Rehabilitation of post-stroke aphasia in Ghana.

BACKGROUND: Aphasia, a common consequence of stroke, which affects both communication and social functioning, and in turn, quality of life, is on the rise due to increases in stroke prevalence and survival rate. The rehabilitation of post-stroke aphasia primarily falls within the purview of speech-language pathology and research supports the effectiveness of such services. However, provision of aphasia rehabilitation services in sub-Saharan Africa is associated with challenges. AIMS: This study aimed to examine rehabilitation services for individuals with post-stroke aphasia in Ghana by exploring the roles of the stakeholder groups involved in the assessment and treatment of post-stroke aphasia in Ghana, as well as the challenges they encounter in providing or identifying services. The stakeholder groups included educational institutions, interdisciplinary healthcare professionals, and family caregivers of individuals with post-stroke aphasia. METHODS & PROCEDURES: A qualitative case study approach was used to collect and integrate from multiple sources data such as demographic information, interview responses and program syllabi to develop a holistic image. Fifteen respondents from the stroke and speech therapy units at Komfo Anokye and Korle-Bu Teaching Hospitals, University of Ghana, and University of Health and Allied Sciences, Ghana were purposively sampled. Interview questions were developed and centred on aphasia education and training, knowledge of speech-language pathology services, speech-language pathology service delivery, access to speech-language pathology services, challenges in both delivery and access to speech-language pathology services and suggestions for improving speech-language pathology services. In-person and virtual interviews were conducted after demographic information was collected. Interviews were analysed thematically, and demographic information and program syllabi were triangulated with the interview data collected. OUTCOMES & RESULTS: All stakeholder groups identified concerns with current aphasia services in Ghana. Issues raised included the insufficient number of speech-language pathologists, lack of awareness of speech-language pathology services for post-stroke aphasia (among healthcare professionals and the public), absence of aphasia management information and clinical training in educational programming, lack of interest in speech-language pathology training programs, financial challenges, spiritual and traditional beliefs and geographic barriers (i.e., speech-language pathology services are currently available in only a few cities). CONCLUSIONS & IMPLICATIONS: These findings emphasised the need to improve post-stroke aphasia rehabilitation in Ghana. The process of data collection itself educated respondents on the importance of post-stroke aphasia rehabilitation, and by identifying barriers, strategies to improving services, such as designing standardised aphasia assessments for the Ghanaian context, can now be initiated. WHAT THIS PAPER ADDS: What is already known on the subject To address post-stroke aphasia, evidence-based speech-language pathology services are provided. However, there is a paucity of studies on post-stroke aphasia services in Ghana, preventing an accurate report of services and practices in the country. What this study adds This study provides an overview of the existing rehabilitation services for post-stroke aphasia in Ghana. It highlights challenges facing the existing services and suggested strategies to improve post-stroke aphasia services. What are the clinical implications of this work? The study created awareness among healthcare professionals and general public (study participants) about the importance of rehabilitation services for post-stroke aphasia. Based on the study findings, appropriate stakeholders such as policy makers, researchers, and healthcare professionals can further design assessments and interventions to improve rehabilitation, including speech-language pathology services, for post-stroke aphasia in Ghana.

Applying the Rehabilitation Treatment Specification System to Functional Communication Treatment Approaches for Aphasia.

There are many different approaches to the rehabilitation of patients with aphasia, a communication disorder that affects a person's understanding and expression of spoken and written language. One approach called "functional communication interventions" aims to enhance communication success as opposed to solely improving linguistic abilities. This approach encompasses many skills (eg, gesturing) and factors (eg, access to communication supports) that support sending and receiving messages in "real-world" daily activities and environments. Functional communication treatments are highly diverse and not always well described. A framework that may provide structure to the description of functional communication interventions for aphasia is the Rehabilitation Treatment Specification System (RTSS). The RTSS was developed by an interdisciplinary research team to describe interventions across any rehabilitation discipline and in any setting or format. The RTSS uses a common language and a systematic approach to describing treatment and includes 3 connected elements-a single target, 1 or more ingredients, and a mechanism of action-that, taken together, attempt to explain how and why a treatment works. Although the RTTS has been described previously within the field of speech-language pathology, it has not yet been applied to the field of aphasiology. We applied the RTSS framework to a sample of peer-reviewed studies that represent functional communication treatments, including Promoting Aphasics' Communicative Effectiveness (PACE), modified Response Elaboration Training (M-RET), script training, conversation treatment, and communication partner training. We discuss both the advantages and disadvantages of using the RTSS framework to better understand the important elements of functional communication treatment approaches for aphasia.

Moderator effects in a randomized controlled trial of the Common Elements Treatment Approach (CETA) for intimate partner violence and hazardous alcohol use in Zambia.

BACKGROUND: Intimate partner violence (IPV) and hazardous alcohol use are prevalent and co-occurring problems in low- and middle-income countries (LMICs). While limited evidence suggests that cognitive behavioral therapy (CBT) interventions can help address these problems, few randomized trials in LMICs have investigated moderators of treatment effectiveness. This study explores moderating factors impacting responsiveness to a CBT-based intervention for IPV and hazardous alcohol use among couples in Zambia. METHODS: Data were obtained from a completed randomized trial of a CBT-based intervention, the Common Elements Treatment Approach (CETA), among 248 couples in Lusaka. Female experiences of IPV and male alcohol use were measured at baseline and 12 months post-baseline. Mixed effects regression models were used to evaluate each moderator: age, educational attainment, employment status, marital status, physical disability, HIV status, trauma exposure, depression, post-traumatic stress disorder, alcohol use disorder, and substance use. RESULTS: Treatment effectiveness for male alcohol use was moderated by female substance use, with greater reductions among men whose partners reported using non-alcohol substances (e.g., cannabis) (p < 0.01). Other marginally significant moderators (p < 0.15) of change in male alcohol use included female education and male depression, substance use, and moderate-to-severe alcohol use at baseline. Female HIV status and depression were marginally significant moderators of change in IPV. CONCLUSIONS: This study suggests that CETA may be especially effective for highly symptomatic individuals with comorbid mental and behavioral health problems, a promising finding given that such comorbidity is widespread in LMICs. Psychotherapeutic treatments that can flexibly and simultaneously address co-occurring problems are needed.

App-based Mindfulness Training for Adolescent Rumination: Predictors of Immediate and Cumulative Benefit.

Objectives: Rumination is a transdiagnostic risk factor for depression and anxiety, which surge during the adolescent years. Mindfulness training - with its emphasis on metacognitive awareness and present-moment attention - may be effective at reducing rumination. Mindfulness apps offer a convenient, engaging, and cost-effective means for accessing mindfulness training for teens. Despite their increasing popularity among adolescents, no study to date has investigated which teens are well-suited to app-based mindfulness training. Methods: Eighty adolescents (M age = 14.01 years, 45% girls) with elevated rumination were enrolled in a 3-week trial of app-based mindfulness training. Repeated daily ecological momentary assessment (EMA) surveys assessed problem-focused and emotion-focused rumination immediately prior to and following each mindfulness exercise. Elastic net regularization (ENR) models tested baseline predictors of "immediate" (post-mindfulness exercise) and "cumulative" (post-3-week intervention) benefit from app-based mindfulness training. Results: Ninety percent (72/80) of adolescents completed the 3-week trial, and the mean number of mindfulness exercises completed was 28.7. Baseline adolescent characteristics accounted for 14%-25% of the variance in outcomes (i.e., reduction in problem-focused or emotion-focused rumination). Higher baseline rumination, and lower emotional suppression, predicted better immediate and cumulative outcomes. In contrast, female gender and older age predicted better immediate, but not cumulative, outcomes. Differences in results across outcome timeframes (immediate vs. cumulative) are discussed. Conclusions: Findings from this study highlight the potential of data-driven approaches to inform which adolescent characteristics may predict benefit from engaging with an app-based mindfulness training program. Additional research is needed to test these predictive models against a comparison (non-mindfulness) condition.

Understanding mechanisms of change: An unpacking study of the evidence-based common-elements treatment approach (CETA) in low and middle income countries.

There is a recognized need to better understand "essential ingredients" of psychological treatments, and refine interventions to be more scalable and sustainable. The goal of the present study was to look within a specific modular, flexible, multi-problem transdiagnostic psychological intervention -the Common Elements Treatment Approach (CETA) - and examine questions that would lead to optimizing CETA for scale up and sustainment. Utilizing data from two trials of CETA in two different countries (Thailand and Iraq), this manuscript aims to: 1) determine the "active treatment dose" or how many sessions are needed to achieve clinically meaningful change overall, in CETA); and 2) test how trajectories of client symptom change varied based on client characteristics and/or on delivery of certain elements. Results showed that overall 50% of CETA clients show some improvement after 4-6 sessions (1 SD) and large improvement (2 SD) after 7-10 sessions. Trajectories of change show steady symptom decline over time. Results support gradual exposure as one of the "active ingredients". Findings suggest that modular, flexible transdiagnostic models may allow for more efficient, targeted treatment as we gain more knowledge about key ingredients, their timing within treatment, and client outcomes.

Treatment of an HIV-affected adolescent with heroin dependence in a low-income country: A clinical case study from Zambia.

INTRODUCTION: Although the World Health Organization (WHO) has recommended guidelines for the treatment of opioid dependence, there are myriad challenges to successfully implementing such guidelines in resource constrained settings, such as in low and middle-income countries (LMICs). To highlight these challenges, this paper presents a clinical case study of an adolescent study participant in a randomized controlled trial comparing two counseling programs in Lusaka, Zambia. CASE DESCRIPTION: This 15 year-old male reported smoking marijuana and heroin daily, and injecting heroin monthly (while needle sharing). The patient was linked to the only physician capable of treating heroin addiction in Zambia. The patient was placed on a 30-day detox regimen of Tramadol administered from home, as in-patient detox services are unavailable in Zambia. The patient experienced complications with out-patient detox, including a relapse that led to violent behavior and temporary incarceration. The patient's treatment regimen was altered to include Lorazepam, a mild sedative, and psychosocial counseling. After completing detox the client was prescribed Naltrexone for maintenance as Methadone is listed as a banned substance in Zambia, and Buprenorphine is not available and is cost prohibitive. CONCLUSIONS: Despite a considerable amount of time and resources expended to successfully treat the patient, the majority of WHO guidelines for opioid dependence treatment were not attainable within the Zambian context. Additional research into the effectiveness and implementation of evidence-based interventions for substance use in LMICs is warranted.

Demonstrating test-retest reliability of electrophysiological measures for healthy adults in a multisite study of biomarkers of antidepressant treatment response.

Growing evidence suggests that loudness dependency of auditory evoked potentials (LDAEP) and resting EEG alpha and theta may be biological markers for predicting response to antidepressants. In spite of this promise, little is known about the joint reliability of these markers, and thus their clinical applicability. New standardized procedures were developed to improve the compatibility of data acquired with different EEG platforms, and used to examine test-retest reliability for the three electrophysiological measures selected for a multisite project-Establishing Moderators and Biosignatures of Antidepressant Response for Clinical Care (EMBARC). Thirty-nine healthy controls across four clinical research sites were tested in two sessions separated by about 1 week. Resting EEG (eyes-open and eyes-closed conditions) was recorded and LDAEP measured using binaural tones (1000 Hz, 40 ms) at five intensities (60-100 dB SPL). Principal components analysis of current source density waveforms reduced volume conduction and provided reference-free measures of resting EEG alpha and N1 dipole activity to tones from auditory cortex. Low-resolution electromagnetic tomography (LORETA) extracted resting theta current density measures corresponding to rostral anterior cingulate (rACC), which has been implicated in treatment response. There were no significant differences in posterior alpha, N1 dipole, or rACC theta across sessions. Test-retest reliability was .84 for alpha, .87 for N1 dipole, and .70 for theta rACC current density. The demonstration of good-to-excellent reliability for these measures provides a template for future EEG/ERP studies from multiple testing sites, and an important step for evaluating them as biomarkers for predicting treatment response.

Trauma-focused CBT for youth with complex trauma.

OBJECTIVES: Many youth develop complex trauma, which includes regulation problems in the domains of affect, attachment, behavior, biology, cognition, and perception. Therapists often request strategies for using evidence-based treatments (EBTs) for this population. This article describes practical strategies for applying Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) for youth with complex trauma. METHODS: TF-CBT treatment phases are described and modifications of timing, proportionality and application are described for youth with complex trauma. Practical applications include (a) dedicating proportionally more of the model to the TF-CBT coping skills phase; (b) implementing the TF-CBT Safety component early and often as needed throughout treatment; (c) titrating gradual exposure more slowly as needed by individual youth; (d) incorporating unifying trauma themes throughout treatment; and (e) when indicated, extending the TF-CBT treatment consolidation and closure phase to include traumatic grief components and to generalize ongoing safety and trust. RESULTS: Recent data from youth with complex trauma support the use of the above TF-CBT strategies to successfully treat these youth. CONCLUSION: The above practical strategies can be incorporated into TF-CBT to effectively treat youth with complex trauma. PRACTICE IMPLICATIONS: Practical strategies include providing a longer coping skills phase which incorporates safety and appropriate gradual exposure; including relevant unifying themes; and allowing for an adequate treatment closure phase to enhance ongoing trust and safety. Through these strategies therapists can successfully apply TF-CBT for youth with complex trauma.

Blood, sweat and semen: the economy of axé and the response of Afro-Brazilian religions to HIV and AIDS in Recife.

This article provides an ethnographic analysis of Afro-Brazilian religious responses to the HIV epidemic in Recife. Drawing on participant observation and in-depth interviews conducted with Afro-Brazilian religious leaders and public health officials, it highlights the importance of the axé--a mystical energy manipulated in religious rituals that is symbolically associated with blood, sweat and semen. In an analysis of the relationship formed between the state AIDS programme and Afro-Brazilian religious centres, we conclude that the recognition of native categories and their meanings is one of the key elements to a fruitful dialogue between public health programmes and religious leaders that in the case studied, resulted in the re-signification of cultural practices to prevent HIV. Although the Afro-Brazilian religious leaders interviewed tended to be more open about sexuality and condom promotion, stigma towards people living with HIV (PLHIV) was still present within the religious temples, yet appeared to be more centred upon the perception of HIV as negatively affecting followers' axé than judgement related to how one may have contracted the virus. We discuss the tensions between taking a more liberal and open stance on prevention, while also fostering attitudes that may stigmatise PLHIV, and make suggestions for improving the current Afro-Brazilian response to the epidemic.

Strange bedfellows: the Catholic Church and Brazilian National AIDS Program in the response to HIV/AIDS in Brazil.

The HIV epidemic has raised important tensions in the relationship between Church and State in many parts of Latin America where government policies frequently negotiate secularity with religious belief and doctrine. Brazil represents a unique country in the region due to the presence of a national religious response to HIV/AIDS articulated through the formal structures of the Catholic Church. As part of an institutional ethnography on religion and HIV/AIDS in Brazil, we conducted an extended, multi-site ethnography from October 2005 through March of 2009 to explore the relationship between the Catholic Church and the Brazilian National AIDS Program. This case study links a national, macro-level response of governmental and religious institutions with the enactment of these politics and dogmas on a local level. Shared values in solidarity and citizenship, similar organizational structures, and complex interests in forming mutually beneficial alliances were the factors that emerged as the bases for the strong partnership between the two institutions. Dichotomies of Church and State and micro and macro forces were often blurred as social actors responded to the epidemic while also upholding the ideologies of the institutions they represented. We argue that the relationship between the Catholic Church and the National AIDS Program was formalized in networks mediated through personal relationships and political opportunity structures that provided incentives for both institutions to collaborate.

Interventions for depression symptoms among adolescent survivors of war and displacement in northern Uganda: a randomized controlled trial.

CONTEXT: Prior qualitative work with internally displaced persons in war-affected northern Uganda showed significant mental health and psychosocial problems. OBJECTIVE: To assess effect of locally feasible interventions on depression, anxiety, and conduct problem symptoms among adolescent survivors of war and displacement in northern Uganda. DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled trial from May 2005 through December 2005 of 314 adolescents (aged 14-17 years) in 2 camps for internally displaced persons in northern Uganda. INTERVENTIONS: Locally developed screening tools assessed the effectiveness of interventions in reducing symptoms of depression and anxiety, ameliorating conduct problems, and improving function among those who met study criteria and were randomly allocated (105, psychotherapy-based intervention [group interpersonal psychotherapy]; 105, activity-based intervention [creative play]; 104, wait-control group [individuals wait listed to receive treatment at study end]). Intervention groups met weekly for 16 weeks. Participants and controls were reassessed at end of study. MAIN OUTCOME MEASURES: Primary measure was a decrease in score (denoting improvement) on a depression symptom scale. Secondary measures were improvements in scores on anxiety, conduct problem symptoms, and function scales. Depression, anxiety, and conduct problems were assessed using the Acholi Psychosocial Assessment Instrument with a minimum score of 32 as the lower limit for clinically significant symptoms (maximum scale score, 105). RESULTS: Difference in change in adjusted mean score for depression symptoms between group interpersonal psychotherapy and control groups was 9.79 points (95% confidence interval [CI], 1.66-17.93). Girls receiving group interpersonal psychotherapy showed substantial and significant improvement in depression symptoms compared with controls (12.61 points; 95% CI, 2.09-23.14). Improvement among boys was not statistically significant (5.72 points; 95% CI, -1.86 to 13.30). Creative play showed no effect on depression severity (-2.51 points; 95% CI, -11.42 to 6.39). There were no statistically different improvements in anxiety in either intervention group. Neither intervention improved conduct problem or function scores. CONCLUSIONS: Both interventions were locally feasible. Group interpersonal psychotherapy was effective for depression symptoms among adolescent girls affected by war and displacement. Other interventions should be investigated to assist adolescent boys in this population who have symptoms of depression. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00280319.

A review of select alternative treatment approaches for acquired neurogenic disorders: relaxation therapy and acupuncture.

Despite increasing consumer utilization of complementary and alternative medicine (CAM) and growing evidence of its positive effects on certain physical (e.g., chronic pain, insomnia) and psychiatric (e.g., anxiety) disorders, few empirical investigations have explored using CAM to treat neurogenic disorders of communication or cognition. Accordingly, to spur clinical and research interest in CAM, we review two forms of CAM, relaxation therapy and acupuncture, that have been used to address the needs of patients with neurogenic cognitive or communicative disorders. For each technique, we describe general therapy procedures, summarize and critique the extant research, and delineate areas in need of further empirical investigation.