Thesis (Ed.D.)--Boston University.

Introduction. Numerous studies, conducted in many different countries, report that cognitive impairment is highly prevalent in people with HIV (PWH). Such impairment can affect adherence to antiretroviral therapy (ART), and adherence is, in turn, essential for PWH to achieve viral suppression. The gold standard to confirm cognitive impairment is a neuropsychological assessment. However, accurate interpretation of neuropsychological test performance requires consideration of, for instance, how impairment is determined and how accurately the contribution of non-HIV factors to poor cognitive test performance is described. These non-HIV factors include sociodemographic variables (e.g., age, sex, educational attainment), psychosocial variables (e.g., socioeconomic status, food security, quality of life), psychiatric variables (e.g., depression, problematic alcohol use), and other medical co-morbidities. Because many existing studies of PWH do not account for (a) the fact that current quantitative methods for defining cognitive impairment may not accurately reflect HIV-associated brain injury, and (b) possible contributions of non-HIV factors to cognitive test performance, it is possible that the reported prevalence rates of cognitive impairment in PWH are inaccurate (or, at least, do not solely reflect the contributions of HIV disease to the impairment). Another uncertainty in the HIV neuropsychology literature concerns sex differences in the cognitive performance of PWH. Some recent studies suggest that women with HIV (WWH) may present with greater cognitive impairment than men with HIV (MWH). Such a sex difference is of potentially significant concern for South African clinicians because two-thirds of the population of PWH in this country are women. However, there is no definitive empirical evidence regarding whether this sex difference exists to a clinically significant degree (in South Africa, specifically, as well as globally) and what its underlying mechanisms might be. To address the knowledge gaps outlined above, this thesis set out to explore the following aims: (1) investigate sex differences in the cognitive performance of PWH by reviewing the current published literature; (2) determine if sex differences exist in a clinic sample of South African PWH; (3) determine how much variation in reported prevalence rates of HIV-associated cognitive impairment are due to the method used to define impairment, and which method correlates best with MRI biomarkers of HIVrelated brain injury in a South African sample of PWH; (4) investigate the contribution of sociodemographic and psychosocial variables, as well as HIV-disease factors and other medical and psychiatric comorbidities, to cognitive performance in a South African sample of PWH; and (5) investigate associations between cognitive performance and ART adherence in 10 a South African sample of PWH. Each of these aims was explored in a separate study. Hence, this thesis reports on findings from five separate journal manuscripts. Method. Study 1 was a systematic review and meta-analysis summarizing the findings of published studies investigating differences in cognitive performance between WWH and MWH. An extensive systematic search of the literature across several databases found 4062 unique articles of potential interest. After thorough screening of that pool of articles, 11 studies (total N = 3333) were included in the narrative systematic review and 6 studies (total N = 2852) were included in the meta-analysis. Effect sizes were calculated to estimate between-sex differences in cognitive performance, both globally and within discrete cognitive domains. Study 2 investigated sex differences in cognitive performance in a sample of PWH with comorbid MDD (N = 105). All participants were attending community clinics in Khayelitsha, a peri-urban community in Cape Town, South Africa, and were part of a larger research program for a randomised controlled trial of a cognitive-behavioral treatment for ART adherence and depression (CBT-AD). As part of this program, they completed baseline neuropsychological, psychiatric, and sociodemographic assessments. T-tests and multivariable regressions controlling for covariates compared baseline cognitive performance of WWH and MWH, both globally and within discrete cognitive domains. Study 3 applied 20 different quantitative methods of determining cognitive impairment to existing data from a different sample of PWH (N = 148). These individuals had also been recruited from community clinics in Khayelitsha, and had completed a comprehensive neuropsychological assessment and a 3T structural MRI and diffusion tensor imaging (DTI) session. Logistic regression models investigated the association between each method and HIV-related neuroimaging abnormalities. Study 4 again used data from the sample of PWH with comorbid MDD who participated in the larger CBT-AD research program. This study investigated which sociodemographic, psychosocial, psychiatric, and medical variables (as measured at baseline) were associated with baseline cognitive performance. Post-baseline, 33 participants were assigned to CBT-AD and 72 to standard-of-care treatment; 81 participants (nCBT-AD = 29) had a follow-up assessment 8 months post-baseline. This study also investigated whether, from baseline to follow-up, depression and cognitive performance improved significantly more in the participants who had received CBT-AD, and examined associations between post-intervention improvements in depression and cognitive performance. Study 5 assessed ART adherence in the same sample of PWH with comorbid MDD. Mixed-effects regression models estimated the relationship between ART adherence (as measured by both self-report and objective measures, and by degree of HIV viral suppression) with cognitive performance 11 and with other sociodemographic, psychosocial, and psychiatric variables at both baseline and follow-up. Results. Study 1: Analyses suggested that, in terms of overall cognitive functioning, there were no significant differences in cognitive performance between WWH and MWH. However, WWH did perform significantly more poorly than MWH in the domains of psychomotor coordination and visuospatial learning and memory. Additionally, the review suggested that cognitive differences between WWH and MWH might be accounted for by sex-based variation in educational and psychiatric characteristics among study samples. Study 2: Analyses suggested that, in our sample of PWH with comorbid MDD, there were no significant differences in cognitive performance between WWH and MWH. Study 3: Findings suggested that there was marked variation in rates of cognitive impairment (20– 97%) depending on which method was used to define impairment, and that none of these methods accurately reflected HIV-associated brain injury. Study 4: Analyses suggested that less education and greater food insecurity were the strongest predictors of global cognitive performance. Improvement in depression severity was not significantly associated with improved cognitive performance, except in the domain of Attention/Working Memory. Overall, factors associated with cognitive performance were unrelated to HIV disease and other medical factors. Study 5: Analyses identified poor global cognitive performance as a potential barrier to achieving HIV suppression. Conclusion. Taken together, the findings from the five studies contained within this thesis suggest that one oft-mooted sociodemographic influence on cognitive performance in PWH, sex, was not a consistent influence on such performance. However, non-biological (mainly psychosocial and socioeconomic) factors were stronger predictors of cognitive performance in PWH than medical factors (including HIV-disease variables). Current quantitative criteria for defining cognitive impairment in PWH also do not accurately reflect the biological effects of HIV in the brain. The implication of these findings is that research studies may be misclassifying PWH as cognitively impaired and consequently overestimating the prevalence of cognitive impairment in this population. When conducting clinical assessments of PWH, future research studies should measure and consider the strong influence of psychosocial and socioeconomic factors on cognitive test performance. Ideally, a diagnosis of impairment should only be made after a comprehensive clinical assessment that includes a detailed history taking. Overall, we need new criteria for defining cognitive impairment in diverse global populations of PWH. Ideally these criteria should be applicable to both research and clinical settings. Assessing for cognitive impairment among PWH and then providing 12 appropriate support could help achieve viral suppression in patients with non-optimal adherence to ART. At public policy levels, addressing larger psychosocial issues (e.g., food insecurity and low educational attainment) may also help improve cognitive performance in PWH.

Introduction: Mental health in the workplace has emerged as an important issue and a number of pieces of legislation at the international and regional level provide a good framework for ensuring that people with mental disorders have equal opportunities for employment and support within the workplace. This issue has not been sufficiently addressed in Namibia. This study therefore explored how mental illness is addressed in human resources policies, processes, procedures, and mental health programmes in the Namibian Public Service workplace. Methods: This study comprised two components: a review of legal documents and a qualitative study with relevant people addressing mental illness in the workplace. Five existing Laws, Policies and Rules were reviewed. The review looked at any reference to Mental Illness or Mental Health and in instances where both were not used, identified other terms used like, severe psychiatric illness, psychological disorders, MNS disorders (mental, neurological and substance abuse). In cases where none of the terms were used to identify the two concepts or general health or illness in all documents, the review identified other terms or phrases that may have been used to identify physical or mental illness. The review further pinpointed the legal provisions in the laws which have direct reference to mental illness in the workplace. These provisions ranged from recruitment, management, and boarding of people with mental illness in the workplace. In the second component, a qualitative study design was used comprising of three semi-structured interviews and seven focus group discussions. The study had a total of thirty nine participants selected through a purposeful sampling method. Two representatives, one from each of the unions representing employees in the public service and one participant from the Medical Review Board were interviewed individually. Sixteen Government Ministries were selected and invited to participate in the study, but only nine sent a total of twelve representatives from HR Departments to participate. The Public Service Commission focus group discussion had twelve participants, while members of the Mental Health Association of Namibia representing people with mental illness (MI) and their support persons participated in two focus groups. Four participants who had experienced being medically boarded due to MI, participated in two focus group discussions. All sessions were audio recorded and transcribed verbatim. A Framework Data Analysis approach was used to extract themes to address the aim and objectives. Results: The findings from the document review show that the legislation framework lacked clear documentation of how to identify and manage mental illness in the workplace, resulting in inconsistencies in how mental illness is managed in the Namibian public sector. The findings of the qualitative study show that participants have limited knowledge of what mental illness is, although people seemed able to describe how to recognize someone with mental illness from the way they act. There is confusion between the concepts of disability and ill-health resulting in many people being boarded prematurely or inappropriately. Conclusion: The participants appreciated and recognized the importance of the study in all the discussions, suggesting that there is a need for platforms to be created where issues of mental illness and mental health can be discussed. The lack of a coordinating structure for mental illness in the Public Service was seen a stumbling block in addressing mental illness in an appropriate way. The recommendations to have at least one trained health worker who will be dedicated to employee wellness, will be a step in the right direction. There is an urgent need to reform some of the legal instruments to be able to create a positive impact for people with mental illness in the workplace.

Previous studies found that children with ASD tend to participate in lower amounts of physical activity (PA), accumulate greater hours of screen time (ST), and have poorer sleep quality (SQ), compared to typically developing (TD) youth. Unfortunately, these poor health behaviors put youth with ASD at a high risk for developing obesity, as well as other obesity-related conditions (e.g. Type 2 diabetes). In order to reduce this risk, it is critical to understand the factors that affect activity levels and sleep in youth with ASD. Several studies have demonstrated that parents may have a large influence on social behaviors in youth with ASD, however, no studies have focused on the association between parent and child health behaviors in youth with ASD. Therefore, the purpose of the current study was to examine the association between parent and child PA, sedentary behavior (SB), ST, and SQ in youth with ASD. Data was collected from 15 child (ages of 6-17) and parent pairs, recruited from a private school in Central Orlando. Daily minutes of PA, SB, and SQ were measured using an Actigraph accelerometer, that both children and parents wore on their wrist over a 7-day period. Parents and children also completed surveys that inquired about both their PA and ST levels during weekdays and weekend. Pearson correlations found significant positive associations between objective parent and child PA and both self-reported weekend PA and ST. This is the first study to examine associations between parent and child health behaviors in youth with ASD, finding positive correlations between PA and ST during the weekend. These findings suggest that there is a relationship between parent and child activity levels in youth with ASD. It is critical for future work to examine the causal factors of this relationship between parent and child activity levels in youth ASD populations. Such results may support the inclusion of parents to develop more effective interventions to target health behaviors in youth with ASD.

It is assumed that stigmas surrounding mental illnesses have begun to lessen over time. Generation Z seems to be the most accepting of neurodivergent individuals and people with mental illnesses (Bethune, 2019). However, existing literature suggests that college students continue to have negative attitudes toward mental illnesses, which could lead to a refusal of mental health services, unsafe social environments, and self-medication (Phelan & Basow, 2007). To further investigate GenZ’s stigmas toward mental illness, this study assesses college students’ attitudes toward various mental health diagnoses including Depression, Anxiety, Attention Deficit-Hyperactivity Disorder (ADHD), Autism Spectrum Disorder (ASD), and Eating Disorders. Specifically, perceptions related to factors such as relationship disruption, visibility, anxiety, and professional efficacy will be investigated. After reviewing situational vignettes depicting peers with diagnoses and the Diagnostic and Statistical Manual Fifth Edition definitions of these diagnoses, participants’ attitudes were assessed using an adapted version of Day’s Mental Illness Stigma Scale, and additional questions regarding participants’ attitudes. Previous studies found prevalent stigmas amongst college students regarding ASD and eating disorders. Students may hold more positive attitudes toward anxiety, depression, and ADHD than eating disorders and ASD. This research helps to address the conflicting claims about GenZ’s attitudes about mental disorders and explore the stigma of mental illnesses among college students. Mean comparisons between each level of both conditions, study limitations, and future directions are discussed.

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