Cross-cultural adaptation and psychometric properties of the Herth Hope Index in Kinyarwanda: adapting a positive psychosocial tool for healthcare recipients and providers in the Rwandan setting.

BACKGROUND: The lack of culturally appropriate instruments to measure hope across cultural settings is a barrier to assessing and addressing the relationship between hope and health outcomes. The study aim was to adapt and evaluate the psychometric properties of the Herth Hope Index (HHI) in Kinyarwanda in a population of healthcare recipients and healthcare workers in Rwanda. METHODS: A transcultural translation and adaptation of the HHI was conducted using qualitative methods (n = 43) to achieve semantic, content, and technical equivalence. The adapted instrument was administered to a purposive sample (n = 206) of Rwandan healthcare patients and providers. Temporal reliability, internal reliability using Cronbach's alpha, and construct validity using confirmatory factor analysis (CFA) were assessed. RESULTS: The Herth Hope Index-Kinyarwanda (HHI-K) was found to have strong internal consistency (α = 0.85) and test-retest reliability (r = 0.85). The original HHI three-factor structure fit the data well in CFA (normed chi-square = 1.53; root mean square error of approximation = 0.05; standardized root mean square residual = 0.05; comparative fit index = 0.96; Tucker-Lewis Index = 0.95). CONCLUSION: This article presents the first rigorous cultural adaptation of the HHI in a low-income country. The HHI-K has acceptable psychometric properties, resulting in a new useful tool for research, program development, and evaluation in Rwandan healthcare settings. The HHI-K instrument can be used to assess the effectiveness of programs that aim to promote hope and health outcomes across health system- and individual-levels. The process also provides a feasible model for adaptation of a positive psychosocial tool for both patients and providers in low-resource settings.

Measuring affiliation in group therapy for substance use disorders in the Women's Recovery Group study: Does it matter whether the group is all-women or mixed-gender?

BACKGROUND AND OBJECTIVES: A Stage II, two-site randomized clinical trial compared the manualized, single-gender Women's Recovery Group (WRG) to mixed-gender group therapy (Group Drug Counseling; GDC) and demonstrated efficacy. Enhanced affiliation and support in the WRG is a hypothesized mechanism of efficacy. This study sought to extend results of the previous small Stage I trial that showed the rate of supportive affiliative statements occurred more frequently in WRG than GDC. METHODS: Participants (N = 158; 100 women, 58 men) were 18 years or older, substance dependent, and had used substances within the past 60 days. Women were randomized to WRG (n = 52) or GDC (n = 48). Group therapy videos were coded by two independent raters; Rater 1 coded 20% of videos (n = 74); Rater 2 coded 25% of videos coded by Rater 1 (n = 19). RESULTS: The number of affiliative statements made in WRG was 66% higher than in GDC. Three of eight affiliative statement categories occurred more frequently in WRG than GDC: supportive, shared experience, and strategy statements. DISCUSSION AND CONCLUSIONS: This larger Stage II trial provided a greater number of group therapy tapes available for analysis. Results extended our previous findings, demonstrating both greater frequency of all affiliative statements, as well as specific categories of statements, made in single-gender WRG than mixed-gender GDC. SCIENTIFIC SIGNIFICANCE: Greater frequency of affiliative statements among group members may be one mechanism of enhanced support and efficacy in women-only WRG compared with standard mixed-gender group therapy for substance use disorders. (Am J Addict 2016;25:573-580).

Dendritic cell vaccines containing lymphocytes produce improved immunogenicity in patients with cancer.

BACKGROUND: Dendritic cells are currently under investigation for their ability to generate anti-cancer immune responses. No consensus has been reached as to the optimal method of dendritic cell vaccine preparation and is a barrier to success in the field. METHODS: Over a course of three separate dendritic cell vaccine studies to treat cancer, we tested two different methods for preparing dendritic cells from peripheral blood mononuclear cells: adherence and antibody-selected CD14+ cells. RESULTS: Surprisingly, we found that patients who received dendritic cell vaccines generated by the adherence method mounted increased T cell proliferation in response to vaccination. This difference could not be accounted for by dendritic cell vaccine dose, cell surface phenotype or dendritic cell function in vitro. One notable difference between the two vaccine preparation methods was that the dendritic cell vaccine cultures generated by the adherence method contained up to 10% lymphocytes, and these lymphocytes were proliferating and producing IFNγ in response to antigen in vitro at the time of administration. CONCLUSIONS: Enhanced immunogenicity of adherence dendritic cell vaccinations may be due to the presence of lymphocytes during dendritic cell culture. TRIAL REGISTRATION: Clinicaltrials.gov identifiers: NCT00289341, NCT00345293, and NCT00893945.

Predictors of drinking and functional outcomes for men and women following inpatient alcohol treatment.

BACKGROUND AND OBJECTIVES: This prospective study uses path analytic models to examine baseline characteristics associated with both functioning and drinking outcomes 12 months after inpatient alcohol treatment. METHODS: Alcohol-dependent participants (N = 101) were recruited during inpatient alcohol treatment and assessed monthly 1 year after discharge. RESULTS: Alcohol severity was negatively associated with education and self-efficacy; marital status was positively associated with self-efficacy; and education and self-efficacy were negatively associated with drinking outcomes. Low alcohol severity, not having a depression diagnosis, and being married were associated with less social support impairment, which was in turn associated with better drinking outcomes. Having a history of sexual abuse did not influence drinking outcomes. However, having a history of sexual abuse was negatively associated with global functioning. CONCLUSIONS AND SCIENTIFIC SIGNIFICANCE: Drinking outcomes were associated with education, self-efficacy, social support, and diagnosis of depression at baseline; however, global functioning 1 year following treatment was primarily and negatively associated with sexual abuse history. Future treatment research should include measures of both functioning and drinking behavior outcomes.

Implementing substance abuse group therapy clinical trials in real-world settings: challenges and strategies for participant recruitment and therapist training in the Women's Recovery Group Study.

BACKGROUND AND OBJECTIVES: Open-enrollment group therapy research is challenged by the participant recruitment necessary to ensure continuous group enrollment. We present successful strategies to overcome the following barriers during the Women's Recovery Group (WRG) two-site clinical trial (N = 158): maintenance of sample size and balanced gender randomization during continuous enrollment, maintenance of group attendance, and training and retention of therapists over the 24-month continuous group enrollment. METHODS: To increase recruitment, we targeted referral sources yielding the highest enrollment conversion at each site. Group sessions were consistently held regardless of group size. Therapists were trained in two teams allowing for coverage and uninterrupted treatment over 24 months. RESULTS: At both sites recruitment and enrollment increased with each successive quarter. Sample size and end date targets were met without disruptions in treatment. Group therapists reported high satisfaction with their training and treatment experiences. DISCUSSION AND CONCLUSIONS: These strategies supported targeted enrollment and study duration, stability of open-enrollment group therapy frame, and therapist retention and satisfaction. SCIENTIFIC SIGNIFICANCE: Applying these strategies can aid in providing evidence-based group therapy in both clinical and research settings.

Assessing ad-hoc adaptations' alignment with therapeutic goals: a qualitative study of lay counselor-delivered family therapy in Eldoret, Kenya.

BACKGROUND: A key question in implementation science is how to balance adaptation and fidelity in translating interventions to new settings. There is growing consensus regarding the importance of planned adaptations to deliver interventions in contextually sensitive ways. However, less research has examined ad-hoc adaptations, or those that occur spontaneously in the course of intervention delivery. A key question is whether ad-hoc adaptations ultimately contribute to or detract from intervention goals. This study aimed to (a) identify ad-hoc adaptations made during delivery of a family therapy intervention and (b) assess whether they promoted or interrupted intervention goals. METHODS: Tuko Pamoja (Swahili: "We are Together") is an evidence-informed family therapy intervention aiming to improve family dynamics and mental health in Kenya. Tuko Pamoja employs a task-shifting model, delivered by lay counselors who are afforded a degree of flexibility in presenting content and in practices they use in sessions. We used transcripts of therapy sessions with 14 families to examine ad-hoc adaptations used by counselors. We first identified and characterized ad-hoc adaptations through a team-based code development, coding, and code description process. Then, we evaluated to what extent ad-hoc adaptations promoted the principles and strategies of the intervention ("TP-promoting"), disrupted them ("TP-interrupting"), or neither ("TP-neutral"). To do this, we first established inter-coder agreement on application of these categories with verification by the intervention developer. Then, coders categorized ad-hoc adaptation text segments as TP-promoting, TP-interrupting, or TP-neutral. RESULTS: Ad-hoc adaptations were frequent and included (in decreasing order): incorporation of religious content, exemplars/role models, community dynamics and resources, self-disclosure, and metaphors/proverbs. Ad-hoc adaptations were largely TP-promoting (49%) or neutral (39%), but practices were TP-interrupting 12% of the time. TP-interrupting practices most often occurred within religious content and exemplars/role models, which were also the most common practices overall. CONCLUSION: Extra attention is needed during planned adaptation, training, and supervision to promote intervention-aligned use of common ad-hoc adaptation practices. Discussing them in trainings can provide guidance for lay providers on how best to incorporate ad-hoc adaptations during delivery. Future research should evaluate whether well-aligned ad-hoc adaptations improve therapeutic outcomes. TRIAL REGISTRATION: Pilot trial registered at clinicaltrials.gov (C0058).

Impact of online Mindfulness-Based Cognitive Therapy on suicidal ideation: A secondary analysis of a randomized trial of Mindful Mood Balance.

BACKGROUND: To address the elevated prevalence of depression, suicide, and suicidal ideation, patients require increased access to effective interventions. Mindfulness-Based Cognitive Therapy has a strong evidence base in relapse prophylaxis and can be delivered digitally through Mindful Mood Balance (MMB). METHODS: This study was a secondary analysis of the impact of MMB paired with usual depression care (UDC) compared to UDC alone on patients in a randomized clinical trial for residual depression (Segal et al., 2020) who had a history of attempted suicide or reported current suicidal ideation (N = 109). RESULTS: MMB relative to UDC was associated with a greater rate of reduction in suicidal ideation (SI; t(103) = 2.50, p = 0.014, d = 0.49, 95% CI [0.09-0.88]) and a greater likelihood of being in a lower severity category of SI (t(103) = 2.02, p = 0.046, odds ratio = 3.43, 95% CI [1.02-11.53]). There was also evidence that MMB reduces depression severity outcomes among this at risk group (t(105) = 2.38, p < 0.02, d = 0.46, 95% CI [0.07-0.85]). LIMITATIONS: Reported findings are based on a subgroup of patients in a clinical trial originally designed to treat residual depressive symptoms. CONCLUSIONS: Online interventions, such as MMB, may offer one solution to the challenge of expanding the reach of services for patients with residual depression who are at risk of suicidal ideation and behavior.

Rape Disclosure and Depression Among Community Women: The Mediating Roles of Shame and Experiential Avoidance.

Many women who disclose a rape encounter victim-blaming responses, which are associated with negative outcomes. The present study examined rape-related shame and experiential avoidance as mediators of the relation between victim-blaming responses to rape disclosure and depression among 103 rape survivors drawn from a community sample. Results revealed that victim-blaming responses were positively associated with depressive symptoms through rape-related shame and experiential avoidance, and shame was indirectly related to depression via avoidance. Findings suggest clinical interventions should focus on rape-related shame and experiential avoidance in targeting depression among rape survivors, and future research should continue to examine how victim-blaming responses to rape disclosure may be related to these factors.

Relational wellbeing following traumatic interpersonal events and challenges to core beliefs.

OBJECTIVE: Prior research has found that the degree to which a traumatic event challenges core beliefs is associated with adjustment problems; however, how such experiences impact relational wellbeing has received little attention. The current study examined whether negative posttraumatic cognitions mediated the relation between examination of core beliefs and relational wellbeing in young adults following experiences of interpersonal trauma. METHOD: A moderated parallel mediation model investigated the relation between core beliefs and relational wellbeing through negative cognitions about the self, the world and others, self-blame, and depressive symptoms, following interpersonal violence (IPV; n = 168) and violent loss (VL; n = 102), with ego-resilience moderating the paths from examination of core beliefs to each mediator and relational wellbeing. RESULTS: For individuals with IPV experiences, greater examination of core beliefs was associated with increased depressive symptoms and negative cognitions about the self and about the world and others, each of which was associated with decreased relational wellbeing. For those reporting VL and lower ego-resilience, only negative cognitions about the self emerged as a mediator. Self-blame did not emerge as a mediator whereas ego-resilience emerged as both promotive and protective. CONCLUSIONS: Results suggest distinct pathways to relational difficulties following IPV and VL. Following IPV, it was not the process of examining core beliefs that impacted relational functioning, but rather the conclusions drawn about the self, others, and the world. Findings suggest that targeting specific posttraumatic cognitions may enhance relational functioning and possible interventions for addressing such cognitions and fostering ego-resilience are presented. (PsycINFO Database Record

Student Mental Health in California's K-12 Schools: School Principal Reports of Common Problems and Activities to Address Them.

Reports results of a survey of K-12 principals to take inventory of student mental health and wellness needs and the types of programs schools are most often implementing to help students in California's public schools.

Readability of self-report alcohol misuse measures.

OBJECTIVE: Self-report measures of alcohol misuse and alcohol use disorders are valuable assessment tools for both research and clinical practice settings. However, readability is often overlooked when establishing the validity of these measures, which may result in measures written at a reading-grade level that is higher than the ability level of many potential respondents. The aim of the current study was to estimate the reading-grade level of validated measures of alcohol misuse and associated problems. METHOD: A total of 45 measures were identified, and reading-grade level was calculated using three validated readability formulas. RESULTS: The majority of measures were written above the recommended reading-grade level for patient materials (5th-6th grade), with particularly poor readability for measure instructions. CONCLUSIONS: Given that many self-report alcohol misuse measures are written at a high reading-grade level, the consideration of readability is important when selecting measures for use in research and practice settings. Moreover, the development or modification of measures to target low-literacy populations may facilitate the broader applicability of these instruments.

Group therapy for women with substance use disorders: results from the Women's Recovery Group Study.

BACKGROUND: This Stage II trial builds on a Stage I trial comparing the single-gender Women's Recovery Group (WRG) to mixed-gender Group Drug Counseling (GDC) that demonstrated preliminary support for the WRG in treating women with substance use disorders. The Stage II trial aims were to (1) investigate effectiveness of the WRG relative to GDC in a sample of women heterogeneous with respect to substance of abuse and co-occurring psychiatric disorders, and (2) demonstrate the feasibility of implementing WRG in an open-enrollment group format at two sites. METHOD: In this randomized clinical trial, participants were included if they were substance dependent and had used substances within the past 60 days (n=158). Women were randomized to WRG (n=52) or GDC (n=48); men were assigned to GDC (n=58). Substance use outcomes were assessed at months 1-6 and 9. RESULTS: Women in both the WRG and GDC had reductions in mean number of substance use days during treatment (12.7 vs 13.7 day reductions for WRG and GDC, respectively) and 6 months post-treatment (10.3 vs 12.7 day reductions); however, there were no significant differences between groups. CONCLUSIONS: The WRG demonstrated comparable effectiveness to standard mixed-gender treatment (i.e., GDC) and is feasibly delivered in an open-group format typical of community treatment. It provides a manual-based group therapy with women-focused content that can be implemented in a variety of clinical settings for women who are heterogeneous with respect to their substance of abuse, other co-occurring psychiatric disorders, and life-stage.

Positive affect and stress reactivity in alcohol-dependent outpatients.

OBJECTIVE: Reactivity to stress is a common feature of alcohol dependence and is associated with poorer treatment outcome among alcohol-dependent patients. Despite the importance of stress reactivity in alcohol dependence, little is known about markers of resilience to stress in this population. The current study examined whether positive affect buffered the effect of stress on negative affect and alcohol craving in an alcohol-dependent sample. METHOD: Outpatients (N = 1,375) enrolled in a large, randomized controlled trial for alcohol dependence (the Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence [COMBINE] Study) completed measures of stress, positive affect, negative affect, and alcohol craving. In this secondary analysis, we hypothesized that positive affect would moderate the association between stress and negative affect and that positive affect would be negatively associated with craving. RESULTS: Results supported these hypotheses, such that patients with higher levels of positive affect exhibited a weaker relationship between stress and negative affect relative to those with low positive affect. Positive affect was negatively associated with craving but did not moderate the association between stress and craving. CONCLUSIONS: These results replicate studies suggesting a protective effect of positive affect on stress reactivity and extend this effect to an alcohol-dependent sample. If positive affect can aid in resilience to stress, the utilization of interventions that enhance positive affect may be of particular utility for alcohol-dependent patients. Future experimental studies testing the causality of this association as well as studies examining the effect of interventions to enhance positive affect are needed.

Harnessing naturally occurring tumor immunity: a clinical vaccine trial in prostate cancer.

BACKGROUND: Studies of patients with paraneoplastic neurologic disorders (PND) have revealed that apoptotic tumor serves as a potential potent trigger for the initiation of naturally occurring tumor immunity. The purpose of this study was to assess the feasibility, safety, and immunogenicity of an apoptotic tumor-autologous dendritic cell (DC) vaccine. METHODS AND FINDINGS: We have modeled PND tumor immunity in a clinical trial in which apoptotic allogeneic prostate tumor cells were used to generate an apoptotic tumor-autologous dendritic cell vaccine. Twenty-four prostate cancer patients were immunized in a Phase I, randomized, single-blind, placebo-controlled study to assess the safety and immunogenicity of this vaccine. Vaccinations were safe and well tolerated. Importantly, we also found that the vaccine was immunogenic, inducing delayed type hypersensitivity (DTH) responses and CD4+ and CD8+ T cell proliferation, with no effect on FoxP3+ regulatory T cells. A statistically significant increase in T cell proliferation responses to prostate tumor cells in vitro (p = 0.002), decrease in prostate specific antigen (PSA) slope (p = 0.016), and a two-fold increase in PSA doubling time (p = 0.003) were identified when we compared data before and after vaccination. CONCLUSIONS: An apoptotic cancer cell vaccine modeled on naturally occurring tumor immune responses in PND patients provides a safe and immunogenic tumor vaccine. TRIAL REGISTRATION: ClinicalTrials.gov NCT00289341.

Expression of CD154 (CD40 ligand) by human lung fibroblasts: differential regulation by IFN-gamma and IL-13, and implications for fibrosis.

The CD40-CD40 ligand (CD40L) system (CD154) is a central means of immune cell communication crucial for Ig class switching and enhanced Ag presentation. CD40 is also a key signaling conduit to activate nonhematopoietic cells, such as fibroblasts and endothelial cells, to produce proinflammatory mediators. Disruption of the CD40-CD40L pathway reduces lung inflammation and fibrosis, autoimmune disease and atherosclerosis. Non-bone marrow-derived structural cells are not known to express CD40L. In this study, we reveal the intriguing finding that primary strains of human lung fibroblasts derived from normal and scarred lung express both CD40L mRNA and protein. Interestingly, CD40L expression is down-regulated by IFN-gamma, a type 1 cytokine with antiscarring properties, and is up-regulated by the profibrogenic type 2 cytokine IL-13. Flow cytometry and laser confocal microscopy revealed that the majority of CD40L was located intracellularly. Importantly, fibroblast strains from human idiopathic pulmonary fibrosis tissue expressed increased levels of CD40L compared with fibroblasts from nonscarred lung. Fibroblasts in the scarred areas of human lung tissue expressed high levels of CD40L. Finally, the blood and lung lavage levels of CD40L are significantly elevated in fibrosis patients compared with normals. These new findings demonstrate that fibroblasts are a new source of CD40L and that those involved in scarring may have undergone a selected expansion for high CD40L expression. Moreover, the antifibrotic activity of IFN-gamma may involve the down-regulation of fibroblast CD40L levels. We speculate that fibroblast-derived CD40L plays a role in promoting fibroblast activation and possibly in interaction with CD40 bearing cells.