Papers by Lunthita M Duthely, EdD, MSc, MS
In an era of global, economic instability, accountability for doctoral student success remains an... more In an era of global, economic instability, accountability for doctoral student success remains an institutional concern. Institutional-level factors for doctoral student success are well-documented in the literature; individual-level factors are investigated to a lesser degree. The purpose of this study is to examine the relationship between the positive psychology trait of “grit” and a spiritual orientation, and how these two orientations contribute to successful completion of a doctoral program. The positive psychology trait of grit—persistence to persevere despite failure—and a spiritual orientation not necessarily tied to religion are the study foci. Specifically, the study findings of non-traditional doctoral graduates who completed a distance learning or hybrid program will be presented. The qualitative aspect of the study seeks to explore the grit-spirituality relationship and shed light on the directionality of this relationship. Study authors will tell the “To Mixed or not to Mixed” tale of their dilemma, as quantitative researchers, of the best methodological approach and best approach to data analysis. Researcher quandaries regarding study methods (mixed-methods vs. quantitative study supplemented with qualitative questions), qualitative data analysis tool (manual vs. software) will be discussed. Finally, the way the qualitative perspective enhanced the quantitative findings will be presented
Open Forum Infectious Diseases, 2016
Background. Mother-to-child human immunodeficiency virus transmission (MTCT) is greatly reduced w... more Background. Mother-to-child human immunodeficiency virus transmission (MTCT) is greatly reduced with initial testing, retest 3rd trimester, and at delivery. Some metropolitan areas such as Miami account for disproportionate MTCT in the United States. Per Centers for Disease Control and Prevention (CDC) guidelines, human immunodeficiency virus (HIV) testing in pregnancy follows "Opt-out testing": include with standard antenatal screening, unless patient "opts out". Specifically, the
American Journal of Obstetrics and Gynecology, 2012
International Journal of Environmental Research and Public Health, Mar 2, 2021
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
The Journal of Infectious Diseases, May 1, 2006
See the editorial commentary by Tuomala and Yawetz, on pages 1191-4.) Background. Data on complic... more See the editorial commentary by Tuomala and Yawetz, on pages 1191-4.) Background. Data on complications of pregnancy associated with antiretroviral therapy are limited. Some small studies have demonstrated an increased preterm delivery rate, but a recent retrospective United States multisite study did not concur with these findings. Our objective was to investigate whether antiretroviral therapy was associated with adverse pregnancy outcome at a single site. Methods. Using prospectively gathered data, women were identified who were determined to be human immunodeficiency virus positive before or during pregnancy who sought care at our prenatal clinic and who gave birth at the University of Miami/Jackson Memorial Medical Center from 1990 through 2002. The outcome measures were preterm delivery, low birth weight, and stillbirth. Results. The cohort included 999 women who received antiretroviral therapy during pregnancy (monotherapy in 492, combination therapy without a protease inhibitor [PI] in 373, and combination therapy with a PI in 134) and 338 women who did not receive therapy. After adjustment for possible confounders, only combination therapy with a PI was associated with an increased risk of preterm delivery, compared with any other combination (odds ratio, 1.8 [95% confidence interval, 1.1-3.0]). There were no differences in rates of low birth weight and stillbirth, regardless of therapy. Conclusion. Compared with monotherapy and combination therapy without a PI, only combination therapy with a PI was associated with an increased risk of preterm delivery. Antiretroviral therapy (ART) is recommended during pregnancy to decrease the risk of perinatal transmission of HIV-1 infection [1] and to improve maternal health [2]. The optimal antiretroviral regimen that provides the most protection with the least toxicity to mother and child has yet to be determined. Data about complications of pregnancy that are associated with ART are limited. A putative association with preterm birth was raised by a small retrospective Swiss study of 30 women who received combination therapy during pregnancy-with protease inhibitors (PIs) in 13 women and
Clinical psychiatry, 2017
Background: Adolescents living in the United States (U.S.) report mental challenges from depressi... more Background: Adolescents living in the United States (U.S.) report mental challenges from depressive symptoms to suicidal ideations. The positive psychology (PP) paradigm is a preventative approach to mental health challenges. Increasing gratitude, well-studied among adolescents, is a PP intervention; yet, most U.S.-based studies were limited with respect study population diversity. Few studies included urban or multicultural youth. Objective: The current study provides a brief introduction to PP and contemplative studies, and how the paradigms were combined into one intervention. A gratitudemeditation intervention was conducted among a diverse cohort of adolescents. The feasibility, acceptability, preliminary outcomes, as well as the challenges and successes of conducting the intervention are described. Method: A four-week, gratitude-meditation study was manualized and tested in a middle school. The science of gratitude was merged with the secular practice of meditation to test a novel intervention among adolescents in an urban setting. The gratitude visualization exercises were extracted from The Jewels of Happiness-a collection of poetry and prose for developing positive qualities. The study feasibility and acceptability is quantified; the study challenges and successes are summarized. Conclusion: Despite challenges encountered in conducting the study, the study was feasible, accepted, and the intervention was completed successfully.
Infectious diseases in obstetrics and gynecology, May 7, 2020
Background. The CDC and ACOG have issued guidelines for HIV screening in pregnancy for patients l... more Background. The CDC and ACOG have issued guidelines for HIV screening in pregnancy for patients living in areas with high prevalence of HIV in order to minimize perinatal vertical transmission. There is a lack of data examining providers' compliance with these guidelines in at-risk patient populations in the United States. Objective. To evaluate if HIV screening in pregnant women was performed according to guidelines at a large, urban, tertiary care medical center in South Florida. Study Design. A retrospective review was performed on 1270 prenatal and intrapartum records from women who delivered a live infant in 2015 at a single institution. Demographic and outcome data were chart abstracted and analyzed using arithmetic means and standard deviations. Results. Of the 1270 patients who met inclusion criteria, 1090 patients initiated prenatal care in the first or second trimester and delivered in the third trimester. 1000 (91.7%) patients were screened in the first or second trimester; however, only 822 (82.2%) of these were retested in the third trimester during prenatal care. Among the 178 patients lacking a third trimester test, 159 (89.3%) received rapid HIV testing upon admission for delivery. Of the 1090 patients who initiated prenatal care in the first or second trimester and delivered in the third trimester, 982 (90.1%) were screened in accordance with recommended guidelines. Of the 1270 patients initiating care in any trimester, 24 (1.9%) had no documented prenatal HIV test during prenatal care, however 22 (91.7%) had a rapid HIV test on admission for delivery. Two (0.16%) patients were not tested prenatally or prior to delivery. Conclusion. Despite 99.8% of women having at least one HIV screening test during pregnancy, there is room for improvement in routine prenatal screening in both early pregnancy and third trimester prior to onset of labor in this high-risk population.
Journal of Midwifery & Women's Health, Jun 20, 2019
curriculum to include HIV content. Nurse-midwives introduced the curriculum in a pilot project to... more curriculum to include HIV content. Nurse-midwives introduced the curriculum in a pilot project to learn if women would enroll in group prenatal care. A retrospective record review was conducted to evaluate perinatal outcomes among women with HIV who received prenatal care in a group setting. Methods: Data were collected from the electronic health records of women with HIV who received either CenteringPregnancy-HIV group prenatal care or traditional prenatal care between March 2015 and July 2016. Sociodemographic factors, HIV immune markers, and pregnancy and birth outcomes were reviewed. Univariate and bivariate statistics and multiple regression models assessed differences between women in CenteringPregnancy-HIV group prenatal care compared with women with HIV in traditional care. Results: Among women with HIV who received prenatal care during the pilot project, 128 met eligibility criteria for review. Perinatal outcomes were analyzed for 117 women who had a live birth; of these, 14 participated in CenteringPregnancy-HIV group prenatal care, and 103 received traditional care. Demographic profiles were similar in both groups. No significant differences in perinatal outcomes were observed among women in CenteringPregnancy-HIV group prenatal care compared with women with HIV in traditional prenatal care. Discussion: Women with HIV can often feel stigmatized and isolated. Group prenatal care can foster patient engagement, self-management, and social support to improve adherence to antiretroviral and other health regimens that promote healthy outcomes for both woman and newborn. Although results of this pilot study were not statistically significant, they show that CenteringPregnancy-HIV group prenatal care may be an option for women with HIV, but the benefits need further exploration in larger studies.
HIV/AIDS : Research and Palliative Care, Mar 1, 2023
Background: Health-related challenges caused and worsened by the global COVID-19 pandemic have pr... more Background: Health-related challenges caused and worsened by the global COVID-19 pandemic have proven broad and multifaceted, particularly for racial/ethnic minority women living with HIV (WLWH). The 2020 pandemic has affected the wellbeing and access to care for WLWH in Southeastern Florida, a region that experienced simultaneous high rates of COVID-19 and HIV. WLWH, over a short-or long-term period, likely utilize different coping mechanisms as they face these challenges. Methods: This analysis compared pandemic-related stress and support endorsed by participants attending an urban clinic in South Florida, from January through May 2021. Participants completed an adapted version of the Pandemic Stress Index (PSI). The items in the PSI assessed emotional distress, stigma, and support, and were dichotomized, as either "stress" or "support". Mann-Whitney U-test assessed differences in distributions of PSI scores (stress and support) comparing long-term survivors (≥10 years with an HIV diagnosis) to those more recently diagnosed (<10 years). Results: The cohort consisted of 63 WLWH, aged 21-71 (Mean = 42 years±12.95). The group of WLWH were almost evenly split, with 50.8% having been diagnosed in the last 10 years (short-term survivors). The high-stress group endorsed lower levels of support, compared to the low-stress group. There was a non-significant trend of higher stress scores for short-term survivors, compared to longterm survivors; and, higher support scores for long-term survivors, compared to short-term survivors. Conclusion: Results suggest a trend in long-term survivor WLWH endorsing lower stress and higher support; the contrary was found for their short-term survivor counterparts. Patterns in COVID-19 related stressors and maladaptive behaviors need further exploration to establish suitable interventions that address disparities within groups of WLWH.
Journal of Lower Genital Tract Disease, Oct 1, 2022
American Journal of Obstetrics and Gynecology, Dec 1, 2019
Streptococcus pseudoporcinus has biochemical characteristics similar to Streptococcus agalactiae ... more Streptococcus pseudoporcinus has biochemical characteristics similar to Streptococcus agalactiae and has recently been found to colonize the female genital tract. It has been reported in association with clinical infections but has not previously been shown to be a cause of serious perinatal morbidity or mortality. Here we present a case of severe maternal morbidity (sepsis) and fetal demise associated with Streptococcus pseudoporcinus. METHODS: Case report. RESULTS: Case: A 41-year-old gravida 2, para 1001 presented with abdominal pain and fetal demise at 34 weeks gestational age. She was found to be in labor, with tachycardia and leakage of purulent fluid from the cervical os. Her maximum temperature was 37.5 degrees Celsius, and labs were significant for a white blood cell count of 29,000 per mL and a serum lactate of 2.4 mmol/L. Intravenous ampicillin and gentamicin were initiated in Labor and Delivery for a diagnosis of chorioamnionitis. She had a spontaneous vaginal delivery. A beta hemolytic streptococcus was isolated from the patient'surine, placenta, endometrium, and two blood culture sets. Testing for Streptococcus Lancefield groups A, B, C, F and G was negative. Biochemical studies included a positive pyrrolidonyl aminopeptidase (PYR) test and a negative catalase reaction. The isolates were resistant to optochin. API identification revealed Streptococcus agalactiae (biotype number 3063214) with 99.8% confidence at 24 hours. Identification of all isolates by matrix assisted laser desorption ionization time-of-flight (MALDI, Bruker) yielded Streptococcus pseudoporcinus, using the research use only database with log scores for each specimen ranging from 1.86 to 2.07. A blood culture isolate sent to a reference laboratory for bacterial 16S rRNA sequencing confirmed the identification of Streptococcus pseudoporcinus, with 100% identity of the first 467 base pairs of the 16S sequence to Streptococcus pseudoporcinus LQ 940-04. The patient recovered well in the postpartum period and left the hospital on postpartum day 4. CONCLUSION: S. pseudoporcinus can be difficult to distinguish from S. agalactiae. Although the exact clinical significance of S. pseudoporcinus remains to be seen, our case demonstrates that it is a potential cause of serious puerperal infection. If there are other reports of puerperal infections with this organism, its significance and prevalence in genital tract flora may warrant further investigation. LEARNING OBJECTIVES: Explain the evidence from a case that demonstrates that S. pseudoporcinus is a potential cause of chorioamnionitis and severe perinatal morbidity and mortality.
Interdisciplinary Perspectives on Infectious Diseases, 2019
Background. Vaginal cancer is a rare disease with poor clinical outcomes and limited therapeutic ... more Background. Vaginal cancer is a rare disease with poor clinical outcomes and limited therapeutic options. In the United States (US), minority women and older women are disproportionately diagnosed with late-stage vaginal cancer. Sociodemographic characteristics, risk behaviors, and cooccurring conditions are linked to vaginal intraepithelial neoplasia (VaIN). The diagnosis of VaIN is more prevalent among older women and women living with HIV (WLWH). The Caribbean basin has one of the highest rates of anogenital cancers in the Western Hemisphere. In the US, vaginal infections are more prevalent among Caribbean women, and these infections contribute to higher rates of Human Papilloma Virus (HPV). Given the high rate of anogenital cancers in the Caribbean and the high rates of HPV among Caribbean women in the US, we sought to describe the occurrence of VaIN in a cohort of Black non-Hispanic WLWH. The cohort was followed by an interdisciplinary team of providers with the University of Miami, Miller School of Medicine. Results. Caribbean Americans were living with HIV longer and more were uninsured; more African Americans endorsed cigarette and illicit substance use. Caribbean Americans trended towards the highest grades of VaIN (VaIN 2+) at baseline, but more African Americans progressed to VaIN 2+ in subsequent biopsies. Conclusion. In this cohort of Caribbean American and African American women living with HIV diagnosed with VaIN, Caribbean Americans had the highest grade of VaIN at baseline, but more African Americans progressed to more advanced stages of the disease.
American Journal of Obstetrics and Gynecology, Dec 1, 2006
OBJECTIVE: 17a-hydroxyprogesterone caproate (17HPC) results in 30% reduction in the rate of recur... more OBJECTIVE: 17a-hydroxyprogesterone caproate (17HPC) results in 30% reduction in the rate of recurrent preterm deliveries. However, the mechanism and site of action of 17HPC as well as its pharmacokinetics are yet to be elucidated. Investigations in our laboratory focus on the transplacental transfer and metabolism of drugs used in treatment of the pregnant patient. The objective of this investigation is to determine the in vitro transplacental transfer and distribution of 17HPC between placental tissue, maternal and fetal circuits. STUDY DESIGN: The technique of dual perfusion of term placental lobule was utilized. The placentas were perfused with 17HPC added to the maternal reservoir at a concentration of 21ng/ml, which is equivalent to its peak levels in maternal circulation following 1000 mg intramuscular injection, together with its dual labeled radioactive isotope (3 H-hydroxyprogesterone and 14 Ccaproate). The amounts of the drug in the tissue and both circuits were determined by liquid scintillation spectrometry. RESULTS: A biphasic decline in concentration of the drug in the maternal circuit was observed, initially rapid then slow. At the end of the perfusion period, a concentration gradient of the drug between the tissue and the two circuits was observed with the following ratios: tissue/maternal circuit, 2.23 G 0.70; tissue/fetal circuit, 2.89 G 1.07 and fetal/maternal circuit 0.79 G 0.07. The drug retained in the tissue did not have any adverse effects on the determined placental tissue viability and functional parameters. CONCLUSION: 17 HPC readily crosses the placenta from the maternal to fetal circuit, is retained by placental tissue and does not affect the in vitro determined placental functions.
Open Forum Infectious Diseases, Mar 18, 2019
Background. There is a knowledge gap on the clinical use of elvitegravir (EVG) during pregnancy a... more Background. There is a knowledge gap on the clinical use of elvitegravir (EVG) during pregnancy and maternal viral suppression. Our objective was to evaluate the effects of EVG use in pregnancy on rates of HIV virologic suppression and perinatal outcomes. Methods. We conducted a retrospective, multicenter study of pregnant women living with HIV (WLHIV) who used EVGcontaining antiretroviral therapy (ART) between January 2014 and March 2017 at 9 tertiary care centers in the United States. WLHIV were included if they took EVG at any time during pregnancy. We described the characteristics of the WLHIV using EVG during the study period and evaluated the rates of HIV suppression and perinatal outcomes. Results. Among 134 pregnant WLHIV who received EVG at any time during pregnancy, viral suppression at delivery (HIV-1 RNA < 40 copies/mL) occurred in 81.3%. In WLHIV who initiated EVG before pregnancy and continued through delivery (n = 68), the rate of viral suppression at delivery was 88.2%. The average gestational age at the time of delivery was 37 weeks 6 days, and the overall rate of preterm birth was 20%. No cases of open neural tube defects were noted in women on EVG at the time of conception (n = 82). The perinatal HIV transmission rate was 0.8%. Conclusions. EVG use was associated with high sustained levels of HIV suppression during pregnancy and a low rate of perinatal HIV transmission. Keywords. HIV viral suppression; obstetrics and gynecology; perinatal outcomes; prevention of mother-to-child transmission.
Frontiers in Communication, Nov 10, 2020
Background: Mobile health technologies (mHealth) are efficacious along the continuum of HIV/AIDS-... more Background: Mobile health technologies (mHealth) are efficacious along the continuum of HIV/AIDS-from prevention of HIV transmission to those at the highest risk of acquiring infection, to adherence to HIV medical care, for those living with the disease-decreasing the public health burden of the disease. HIV/AIDS is a complex condition, as certain population subgroups are disproportionately affected. Furthermore, barriers experienced at the individual level (e.g., HIV stigma) and at the systems level (i.e., access to care) contribute to these disparities. Low cost, high penetration rates and ease of use mean mHealth SMS/texting solutions hold the biggest promise for curbing the global HIV/AIDS epidemic; yet these technologies have their own challenges. Our primary objective was to assess interventions that promote adherence, which are delivered via SMS/texting, and important design and ethical considerations of these technologies. Specifically, we evaluated the underlying frameworks underpinning intervention design, strategies to safeguard privacy and confidentiality, and measures taken to ensure equity and equitable access across different subgroups of persons living with HIV (PLWH). We also synthesized study outcomes, barriers/facilitators to adherence, and barriers/facilitators of technology to support HIV adherence. Methods: A scoping review methodology was utilized, searching the Medline database for recently published articles (January 2017 to June 2019). Two reviewers independently screened titles and abstracts for relevancy using the following eligibility criteria: (a) original research or protocol; (b) inclusion of persons living with HIV; (c) intervention delivery via SMS/text messaging; and, (d) intervention included HIV care adherence. Results: Seven (7) of the 134 articles met full criteria. The great majority (n = 6) did not report whether the interventions were developed under established behavioral change models or frameworks. Strategies to address privacy, confidentiality and equity/equitable access were taken in four (n = 4) studies. Conclusion: Our mixed methods review determined that privacy and confidentiality remain a concern for PLWH. Provisions to accommodate literacy, infrastructure, technology and other challenges (e.g., access to smartphones and Wifi) are important Duthely and Sanchez-Covarrubias Recent HIV/AIDS, SMS/Texting Interventions ethical considerations that guarantee equity and equitable access. Further investigation will determine the contexts within which theoretical models and frameworks remain relevant in the rapidly evolving field of digitized interventions that support adherence.
Sleep Medicine Clinics, Sep 1, 2023
Obstetrics & Gynecology, May 1, 2022
INTRODUCTION: Immunization plays an essential role in protecting the mother and child dyad from s... more INTRODUCTION: Immunization plays an essential role in protecting the mother and child dyad from serious illnesses. Despite current recommendations from the American College of Obstetricians and Gynecologist, Advisory Committee on Immunization Practices, and Centers for Disease Control and Prevention, vaccination rates in the U.S. are significantly below 100%. The aim of this study is to assess uptake of influenza, Tdap, and COVID-19 vaccination in pregnancy among a culturally diverse population in South Florida. METHODS: An institutional review board‒approved cross-sectional survey was administered among inpatient postpartum persons between July and September 2021. The 359 enrolled participants completed a survey assessing basic demographics and vaccination history. Chi-square tests, set at a significance level of P&lt;.05, compared uptake of each vaccine by ethnicity and U.S.-born status. RESULTS: Of the 359 participants, 67.7% self-identified as White, 67.4% reported Hispanic ethnicity, and 68.5% were non-U.S.-born. Compared to the 2019–2020 national average, Tdap vaccine uptake in this cohort was higher (74.7% versus 56.6%) and influenza vaccine uptake was lower (45.1% versus 61.2%). COVID-19 vaccine uptake during the study period mirrored the national average (18.1% versus 18.9%). Generally, there was higher vaccination uptake among Hispanics and non-U.S.-born individuals. However, a significant difference was only observed for uptake in influenza vaccine between U.S.-born and non-U.S.-born persons (chi-square=11.54, P=.0007). CONCLUSION: The suboptimal rates of influenza, Tdap, and COVID-19 vaccination seen in this cohort demonstrate the necessity for interventions to improve education about the safety and effectiveness of vaccination in pregnancy. Furthermore, increased efforts to maximize availability and access to vaccines during prenatal care are also needed. Together, these strategies may increase vaccine uptake in pregnancy, especially across diverse populations.
American Journal of Obstetrics and Gynecology, 2014
These pain scores were averaged at < 24hrs, 24-47hrs, 48-72hrs, and day of discharge. Use of anal... more These pain scores were averaged at < 24hrs, 24-47hrs, 48-72hrs, and day of discharge. Use of analgesics, including narcotics (converted to morphine equivalents), NSAIDs, and acetaminophen were recorded for the total postoperative hospital stay. RESULTS: A total of 746 women were randomized from 2010-2012. There were no differences in pain scores between those closed with suture as compared to those closed with staples (Table). There were no differences in analgesic use in terms of IV or oral narcotics, IV or oral NSAIDs, or oral acetaminophen between the groups (Table). CONCLUSION: There were no differences in pain scores or analgesic use postoperatively regardless of whether the cesarean skin incision is closed with suture or with staples. Pain scores and analgesic use during postoperative hospital stay *Mean (standard deviation) is noted for the pain scores, as the data were normally distributed; **Median (Interquartile range) is noted for the analgesic medications.
Aids Patient Care and Stds, Jun 1, 2023
World Academy of Science, Engineering and Technology, International Journal of Psychological and Behavioral Sciences, May 26, 2016
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Papers by Lunthita M Duthely, EdD, MSc, MS
Many approaches to understanding physician engagement exist. Pooling of physician resources (Ahgren & Axelsson, 2007), in the form of teamwork (Morgan, 1986), for example, yields higher engagement, satisfaction, and retention among physicians (Cossman, 2010; Wai et al., 2014). Another example is Swensen, Kabcenell, and Shanafelt’s (2016) framework—a physician engagement model based on level of choice, connectedness, and opportunity to excel. A strengths-based approach on the horizon within the positive psychology paradigm is the research exploring physician correlates and antecedents of physician “grit”. The positive psychology characteristic of grit, described as the perseverance and passion to achieve long-term goals, even when experiencing plateaus of progress, adversity, or failure, was proposed original by proposed by Duckworth, Peterson, Mathews, and Kelly (2007). Later, Duckworth and Quinn (2009) quantified grit and its correlates among high achievers.
Burnout has been examined among those in the medical profession as a contributor to lower job satisfaction and higher turnover, both in the U.S. and internationally. Certain subgroups of physicians under extreme pressure, such as residents in training and surgeons, have been studied more frequently. Among those in the surgical subgroups, grit correlated to lower levels of burnout among residents (Salles, Cohen, & Mueller, 2014) and senior surgical practitioners (Walker et al., 2016); grit correlated to higher rates of attrition among surgical residents (Burkhart, Tholey, Guinto, Yeo, & Chojnacki, 2014). Although one study found physician grit to be independent of satisfaction among U.S. primary care physicians (see Reed, Schmitz, Baker, Nukui, & Epperly, 2012), the evidence of the relationship between grit and satisfaction among physicians is growing.
The primary aim of this paper is to summarize the most current research on physician job satisfaction, engagement, and grit within the positive psychology paradigm. The correlates and determinants of retention will be reviewed as well. The secondary aim of this paper is to work with this understanding and explore ways to make physicians “grittier”, with the goal of increasing retention among this group of high achieving individuals.
Objective: The purpose of this study is to quantify documented prenatal HIV screening in Miami for women delivered at a tertiary care academic medical center.
cross-cultural study was to identify common
well-being themes expressed by two convenience
samples of adolescent students exposed to meditation
and mantric poetry. Content analysis was conducted
(n=64) on end-of-course essays of Japanese postsecondary
students (Cohort #1), and end-of-study
interviews conducted with American secondary students
(Cohort #2).