The association between urban greenspace and psychological health among young adults in Addis Ababa, Ethiopia.

INTRODUCTION: Psychological disorders are emerging as health priorities in Sub-Saharan Africa, specifically Ethiopia. Urban greenspace - parks, trees, and other vegetation integrated into urban form - may facilitate population psychological health, but is largely understudied outside high-income countries. We explore greenspace in relation to psychological health among young adults in Addis Ababa, Ethiopia. METHOD: Greenspace exposure was calculated using the normalized difference vegetation index (NDVI) derived from publicly available satellite imagery (2018-2019). We used tests of spatial clustering to characterize greenspace distribution. Derived NDVI values were linked to Positive Outcomes for Orphans study participants to explore cross-sectional associations between greenspace exposure and psychological health (measured 2019-2021). Two continuous scores of psychological health were examined: total difficulties from the Strengths and Difficulties Questionnaire and depressive symptoms from the 8-item Patient Health Questionnaire. Multilevel generalized linear regression, nested by administrative units, was used to estimate the association between greenspace and psychological health. We also explored effect modification by gender and having income. RESULTS: We found greenspace is spatially clustered in Addis Ababa, with high greenspace density in the northeast region and low greenspace density in the center of the city. Our findings suggest residing in greener areas is associated with fewer emotional and behavioral difficulties (ß = -1.89; 95% CI: -3.50, -0.29), but not significantly associated with depressive symptomology (ß = -0.61; 95% CI: -2.33, 1.11). We observed stronger associations between greenspace and total difficulties among those reporting any income and among males, and for the association between greenspace and depression symptomology among males. CONCLUSION: We offer initial exploration into the role of greenspace in psychological well-being in Addis Ababa, with potential implications for urban communities across Sub-Saharan Africa. Further research should continue to explore how the built and natural environment could be leveraged in similar settings to promote population psychological health.

Predictors of HIV Testing among Orphaned Youths in Three East African Countries.

In parts of sub-Saharan Africa, where HIV prevalence is high, HIV is a leading cause of death among youths. Orphaned and separated youths are an especially vulnerable group, yet we know little about what influences their testing behavior. We conducted multiple logistical regression to examine theory-based predictors of past-year HIV testing among 423 orphaned and separated youths in Ethiopia, Kenya and Tanzania. We also conducted moderation, assessing whether predictors varied by sex. Over one-third of our sample reported past-year HIV testing. Those with greater perceived social support and those who reported sexual HIV risk behavior were more likely to report past-year testing. Furthermore, boys who reported ever previously testing for HIV were more likely, a year later, to report past-year HIV testing. In conclusion, our findings have important implications for intervention development, including the potential for enhanced perceived social support to positively influence HIV testing among orphaned and separated youths.

Advancing successful implementation of task-shifted mental health care in low-resource settings (BASIC): protocol for a stepped wedge cluster randomized trial.

BACKGROUND: The mental health treatment gap-the difference between those with mental health need and those who receive treatment-is high in low- and middle-income countries. Task-shifting has been used to address the shortage of mental health professionals, with a growing body of research demonstrating the effectiveness of mental health interventions delivered through task-shifting. However, very little research has focused on how to embed, support, and sustain task-shifting in government-funded systems with potential for scale up. The goal of the Building and Sustaining Interventions for Children (BASIC) study is to examine implementation policies and practices that predict adoption, fidelity, and sustainment of a mental health intervention in the education sector via teacher delivery and the health sector via community health volunteer delivery. METHODS: BASIC is a Hybrid Type II Implementation-Effectiveness trial. The study design is a stepped wedge, cluster randomized trial involving 7 sequences of 40 schools and 40 communities surrounding the schools. Enrollment consists of 120 teachers, 120 community health volunteers, up to 80 site leaders, and up to 1280 youth and one of their primary guardians. The evidence-based mental health intervention is a locally adapted version of Trauma-focused Cognitive Behavioral Therapy, called Pamoja Tunaweza. Lay counselors are trained and supervised in Pamoja Tunaweza by local trainers who are experienced in delivering the intervention and who participated in a Train-the-Trainer model of skills transfer. After the first sequence completes implementation, in-depth interviews are conducted with initial implementing sites' counselors and leaders. Findings are used to inform delivery of implementation facilitation for subsequent sequences' sites. We use a mixed methods approach including qualitative comparative analysis to identify necessary and sufficient implementation policies and practices that predict 3 implementation outcomes of interest: adoption, fidelity, and sustainment. We also examine child mental health outcomes and cost of the intervention in both the education and health sectors. DISCUSSION: The BASIC study will provide knowledge about how implementation of task-shifted mental health care can be supported in government systems that already serve children and adolescents. Knowledge about implementation policies and practices from BASIC can advance the science of implementation in low-resource contexts. TRIAL REGISTRATION: Trial Registration: ClinicalTrials.gov Identifier: NCT03243396. Registered 9th August 2017, https://clinicaltrials.gov/ct2/show/NCT03243396.

Associations between environmental quality and adult asthma prevalence in medical claims data.

As of 2014, approximately 7.4% of U.S. adults had current asthma. The etiology of asthma is complex, involving genetics, behavior, and environmental factors. To explore the association between cumulative environmental quality and asthma prevalence in U.S. adults, we linked the U.S. Environmental Protection Agency's Environmental Quality Index (EQI) to the MarketScan® Commercial Claims and Encounters Database. The EQI is a summary measure of five environmental domains (air, water, land, built, sociodemographic). We defined asthma as having at least 2 claims during the study period, 2003-2013. We used a Bayesian approach with non-informative priors, implementing mixed-effects regression modeling with a Poisson link function. Fixed effects variables were EQI, sex, race, and age. Random effects were counties. We modeled quintiles of the EQI comparing higher quintiles (worse quality) to lowest quintile (best quality) to estimate prevalence ratios (PR) and credible intervals (CIs). We estimated associations using the cumulative EQI and domain-specific EQIs; we assessed U.S. overall (non-stratified) as well as stratified by rural-urban continuum codes (RUCC) to assess rural/urban heterogeneity. Among the 71,577,118 U.S. adults with medical claims who could be geocoded to county of residence, 1,147,564 (1.6%) met the asthma definition. Worse environmental quality was associated with increased asthma prevalence using the non-RUCC-stratified cumulative EQI, comparing the worst to best EQI quintile (PR:1.27; 95% CI: 1.21, 1.34). Patterns varied among different EQI domains, as well as by rural/urban status. Poor environmental quality may increase asthma prevalence, but domain-specific drivers may operate differently depending on rural/urban status.

County-level cumulative environmental quality associated with cancer incidence.

BACKGROUND: Individual environmental exposures are associated with cancer development; however, environmental exposures occur simultaneously. The Environmental Quality Index (EQI) is a county-level measure of cumulative environmental exposures that occur in 5 domains. METHODS: The EQI was linked to county-level annual age-adjusted cancer incidence rates from the Surveillance, Epidemiology, and End Results (SEER) Program state cancer profiles. All-site cancer and the top 3 site-specific cancers for male and female subjects were considered. Incident rate differences (IRDs; annual rate difference per 100,000 persons) and 95% confidence intervals (CIs) were estimated using fixed-slope, random intercept multilevel linear regression models. Associations were assessed with domain-specific indices and analyses were stratified by rural/urban status. RESULTS: Comparing the highest quintile/poorest environmental quality with the lowest quintile/best environmental quality for overall EQI, all-site county-level cancer incidence rate was positively associated with poor environmental quality overall (IRD, 38.55; 95% CI, 29.57-47.53) and for male (IRD, 32.60; 95% CI, 16.28-48.91) and female (IRD, 30.34; 95% CI, 20.47-40.21) subjects, indicating a potential increase in cancer incidence with decreasing environmental quality. Rural/urban stratified models demonstrated positive associations comparing the highest with the lowest quintiles for all strata, except the thinly populated/rural stratum and in the metropolitan/urbanized stratum. Prostate and breast cancer demonstrated the strongest positive associations with poor environmental quality. CONCLUSION: We observed strong positive associations between the EQI and all-site cancer incidence rates, and associations differed by rural/urban status and environmental domain. Research focusing on single environmental exposures in cancer development may not address the broader environmental context in which cancers develop, and future research should address cumulative environmental exposures. Cancer 2017;123:2901-8. © 2017 American Cancer Society.

Potentially traumatic experiences and sexual health among orphaned and separated adolescents in five low- and middle-income countries.

Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in sub-Saharan Africa and Asia. Over 153 million children worldwide have lost one or both parents, including 17 million orphaned by AIDS, and millions more have been separated from their parents. As younger orphans enter adolescence, their sexual health and HIV-related risk behaviors become key considerations for their overall health. Importantly, their high prevalence of exposure to potentially traumatic events (PTEs) may put OSC at additional risk for adverse sexual health outcomes. The Positive Outcomes for Orphans study followed OSC randomly sampled from institution-based care and from family-based care, as well as a convenience sample of non-OSC, at six sites in five low-and middle-income countries. This analysis focused on the 90-month follow-up, during which adolescents 16 and older were assessed for sexual health, including age at sexual debut, past-year sex, past-year condom use, and perceptions of condom use. We specifically examined the relationship between PTEs and sexual health outcomes. Of the 1258 OSC and 138 non-OSC assessed, 11% reported ever having sex. Approximately 6% of participants reported recent sex and 5% reported having recent unprotected sex. However, 70% of those who had recent sex reported that they did not use a condom every time, and perceptions of condom use tended to be unfavorable for protection against sexual risk behavior. Nearly all (90%) of participants reported experiencing at least one lifetime PTE. For those who experienced "any" PTE, we found increased prevalence of recent sex (PR = 1.39 [0.47, 4.07]) and of recent unprotected sex (PR = 3.47 [0.60, 19.91]). This study highlights the need for caregivers, program managers, and policymakers to promote condom use for sexually active OSC and identify interventions for trauma support services. Orphans living in family-based care may also be particularly vulnerable to early sexual debut and unprotected sexual activity.

Civic engagement among orphans and non-orphans in five low- and middle-income countries.

BACKGROUND: Communities and nations seeking to foster social responsibility in their youth are interested in understanding factors that predict and promote youth involvement in public activities. Orphans and separated children (OSC) are a vulnerable population whose numbers are increasing, particularly in resource-poor settings. Understanding whether and how OSC are engaged in civic activities is important for community and world leaders who need to provide care for OSC and ensure their involvement in sustainable development. METHODS: The Positive Outcomes for Orphans study (POFO) is a multi-country, longitudinal cohort study of OSC randomly sampled from institution-based care and from family-based care, and of non-OSC sampled from the same study regions. Participants represent six sites in five low-and middle-income countries. We examined civic engagement activities and government trust among subjects > =16 years old at 90-month follow-up (approximately 7.5 years after baseline). We calculated prevalences and estimated the association between key demographic variables and prevalence of regular volunteer work using multivariable Poisson regression, with sampling weights to accounting for the complex sampling design. RESULTS: Among the 1,281 POFO participants > =16 who were assessed at 90-month follow-up, 45 % participated in regular community service or volunteer work; two-thirds of those volunteers did so on a strictly voluntary basis. While government trust was fairly high, at approximately 70 % for each level of government, participation in voting was only 15 % among those who were > =18 years old. We did not observe significant associations between demographic characteristics and regular volunteer work, with the exception of large variation by study site. CONCLUSION: As the world's leaders grapple with the many competing demands of global health, economic security, and governmental stability, the participation of today's youth in community and governance is essential for sustainability. This study provides a first step in understanding the degree to which OSC from different care settings across multiple low- and middle-income countries are engaged in their communities.

The associations between environmental quality and preterm birth in the United States, 2000-2005: a cross-sectional analysis.

BACKGROUND: Many environmental factors have been independently associated with preterm birth (PTB). However, exposure is not isolated to a single environmental factor, but rather to many positive and negative factors that co-occur. The environmental quality index (EQI), a measure of cumulative environmental exposure across all US counties from 2000-2005, was used to investigate associations between ambient environment and PTB. METHODS: With 2000-2005 birth data from the National Center for Health Statistics for the United States (n = 24,483,348), we estimated the association between increasing quintiles of the EQI and county-level and individual-level PTB; we also considered environmental domain-specific (air, water, land, sociodemographic and built environment) and urban-rural stratifications. RESULTS: Effect estimates for the relationship between environmental quality and PTB varied by domain and by urban-rural strata but were consistent across county- and individual-level analyses. The county-level prevalence difference (PD (95% confidence interval) for the non-stratified EQI comparing the highest quintile (poorest environmental quality) to the lowest quintile (best environmental quality) was -0.0166 (-0.0198, -0.0134). The air and sociodemographic domains had the strongest associations with PTB; PDs were 0.0196 (0.0162, 0.0229) and -0.0262 (-0.0300, -0.0224) for the air and sociodemographic domain indices, respectively. Within the most urban strata, the PD for the sociodemographic domain index was 0.0256 (0.0205, 0.0307). Odds ratios (OR) for the individual-level analysis were congruent with PDs. CONCLUSION: We observed both strong positive and negative associations between measures of broad environmental quality and preterm birth. Associations differed by rural-urban stratum and by the five environmental domains. Our study demonstrates the use of a large scale composite environment exposure metric with preterm birth, an important indicator of population health and shows potential for future research.

Throwing out the baby with the bathwater?: Comparing 2 approaches to implausible values of change in body size.

BACKGROUND: In childhood obesity research, the appearance of height loss, or "shrinkage," indicates measurement error. It is unclear whether a common response--excluding "shrinkers" from analysis--reduces bias. METHODS: Using data from the National Longitudinal Study of Adolescent Health, we sampled 816 female adolescents (≥17 years) who had attained adult height by 1996 and for whom adult height was consistently measured in 2001 and 2008 ("gold-standard" height). We estimated adolescent obesity prevalence and the association of maternal education with adolescent obesity under 3 conditions: excluding shrinkers (for whom gold-standard height was less than recorded height in 1996), retaining shrinkers, and retaining shrinkers but substituting their gold-standard height. RESULTS: When we estimated obesity prevalence, excluding shrinkers decreased precision without improving validity. When we regressed obesity on maternal education, excluding shrinkers produced less valid and less precise estimates. CONCLUSION: In some circumstances, ignoring shrinkage is a better strategy than excluding shrinkers.

Uncovering determinants of perceived feasibility of TF-CBT through coincidence analysis.

Introduction: A mental health provider's perception of how well an intervention can be carried out in their context (i.e., feasibility) is an important implementation outcome. This article aims to identify determinants of feasibility of trauma-focused cognitive behavioral therapy (TF-CBT) through a case-based causal approach. Method: Data come from an implementation-effectiveness study in which lay counselors (teachers and community health volunteers) implemented a culturally adapted manualized mental health intervention, TF-CBT, delivered to teens who were previously orphaned and were experiencing posttraumatic stress symptoms and prolonged grief in Western Kenya. The intervention team identified combinations of determinants that led to feasibility among teacher- and community health volunteer-counselors through coincidence analysis. Results: Among teacher-counselors, organizational-level factors (implementation climate, implementation leadership) determined moderate and high levels of feasibility. Among community health volunteer-counselors, a strong relationship between a clinical supervisor and the supervisee was the most influential determinant of feasibility. Conclusion: Methodology and findings from this article can guide the assessment of determinants of feasibility and the development of implementation strategies for manualized mental health interventions in contexts like Western Kenya. Plain Language Summary: A mental health provider's perception of how easy a therapy is to use in their work setting (i.e., feasibility) can impact whether the provider uses the therapy in their setting. Implementation researchers have recommended finding practices and constructs that lead to important indicators that a therapy will be used. However, limited research to our knowledge has searched and found practices and constructs that might determine feasibility of a therapy. This article uses existing data from a large trial looking at the continued use of a trauma-focused therapy to find practices and constructs that lead to moderate and high levels of feasibility. We found that in settings with a strong organizational structure that organization and leadership support for the therapy led to teachers in Kenya to perceive the therapy as easy to use. On the other hand, in settings with a weaker organizational structure, outside support from a clinical supervisor led to community health volunteers in Kenya perceiving the therapy as easy to use. The findings from this article can guide context-specific recommendations for increasing perceived therapy feasibility at the provider-, organization-, and policy levels.

Is gastroschisis associated with county-level socio-environmental quality during pregnancy?

BACKGROUND: Gastroschisis prevalence more than doubled between 1995 and 2012. While there are individual-level risk factors (e.g., young maternal age, low body mass index), the impact of environmental exposures is not well understood. METHODS: We used the U.S. Environmental Protection Agency's Environmental Quality Index (EQI) as a county-level estimate of cumulative environmental exposures for five domains (air, water, land, sociodemographic, and built) and overall from 2006 to 2010. Adjusted odds ratios (aOR) and 95% confidence interval (CI) were estimated from logistic regression models between EQI tertiles (better environmental quality (reference); mid; poorer) and gastroschisis in the National Birth Defects Prevention Study from births delivered between 2006 and 2011. Our analysis included 594 cases with gastroschisis and 4105 infants without a birth defect (controls). RESULTS: Overall EQI was modestly associated with gastroschisis (aOR [95% CI]: 1.29 [0.98, 1.71]) for maternal residence in counties with poorer environmental quality, compared to the reference (better environmental quality). Within domain-specific indices, only the sociodemographic domain (aOR: 1.51 [0.99, 2.29]) was modestly associated with gastroschisis, when comparing poorer to better environmental quality. CONCLUSIONS: Future work could elucidate pathway(s) by which components of the sociodemographic domain or possibly related psychosocial factors like chronic stress potentially contribute to risk of gastroschisis.

Prevention of autoimmune disease by induction of tolerance to Toll-like receptor 7.

Activation of Toll-like receptors (TLR) contributes to the initiation and maintenance of chronic inflammation in autoimmune diseases, yet repeated exposure to a TLR agonist can induce hyporesponsiveness to subsequent TLR stimulation. Here, we used a synthetic TLR7 agonist, 9-benzyl-8-hydroxy-2-(2-methoxyethoxy) adenine (SM360320, 1V136) to study TLR7 induced attenuation of inflammatory responses and its application to autoimmune diseases. Repeated low dose administration of this TLR7 agonist induced hyporesponsiveness or tolerance to TLR2, -7, and -9 activators and limited the course of neural inflammation in an experimental allergic encephalomyelitis model. The hyporesponsiveness did not depend on T or B lymphocytes, but did require bone marrow derived cells. In addition, TLR7 tolerance reduced inflammation in a passive antibody mediated arthritis model. TLR7 tolerance did not cause global immunosuppression, because susceptibility to Listeria monocytogenes infection was not altered. The mechanism of TLR7 tolerance involved the up-regulation of 2 inhibitors of TLR signaling: Interleukin 1 Receptor Associated Kinase (IRAK) M, and Src homology 2 domain-containing inositol polyphosphate phosphatase (SHIP)-1. These findings suggest that induction of TLR7 tolerance might be a new therapeutic approach to subdue inflammation in autoimmune diseases.

Synthesis and characterization of PEGylated toll like receptor 7 ligands.

Toll-like receptor 7 (TLR7) is located in the endosomal compartment of immune cells. Signaling through TLR7, mediated by the adaptor protein MyD88, stimulates the innate immune system and shapes adaptive immune responses. Previously, we characterized TLR7 ligands conjugated to protein, lipid, or poly(ethylene glycol) (PEG). Among the TLR7 ligand conjugates, the addition of PEG chains reduced the agonistic potency. PEGs are safe in humans and widely used for improvement of pharmacokinetics in existing biologics and some low molecular weight compounds. PEGylation could be a feasible method to alter the pharmacokinetics and pharmacodynamics of TLR7 ligands. In this study, we systematically studied the influence of PEG chain length on the in vitro and in vivo properties of potent TLR7 ligands. PEGylation increased solubility of the TLR7 ligands and modulated protein binding. Adding a 6-10 length PEG to the TLR7 ligand reduced its potency toward induction of interleukin (IL)-6 by murine macrophages in vitro and IL-6 and tumor necrosis factor (TNF) in vivo. However, PEGylation with 18 or longer chain restored, and even enhanced, the agonistic activity of the drug. In human peripheral blood mononuclear cells, similar effects of PEGylation were observed for secretion of proinflammatory cytokines, IL-6, IL-12, TNF-α, IL-1ß, and type 1 interferon, as well as for B cell proliferation. In summary, these studies demonstrate that conjugation of PEG chains to a synthetic TLR ligand can impact its potency for cytokine induction depending on the size of the PEG moiety. Thus, PEGylation may be a feasible approach to regulate the pharmacological properties of TLR7 ligands.

Family Composition and Stability for Orphans: A Longitudinal Study of Well-Being in 5 Low- and Middle-Income Countries.

Objectives: Many orphaned children in low- and middle-income countries live with family. Yet, their household composition and its stability are not well-characterized, nor is impact of stability on longer-term outcomes. Methods: We used the longitudinal, multi-country Positive Outcomes for Orphans cohort to describe adult family living with orphans. Stability was measured by changes in presence of six familial relations over time, and related to three outcomes: 1) incident abuse, 2) cognitive functioning, 3) emotional difficulties. Associations were estimated using generalized linear models fit with generalized estimating equations. For abuse, Poisson regression estimated risk ratios. For continuous scores of cognitive functioning and emotional difficulties, linear models estimated mean differences (MDs) with 95% confidence intervals. Results: Among 1,359 orphans, 53-61% reported living with their mother each year; 7-13% with father; nearly 60% reported ≥1 change in composition over follow-up. Compared to 0 changes, difficulties increased with 1 change [MD: 0.23 (-0.33, 0.79)], 2 changes [MD: 0.57 (0.00, 1.16)] and ≥3 changes [MD: 0.73 (0.18, 1.29)]. No associations were found with abuse or cognitive functioning. Conclusion: Orphan well-being may be improved through supports stabilizing household composition or targeting emotional resilience.

Synthesis and immunological characterization of toll-like receptor 7 agonistic conjugates.

Activation of toll-like receptors (TLRs) on cells of the innate immune system initiates, amplifies, and directs the antigen-specific acquired immune response. Ligands that stimulate TLRs, therefore, represent potential immune adjuvants. In this study, a potent TLR7 agonist was conjugated to phospholipids, poly(ethylene glycol) (PEG), or phospholipid-PEG via a versatile benzoic acid functional group. Compared to the unmodified TLR7 agonist, each conjugate displayed a distinctive immunological profile in vitro and in vivo. In mouse macrophages and human peripheral blood mononuclear cells, the phospholipid TLR7 agonist conjugate was at least 100-fold more potent than the free TLR7 ligands, while the potency of PEG-phospholipid conjugate was similar to that of the unmodified TLR7 agonist. When administered systemically in mice, the phospholipid and phospholipid-PEG TLR7 conjugates induced prolonged increases in the levels of proinflammatory cytokines in serum, compared to the unmodified TLR7 activator. When the conjugates were used as adjuvants during vaccination, only the phospholipid TLR7 agonist conjugates induced both Th1 and Th2 antigen-specific immune responses. These data show that the immunostimulatory activity of a TLR7 ligand can be amplified and focused by conjugation, thus broadening the potential therapeutic application of these agents.

Divergent trends in life expectancy across the rural-urban gradient and association with specific racial proportions in the contiguous USA 2000-2005.

OBJECTIVES: To estimate county-level adult life expectancy for Whites, Black/African Americans (Black), American Indian/Alaska Native (AIAN) and Asian/Pacific Islander (Asian) populations and assess the difference across racial groups in the relationship among life expectancy, rurality and specific race proportion. METHODS: We used individual-level death data to estimate county-level life expectancy at age 25 (e25) for Whites, Black, AIAN and Asian in the contiguous USA for 2000-2005. Race-sex-stratified models were used to examine the associations among e25, rurality and specific race proportion, adjusted for socioeconomic variables. RESULTS: Lower e25 was found in the central USA for AIANs and in the west coast for Asians. We found higher e25 in the most rural areas for Whites but in the most urban areas for AIAN and Asians. The associations between specific race proportion and e25 were positive or null for Whites but were negative for Blacks, AIAN, and Asians. The relationship between specific race proportion and e25 varied across rurality. CONCLUSIONS: Identifying differences in adult life expectancy, both across and within racial groups, provides new insights into the geographic determinants of life expectancy disparities.

Lay Counselor Perspectives of Providing a Child-Focused Mental Health Intervention for Children: Task-Shifting in the Education and Health Sectors in Kenya.

The global mental health treatment gap has increasingly been addressed using task-shifting; however, very little research has focused on lay counselors' perspectives on the acceptability, feasibility, and appropriateness of mental health interventions in specific government-supported sectors that might scale up and sustain mental health care for children and adolescents. In western Kenya, these sectors include Education and Health. Data come from a large hybrid effectiveness-implementation study examining implementation practices and policies in either or both sectors that support successful implementation of a child-focused intervention, Trauma-focused Cognitive Behavioral Therapy (TF-CBT), for children and adolescents who had experienced parental death. We examined lay counselors' self-report of acceptability, feasibility, and appropriateness of TF-CBT. Lay counselors were teachers (n = 30) from the Education sector and Community Health Volunteers (CHVs; n = 30) from the Health sector, who were part of Sequence 1 of a large stepped-wedge, cluster randomized trial. Lay counselor self-report surveys included reflective and formative measurement of acceptability, feasibility, and appropriateness administered after lay counselors in both sectors had experience delivering the locally-adapted, group-based TF-CBT intervention. Descriptive statistics (means, standard deviations) were used to understand counselors' perspectives stratified by sector. Both teachers and CHVs endorsed high acceptability, feasibility, and appropriateness of TF-CBT, with lay counselors' responses on items from the formative measures providing some insight into specific aspects of acceptability, feasibility, and appropriateness that may be important to consider when planning for implementation support. These early findings suggest that both sectors may hold promise for task-shifting of mental health care for children and adolescents but also underline the importance of considering the multiple facets of these three implementation outcomes as well as lay counselor context (Education vs. Health).

Factors affecting the psychosocial well-being of orphan and separated children in five low- and middle-income countries: Which is more important, quality of care or care setting?

As millions of children continue to live without parental care in under-resourced societies in low- and middle-income countries (LMICs), it is important for policymakers and practitioners to understand the specific characteristics within different care settings and the extent to which they are associated with outcomes of orphan and separated children (OSC). This study was designed to (1) examine if the psychosocial well-being of OSC in under-resourced societies in LMICs is more dependent on the availability of certain components of quality of care rather than the care setting itself (i.e. the residential care-based or community family-based setting), and (2) identify the relative significance of certain components of quality of care that are associated with a child's psychosocial well-being across different OSC care settings. This study drew from 36-month follow-up data from the Positive Outcomes for Orphans (POFO) Study and used a sample population of 2,013 (923 institution- and 1,090 community-based) OSC among six diverse study sites across five LMICs: Cambodia, India (Hyderabad and Nagaland), Kenya, Tanzania, and Ethiopia. Analyses showed that all four components of quality of care significantly predicted child psychosocial well-being. Child psychosocial well-being across "high" and "low" levels of quality of care showed negligible differences between residential- and community-based care settings, suggesting the important factor in child well-being is quality of care rather than setting of care. Practical and policy implications and future research are discussed.

Evaluating the effectiveness and implementation of evidence-based treatment: A multisite hybrid design.

The gap between treatment development and efficacy testing to scaled up implementations of evidence-based treatment (EBT) is an estimated 20 years, and hybrid research designs aim to reduce the gap. One was used for a multisite study in cancer control, testing coprimary aims: (a) determine the feasibility and utility of a flexible EBT implementation strategy and (b) determine the clinical effectiveness of an EBT as implemented by newly trained providers. Therapists from 15 diverse sites implemented the biobehavioral intervention (BBI) for cancer patients (N = 158) as part of standard care. For implementation, therapists determined treatment format, number of sessions, and so forth and reported session-by-session fidelity. Patients completed fidelity and outcome assessments. Results showed therapists BBI implementation was done with fidelity, for example, session "dose" (59%), core content coverage (60-70%), and others. Patient reported fidelity was favorable and comparable to the BBI efficacy trial. Effectiveness data show the primary outcome, patients' scores on the Profile of Mood States total mood disturbance, significantly improved (R² = 0.06, ß = -0.24, p < .01) as did a secondary outcome, physical activity (R² = 0.02, ß = 0.13, p < .05). This first use of a hybrid design in health psychology provided support for a novel strategy that allowed providers implementation flexibility. Still, the EBT was delivered with fidelity and in addition, therapists generated novel procedures to enhance setting-specific usage of BBI and its ultimate effectiveness with patients. This research is an example of translational research spanning theory and efficacy tests to dissemination and implementation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The association between physical inactivity and obesity is modified by five domains of environmental quality in U.S. adults: A cross-sectional study.

Physical inactivity is a primary contributor to the obesity epidemic, but may be promoted or hindered by environmental factors. To examine how cumulative environmental quality may modify the inactivity-obesity relationship, we conducted a cross-sectional study by linking county-level Behavioral Risk Factor Surveillance System data with the Environmental Quality Index (EQI), a composite measure of five environmental domains (air, water, land, built, sociodemographic) across all U.S. counties. We estimated the county-level association (N = 3,137 counties) between 2009 age-adjusted leisure-time physical inactivity (LTPIA) and 2010 age-adjusted obesity from BRFSS across EQI tertiles using multi-level linear regression, with a random intercept for state, adjusted for percent minority and rural-urban status. We modelled overall and sex-specific estimates, reporting prevalence differences (PD) and 95% confidence intervals (CI). In the overall population, the PD increased from best (PD = 0.341 (95% CI: 0.287, 0.396)) to worst (PD = 0.645 (95% CI: 0.599, 0.690)) EQI tertile. We observed similar trends in males from best (PD = 0.244 (95% CI: 0.194, 0.294)) to worst (PD = 0.601 (95% CI: 0.556, 0.647)) quality environments, and in females from best (PD = 0.446 (95% CI: 0.385, 0.507)) to worst (PD = 0.655 (95% CI: 0.607, 0.703)). We found that poor environmental quality exacerbates the LTPIA-obesity relationship. Efforts to improve obesity through LTPIA may benefit from considering this relationship.