The current study consisted of two experiments to examine the impact of home-based therapy on mental illness in multiproblem families. Review of the literature focused on the interplay between poverty and mental illness in defining multiproblem families and the utilization of home-based therapy with this population and others. Experiment 1 focused on delineating the type and severity of psychological distress in families characterized as multiproblem. Subjects were 58 participants in the Community-Family Partnership, a Comprehensive Child Development Program located at Utah State University in Logan, Utah. In this sample, serious psychological distress was evident with depression in both women and men as a primary symptom. Female participants in Experiment 1 showed psychological distress across more subscales and higher standardized mean difference effect sizes on the global subscales of the Symptom Checklist-90-Revised than male participants. Significant distress was also evident on the Somatization and Obsessive-Compulsive subscales for female participants and on the Hostility subscale for male participants. In a corollary to Experiment 1, participants in this study also fit the description of multiproblem based on their demographic characteristics. Experiment 2 implemented a home-based therapy program based on Sherman's Action Counseling model and evaluated its effectiveness in terms of reduction of psychological distress. Six individuals drawn from the Experiment 1 sample participated in Experiment 2. At pretest, they were not demographically different from the Experiment 1 sample, and they exhibited severe psychological symptoms such that their score profiles on the Symptom Checklist 90-Revised met both definitions of caseness for that instrument. These subjects participated in nine weekly sessions of home-based therapy based on the Action Counseling model. Therapy was very successful for one subject, moderately successful for four subjects, and not successful for one subject using reduction of psychological distress as the measure of effectiveness. Additionally, Experiment 2 examined elements of the therapy that contributed to effectiveness. Mastery of and implementation of the 10 Action Counseling steps appeared to contribute to therapy success. Limitations were discussed with respect to internal and external validity in the current study. Recommendations for future work were provided.

Master of Public Health - MPH / BACKGROUND: The Zambian anti-retroviral therapy (ART) program has successfully enrolled over 770, 000 people living with HIV (PLWH), out of a population of 1.2 million PLWH. This tremendous success has overburdened the clinic system resulting in many challenges for both patients and healthcare staff. To promote ART initiation, adherence, and retention and at the same time relieve pressure on the health system, a home-based ART delivery model (HBM) was piloted in two urban communities of Lusaka. This study explored levels of acceptability of the model and factors influencing this among PLWH living in the two communities. Acceptability was defined as degree of fit between the patient’s expectations and circumstances and the home-based delivery model of ART, taking into consideration all the contextual elements surrounding the patient. METHODOLOGY: A qualitative study of HBM acceptability was nested within a clusterrandomized trial comparing outcomes in patients receiving HBM intervention compared to the standard of care in two communities in Lusaka, Zambia. Using an exploratory qualitative study design and a purposive sampling technique, qualitative data were collected using observations of HBM delivery (n=12), in-depth interviews with PLWH (n=15) and Focus Group Discussions with a cadre of community health workers called community HIV care providers (CHiPs) administering the HBM (n=2). Data were managed and coded using Atlas.ti 7 and analysed thematically. RESULTS: Overall, the HBM was found to be a good fit with the lives and expectations of PLWH and therefore highly acceptable to them. This acceptability was influenced by a combination of cross cutting clinic based, program design and socio-economic factors that have been categorized into push and pull factors. Push factors were those related to the challenges that PLWH faced when accessing ART from the clinic and included congestion, long waiting times, confidentiality breaches and stigma arising from attending a dedicated clinic. These factors resulted in considerable direct and indirect livelihood opportunity costs. The HBM as an alternative had a number of ‘pull factors’. PLHW described services offered through the model as convenient, confidential, trusted, personalized, less stigmatizing, comprehensive, client centred, responsive, and respectful. Disclosure of client’s HIV status to people they lived with was found to be critical for the acceptability of the model. CONCLUSIONS AND RECOMMENDATIONS: The HBM is highly acceptable and this acceptability is influenced by a combination of crosscutting push and pull factors. Key to the HBM’s acceptability was its delivery design that was responsive to individual patient needs and the steps CHiPs took to minimize the ever-present threat of disclosure and stigma. Future adoption and scaling up of HBM should recognize the importance of these design features.

Yes / Changes in world-wide population trends have provided new demands for new technologies in areas such as care and rehabilitation. Recent developments in the the field of robotics for neurorehabilitation have shown a range of evidence regarding usefulness of these technologies as a tool to augment traditional physiotherapy. Part of the appeal for these technologies is the possibility to place a rehabilitative tool in one’s home, providing a chance for more frequent and accessible technologies for empowering individuals to be in charge of their therapy. this manuscript introduces the Supervised Care and Rehabilitation Involving Personal Tele-robotics (SCRIPT) project. The main goal is to demonstrate design and development steps involved in a complex intervention, while examining feasibility of using an instrumented orthotic device for home-based rehabilitation after stroke. Methods: the project uses a user-centred design methodology to develop a hand/wrist rehabilitation device for home-based therapy after stroke. The patient benefits from a dedicated user interface that allows them to receive feedback on exercise as well as communicating with the health-care professional. The health-care professional is able to use a dedicated interface to send/receive communications and remote-manage patient’s exercise routine using provided performance benchmarks. Patients were involved in a feasibility study (n=23) and were instructed to use the device and its interactive games for 180 min per week, around 30 min per day, for a period of 6 weeks, with a 2-months follow up. At the time of this study, only 12 of these patients have finished their 6 weeks trial plus 2 months follow up evaluation. Results: with the “use feasibility” as objective, our results indicate 2 patients dropping out due to technical difficulty or lack of personal interests to continue. Our frequency of use results indicate that on average, patients used the SCRIPT1 device around 14 min of self-administered therapy a day. The group average for the system usability scale was around 69% supporting system usability. Conclusions: based on the preliminary results, it is evident that stroke patients were able to use the system in their homes. An average of 14 min a day engagement mediated via three interactive games is promising, given the chronic stage of stroke. During the 2nd year of the project, 6 additional games with more functional relevance in their interaction have been designed to allow for a more variant context for interaction with the system, thus hoping to positively influence the exercise duration. The system usability was tested and provided supporting evidence for this parameter. Additional improvements to the system are planned based on formative feedback throughout the project and during the evaluations. These include a new orthosis that allows a more active control of the amount of assistance and resistance provided, thus aiming to provide a more challenging interaction. / This work has been partially funded under Grant FP7-ICT-288698(SCRIPT) of the European Community Seventh Framework Programme.

Home-based psychotherapy has expanded in the mental health community; however, little was known about the therapists' comfort level in a home-based venue. The purpose of this quantitative study was to assess therapists' comfort level (TCL) in providing psychotherapy in a home-based setting and how therapeutic competency (TC), therapeutic relationship (TR), and advanced therapeutic training (ATT) related to the comfort level. The social-ecological systems theory and the theory of comfort served as the theoretical frameworks. The present study used the Therapist Comfort Scale, Counseling Competencies Scale-Revised, the Scale to Assess Therapeutic Relationship in Community Mental Health Care-Clinician, and a demographic questionnaire. A multiple linear regression and correlational analysis were conducted to assess the predictive relationships among the variables. The participants were 76 therapists who provided psychotherapy in a home-based setting. The results revealed a statistically significant positive relationship between TCL and TR. This finding indicated that as the TR score increased, TCL also increased. There was a statistically significant positive relationship between TCL and TC, which indicated that as the TC score increased, TCL also increased. There was a statistically significant positive relationship between TCL and ATT, which indicated that as the ATT score increased, TCL also increased. It was hoped that this study's findings can serve to inform and guide the home-based psychotherapists to improve their therapeutic relationship. Once the therapeutic relationship is formed, the therapists will obtain a high level of comfort in discussing concerns openly with the patients, and parents/caregivers. In addition, when therapists reach a high level of comfort, it could make a positive difference in the patients' treatment outcomes. Thus, the findings of this study initiated positive social change at the level of the individual home-based therapist as well as to the vulnerable population that they serve.

In-home family therapy has become one of the most common options of treatment for providing services to families who do not typically utilize a private clinic (Lawson, 2005; Reiter, 2000; Yorgason, McWey, & Felts, 2005). Researchers have given some attention to the topic of home-based therapy and to general supervision, but little attention has focused on the actual supervision experiences of home-based therapy providers. This phenomenological study explored the supervision experiences of seven past and current in-home therapists: marriage and family therapists (MFTs) and social workers (MSWs). Semi-structured interviews were conducted with the participants, and data was analyzed to develop structured descriptions and meanings via highlighted “significant statements” that described the participants’ experiences (Kvale, 2007). The participants’ descriptive accounts were categorized as 1) in-home therapy descriptions, 2) factors affecting in-home therapy supervision, and 3) effective and ineffective supervisory practices. Implications of the research findings suggested that clinicians’ needs and expectations related to safety, burn out, and supervisory knowledge were often unmet. Supervisory practices that appeared significantly effective were 1) developing trusting supervisor-supervisee relationships, 2) reviewing models and clinical application collaboratively, and 3) actively prioritizing clinician safety and burn out prevention.

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