cultural competence". Self-knowledge of the social worker and openness to cultural differences are important characteristics of a "culture competent” socialworker according to the guiding literature for social workers. Through an separately examination of the concepts we found in the literature , but also by comparing them, we have found that culture almost always is linked to ethnicity in debates on "cultural competence". In the problematization of the meaning of “culture competence” as a concept, we have pointed out how the meeting between the socialworker and the client may be affected when the social work is based on thoughts of "cultural competence".

BACKGROUND: This doctoral project describes an occupational therapy clinic created by this author within an outpatient health center located on a rural reservation serving the Navajo Native-American community residents. This was the center’s first occupational therapy program. Occupational therapy services included community outreach activities and innovative approaches that were inclusive, culturally appropriate, and client-centered. PROBLEM: Some challenges occurred during the implementation of the occupational therapy program such as: client resistance, cultural differences, lack of public transportation to the reservation, little to no awareness of occupational therapy, and limited funds and resources. METHODOLOGY: A thorough literature review on developing healthcare programs in rural areas was performed to collect relevant information on current methods and approaches. Moreover, programs that incorporated cultural orientation programs and awareness was taken into consideration to develop the occupational therapy program and its activities. This facilitated building a positive rapport and relationship with the Navajo community residents. RESULTS: Innovative approaches were developed to help reduce some of the barriers. Four key program elements were chosen to focus on developing a sustainable and culturally appropriate operating occupational therapy clinic to serve the Navajo Native Americans living on a rural reservation community. Collaboration with pertinent stakeholders, integration of some of the population’s cultural values, conveying cultural respect, and including community outreach events helped the development and operation of the new occupational therapy program. IMPLICATIONS: The development of the new occupational therapy clinic provided several occasions for the clinician to integrate culturally-based activities when providing services to an underserved community. It was able to set an example for future occupational therapy practitioners to create an academic course (and/or internship) to educate students about providing occupational therapy services to an indigenous population.

Culturally diverse clients often face barriers to accessing and using health and education services, which may affect the clients’ performance outcomes and impact the quality of services. These barriers include practitioners’ insufficient cultural competence and humility and an ineffective health care system. The Cultural Humility program aims to train and educate occupational therapy practitioners to gain confidence and improve their cultural humility and practical communication skills to maintain, establish, and manage therapeutic relationships. The program duration will be twelve 2-hour biweekly sessions over 6 months, in person at clinical settings or on a virtual platform. The program includes learning modules, such as lectures, simulation or video modeling, and discussion sessions with brain-based learning for occupational therapy practitioners. The program will provide meaningful opportunities for practitioners to reflect on their practice attitudes, gain confidence, change their mindsets, and learn practical communication skills for use with clients from various cultural backgrounds. The aim of the Cultural Humility program is to apply these practical techniques related to cultural humility, bringing synergy and authenticity to practitioners’ daily practice, and improving their clients’ performance and outcomes.

Public school closures and the provision of occupational therapy services during the COVID-19 pandemic revealed inequities and barriers that affect Latinx families’ and children’s access to resources. In Massachusetts, many students receiving occupational therapy services may have missed mandated and necessary occupational therapy services due to systemic barriers and the lack of skills to advocate for their needs. Occupational therapy practitioners (OTPs) may have lacked the self-efficacy and ability to facilitate the families’ advocacy. Culturally appropriate evidence-based interventions are needed to serve Latinx families and their children and prevent them from being underserved. A literature review identified that OTPs might not have the necessary skills to work effectively with culturally diverse groups. This skills gap reduces the OTPs’ ability to provide culturally appropriate interventions and holistic care to Latinx children and their families. A proposed solution to this problem is the 6-month, theory- and evidence-based I AM. Intercultural Advocacy and Mentoring Program: Increasing Occupational Therapy Practitioners’ Advocacy Skills in Collaboration With Latinx Families With Young Children for OTPs who work with Latinx families and children. The program aims to promote OTPs’ self-efficacy, cultural humility, and rapport- and trust-building skills. The I AM Program will ensure professionals working with Latinx families and children practice cultural humility, thus enhancing services for the client and building strong, trusting relationships and thriving communities.

This PhD by published work consists of: five single authored articles in refereed journals; two main author articles in refereed journals; four jointly authored articles in refereed journals; a single authored article in a non-refereed journal; one jointly authored book, including five single authored chapters; two single authored chapters in edited books. They were published in the period 2003-2013. None has been submitted for any other degree or diploma by me or any other person. The theme running through these publications is the need for social workers to pay significant attention to issues arising from religion, belief and culture. The research reported highlights the impact of such issues on the lives, experiences, resources and responses of individuals, groups and communities for whom they are important. The work emphasises the importance of developing such understanding and of enhancing knowledge of different ways in which religion, belief and culture impact on the issues that social workers deal with. I suggest that these are essential aspects of culturally competent social work practice which have too often been neglected in both research and professional training. The publications are listed in Appendix 1 (pp 56 - 59). They demonstrate how my thinking has developed over the past decade. They reflect and are, in part, a response to the developing professional, theoretical and political ii context within which I have operated as a social work practitioner, manager and academic over a longer period. The majority are solo-authored. However, I remain committed to collaborative work and recognise that discussions with those researched, my collaborators, and others remain invaluable to the ongoing development of my thinking. Joint authorship declaration forms have been completed, in respect of all relevant publications, and are appended. Eight publications (Art.12, Art.11, Art.10, Art.9, Art.8, Art.6, Art.5 and Art.3) are based on findings from primary research, while Art.1 and Art.2 explore published data or data supplied by others to provide original analyses of particular issues. The remaining publications, notably book chapters, are primarily conceptual in their approach. They are underpinned by findings from both the primary research reported elsewhere and the use of case examples collected from semi-structured interviews with social work practitioners. / PhD by published work. The published articles are not displayed in full text with the online version of the PhD due to publisher copyright restristrictions.

Background: The nursing workforce needs to be adequately prepared to deliver care to an increasingly diverse patient population in the United Kingdom (UK). The Nursing and Midwifery Council (NMC) expects newly qualified nurses (NQNs) to deliver culturally sensitive and respectful care. Aim: The study aimed to explore NQNs’ perceptions of culturally competent practice during the first 9 months post qualification. Methods: A qualitative longitudinal study was conducted with a volunteer sample of 14 NQNs recruited from 3 Higher Education Institutions in the north of England. Data was collected using directed reflections (at 2-3 and 5-6 months) and semi-structured interviews (at 8-9 months) and analysed using a phenomenological approach informed by symbolic interactionism. Results: Perceptions of culturally competent nursing practice were associated with core concepts such as individualised patient care, compassionate and respectful care, respecting individual differences, professionalism and patient trust. Specific behaviours were associated with verbal and non-verbal communication, care planning and diversity-specific adjustments. Discussion: Self-perceived competence and confidence in caring for, and interacting with, patients from diverse backgrounds developed and changed throughout the transition period with experience and interaction opportunities. An ability to reflect upon and learn from novel experiences, plus an enabling ward culture and environment which responded positively to nurses seeking advice and support was important. Conclusion: Educational preparation may have enabled NQNs’ opportunities to develop some but not necessarily all of the skills and behaviours required to demonstrate culturally competent practice. During transition, supported development and professional socialisation can assist in enhancing competence and confidence.

Background: Much research consistently shows that there are disparities in healthcare delivery. Healthcare disparities affect individuals across a broad range of demographics such as gender, race or ethnicity, and it is also related to socioeconomic factors such as income levels, access to health benefits and insurance, and health literacy. Recent immigrants to Canada encounter a different and unfamiliar healthcare system. This situation presents challenges to the practice of health care delivery. Therefore, it is crucial that innovative strategies be identified to reduce disparities in health care to promote the overall quality of care and public health services. Purpose: The purpose of this dissertation research was two-fold: (1) to examine cultural competence strategies, if any, that are used by healthcare organizations to improve interaction and communication between healthcare providers and their immigrant patients with the purpose to reduce healthcare disparities; and specifically, (2) to explore the use of Information and Communications Technologies (ICTs) to improve communication between healthcare providers and immigrant patients with the objective of reducing healthcare disparities. Methods: This dissertation research employed a mixed methods approach for data collection and analysis. The research was carried out in three phases. In the first phase, a series of focus group discussions with a sample of recent immigrants was conducted. In the second phase, an online survey was conducted to gain insights from healthcare providers regarding the role of ICTs in improving communication with immigrant patients to help reduce healthcare disparities. In the third phase, healthcare providers who participated in the survey were invited to participate in face-to-face, in-depth semi-structured interviews to further reflect on and extend the survey responses. Campinha-Bacote's Cultural Competence Model and Unified Theory of Acceptance and Use of Technology were employed for this dissertation research as its theoretical framework. Results: The findings indicated that the absence of effective communication as well as cultural and language barriers were major issues related to communication between healthcare providers and immigrant patients. The findings also indicated that immigrant patients might need to improve their digital and health literacy skills in order to improve their communication with their healthcare providers. Further, the findings indicated that it was important for healthcare providers to have access to more demographic data on immigrant patients because such data will allow healthcare providers to be better informed on how to most effectively tailor their healthcare services to this population group. Conclusion: Findings obtained from this dissertation research shed light on cross cultural communication issues related to working with immigrant patients that may lead to disparities in health care. Healthcare organizations may use these findings to better inform their decision making with regard to effective patient-provider communication. Finally, the findings bear important implications for the line of research that examines patient-provider communication from immigrant patients' perspectives. They can inform the design of cultural competence strategies for healthcare organizations.

Our world is evolving into a global community. Increased access to travel, diversification of the population, human displacement and migration, and advances in technology contribute to this evolution. Globalization can impact the health and well-being of humankind. Organizations such as AOTA (2017) and WFOT (2018) advocate for occupational therapists promoting health, well-being and occupation as a human right globally (WFOT, 2006). However, therapists are mostly untrained and unmotivated to ‘think globally and act locally’. This problem is due to OTs adhering to traditional, practices and paradigms, learning the profession within a local context with an emphasis on western theories, a focus on individualized care and an inability to recognize human-rights issues with clients. OTs must become global citizens in order to bring relevant health promotion and wellness interventions to people with different worldviews and in global communities. The program was developed into a course for post-professional doctoral students at Boston University to learn skills and confidence to become an agent of global change titled “The Occupational Therapist as A Global Citizen”. This course was designed with an evidence base and theoretical foundation in Self-Determination Theory to improve the students’ motivation and confidence to act as a global agent of change and promote occupational justice. Preliminary findings of the program revealed three main themes in the students’ thoughts regarding global citizenship. Students reported a positive learning experience coupled with a curiosity to expand and apply their knowledge, feelings of motivation and inspiration and an increased sense of responsibility to use their role as an OT to promote occupation as a human right. The proximal goals of this program were achieved in a cost-effective manner. It will be repeated as a full-scale study in 2019 and the project will be widely disseminated to occupational therapy and global health audiences.