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Developing Research Capacity for Mental Health Interventions for Youth in Haiti
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    >> Giuseppe Raviola: My name's Giuseppe
    and I direct mental health for Partners in
    And here on the video you can see our team. And here to the far right is Father Eddy
    Eustache who is the PI from Haiti and next
    to him is Professor Anne Becker from Harvard
    Medical School.
    And then to the left of Anne, we have Ermaze
    Louis, one of our social workers, Director
    of Social Work and Social Assistance. And next to her Tatiana Therosme who is one
    of our psychologists here in Cange.
    And next to her is Emmeline Affricot, one of our
    psychologists in Lascahobas.
    And next to her Jennifer Severe, one of our
    And there is Dr. Reginald Fils-Aime, one of our
    And to Dr. Fils-Aime' left is Dr. David Grelotti, one of psychiatrists at Partners in Health. And so these are just some of the team who
    are involved in the project.
    So basically I'm going to give -- I'm going to try
    to give like a 15-20 minute overview leading
    up to a discussion with Anne and Pere Eddy
    and the team and...okay.
    So when we decided to put this proposal
    together, and we gratefully received funding
    to develop research capacities for mental
    health interventions for use in Haiti,
    we recognized that there was a high mental
    health need in Haiti after the earthquake.
    We felt that supporting the needs of youth was
    a major priority
    and we had a limited capacity to do that. And we also felt that this was a wonderful
    to build mental health clinical capacity and
    then to help research capacity
    into what Zanmi Lasante does and into a
    mental health program that grew significantly
    after the earthquake and I'll explain some of
    Fundamentally, we felt that the Partners in
    Health ZL model, the community-based
    with its proven record for community-based
    care would potentially be an effective way to
    about delivering youth mental health services. And we thought that the best way to start would
    be through the school system.
    So we're located -- I'll use my new pointer
    We're located right here in the Central Plateau
    of Haiti.
    The catchment area of Zanmi Lasante covers
    about 12 percent
    of the national population, about 1.3 million
    And of course, the earthquake happened here
    in Port-au-Prince.
    After the earthquake, Partners in Health and
    Zanmi Lasante responded that most
    of the medical infrastructure and health camp
    in the Central Plateau remained intact with the
    So the Partners in Health mission statement
    talks about a preferential option
    for the poor and our mission being to provide
    that preferential option to the poor
    in health care by establishing long-term
    partnerships with sister organizations based
    in settings of poverty and achieving two
    overarching goals, bringing the benefits
    of modern medical science to those most in
    need and serving as an antidote to despair.
    And that model is based on five principles of
    community-based care which we call the
    which fundamentally was developed originally
    for the care of HIV and TB in the 1980s.
    And that includes access to primary
    healthcare, free healthcare and education for
    the poor,
    community partnerships, addressing basic
    social and economic needs
    and serving the poor through the public sector. Other components of that model include the
    program of social and economic rights
    which really is the core of our social
    assistance program, food and nutrition,
    employment, water and sanitation, and
    And so as you can see here, essentially those
    red dots denote each Zanmi Lasante Hospital.
    There are 11. The southernmost one, Mirebalais is where
    we will be building a new hospital.
    And then if you look at Port-au-Prince after the
    earthquake, Zanmi LaSante took responsibility
    for providing care in four IDP settlements for a
    population of approximately of 100,000 people.
    And so the healthcare system in the Central
    and in the Artibonite region was comprised of
    approximately 5000 Haitian staff,
    2500 community health workers, as I
    mentioned serving a catchment area
    of about 1.2 million people. So some of the projects we've had going on
    have included a mental health systems scale-
    in Haiti through PIH and ZL which has included
    the close relationship with the Haitian Ministry
    of Health with the idea that we would try to
    compile a community-based system
    of mental healthcare within the ZL catchment
    something that ZL had not been doing
    previously and really nobody in Haiti had been
    Also, with the construction of this new hospital
    in Mirebalais, we've advocated strongly
    for the development of a mental health service
    at that hospital including a mobile team
    that will serve as an expert clinical consultation
    team for the system of care.
    And then, the NIMH R21 on school-based
    mental health which we feel will play a critical
    in the development of child adolescence and
    mental health services over the long term.
    So the R21 has three major goals extending
    mental health case finding capacity
    to schools in central Haiti and endowment of
    Haitian educators with information and skills
    that will enhance their capacity to respond to
    youth at risk for mental illness,
    and enhancing youth access to appropriate
    psychosocial support and mental health
    in central Haiti by adopting the locally
    successful accompagnatueur model
    which is the community health worker model to
    the school setting.
    You can see here the team is comprised of a
    significant group of people at ZL.
    And these people on the left, most of them are
    the people who have --
    who are formally part of the team. You know, they have gone through all of the
    paperwork and approvals as well.
    But there's other people as well who we've
    trained who are going to be coming
    on to our team as we move forward. And on the right here, you can see our Harvard
    Medical School team lead by Anne Becker,
    Mary Kay Smith Fawzi, Joia Mukherjee, who is
    also the Medical Director at PIH, Norma Ware,
    Nina Muriel, Eugene Beresin, Claire Hampton. And I'll have to introduce you to the Haiti team
    as we move forward with this discussion.
    And so, you know, part of the challenge has
    been to integrate mental health
    into the health system strengthening work of
    Partners in Health and to do that in a way
    where service delivery really sets the priorities and those priorities are really identified by our
    ZL team improving the quality of care
    and evaluating what we're doing, innovating
    and improving evidence around the
    and programs we're thinking to develop and
    bringing those problems and interventions
    and solutions to those problems to scale and
    hopefully being able
    to use our successes to inform advocacy and
    And really identifying research as a key
    component to doing that
    and that has been consistent with what
    Partners in Health has been trying to do which
    to leverage every service delivery and
    implementation project
    with research and training and education. Paul Farmer, whose one of the founders of
    Partners in Health has become the chairman
    of the Department of Global Health and Social
    Medicine at Harvard Medical School.
    And this R21 I think really represents the idea
    of the feedback group
    of really supporting service delivery and locally
    driven means through research and doing
    that through effector arms or implementers
    such as Zanmi Lasante.
    I just want to say that from 2006 to '08, there
    was an important NIMH R21 which lead
    to the development of a support group for
    children and families affected
    by HIV that's now called Tout Timoun se Moun
    and that project had a very important impact
    on the care that was being provided at ZL. It also lead to the retention of three
    psychologists by ZL and really the base
    of activity which lead to the development of ZL
    Psychosocial Program which has been led
    by Father Eddy and Ermaze Louis Pierre. Father Eddy came to ZL in 2005. Ermaze might have been 2004. And so you can see here that there were quite
    significant psychosocial services being offered
    prior to the earthquake with a particular focus
    on HIV and TB.
    So with the earthquake, significant mental
    health means were identified
    by us. This is a picture -- this is at the National
    University Hospital in Port-au-Prince.
    That's the nursing school in the background. Those lockers were from the fifth floor of the
    nursing school.
    The entire second year class died and I was
    just struck by --
    I mean, the reason I picked this picture was because of this gentleman sitting in front of the
    You know this is right around the corner from
    the main psychiatric hospital.
    There are two lock psychiatric hospitals in
    They received a fair amount of press because I
    think that the conditions
    that have been identified at those hospitals
    kind of laid there.
    One of the major challenges in global mental
    health generally which is with the global
    of mental disorders is estimated to be at 13 to
    15 percent.
    Generally, ministries of health and government
    spend between two to four percent.
    And in low income countries, that number can
    approach one to two percent
    and generally those resources tend to go into
    locked facilities like this.
    So the earthquake, you know, in some way
    opened the window to really picking
    up at decentralizing mental health services. And what we've tried to do is support the
    ministry of health in thinking
    about how to do that in a number of ways. And of course, you know, one-and-a-half
    million people were displaced to IDP
    There were thousands of casualties. And so Zanmi Lasante found itself both
    responding to acute needs
    in the Central Plateau but also in Port-au-
    And of course, many at-risk groups were
    identified months after the earthquake.
    Something we identified early on was that child
    and adolescent means were significant
    and how were we going to build the capacity
    within ZL to be able to address those
    in a safe evidence-based and culturally sound
    So in the first couple months after the
    we undertook a significant capacity building
    project in mental health services.
    We tried to do our best to provide support to
    our own staff including memorial ceremonies
    at sites that Father Eddy and Ermaze Louis
    And within three months after the earthquake
    we hired 14 new psychologists,
    a number of new social workers, and we significantly increased the human
    resource capacity within ZL
    to provide dedicated mental health services. We built up our clinical psychopharmacologic
    We started to develop evaluation protocols. We identified the need to have strong mentor
    and support around mental health services.
    So we have Dr. Grelotti here for a year who is providing significant support to the
    team as well.
    This is Ermaze, one of our social workers. These are the memorial ceremonies within
    two months of the earthquake that the team
    These were quite a few of our new staff who
    we've hired and trained
    who are now part of this research study group. We provided services in IDP settlements in
    Eight of the psychologists were placed in
    those settlements.
    And we engaged in a high level of community
    outreach around providing mental healthcare,
    both embedded with other teams such as the
    rehabilitation team
    but also providing some dedicated mental
    health services in the community.
    And we've identified, you know, over the last
    year continued challenges
    of course with Cholera. Interestingly, those group interventions that
    came out of that initial R21 were able
    to be adapted to provide support to people
    affected by the Cholera epidemic which it
    out had a very strong mental health component
    given that people who were recovering
    from Cholera were facing a lot of stigma. And you know many of them were not being
    allowed back home.
    And so there was a very effective group
    that was developed by the team at that time. Neurologic care is a huge issue. This is a girl who fell into a fire with a seizure
    recovering in the hospital in Hinche.
    And we're having huge issues around epilepsy
    and neurologic care.
    You know the treatment gap for neurologic
    and epilepsy is something between 75 to 80
    And then of course child and adolescent
    ZL and PIH took responsibility for a significant
    number of children
    with developmental disabilities who were
    when the earthquake happened in the
    university hospital.
    These children are at the orphanage that ZL is
    now supporting called Zanmi Beni.
    And we've seen incredible strides for them just
    in terms of their developmental trajectory.
    And then after the earthquake many people
    flooded to the hospitals,
    the ZL hospitals and lost everything. So settlements formed near the hospitals, and
    so there were large populations of people
    who had suffered significant injuries. And so our social workers and psychologists
    also provided services in those camps.
    And so essentially, we tried to use the platform of you know the PIH/ZL platform originally
    developed to address HIV and TB to start
    to build more dedicated mental health
    And in the upper right, you can see that we
    increased our psychologists and social
    and provided a whole bunch of dedicated
    mental health services and also started
    to bring social workers and community health
    into the care of people with mental disorders. Although we are trying to do that in a more
    dedicated way.
    We've developed a locally valid and reliable
    depression screen for use
    by community health workers so that
    community health workers can start to screen,
    and even care for people with mental
    We're developing a manual with Elena Radeli
    [phonetic] from Colombia for a toolbox
    of skills for community health workers. And one of our psychologists here in the room, Tatiana is moving on to being our training
    coordinator for community health workers.
    So you can see here based on the cutoffs on
    that depression screen, we can start to refer
    into the system people with higher scores on
    that depression screen will be referred
    to social workers and psychologists. And more and less acute triage decisions can
    be made
    which will include physicians prescribing
    medications potentially
    and we have built our psychopharmacologic
    formulary significantly.
    But also, training psychologists and social
    workers in a personal therapy
    which is evidence-based treatment for
    So we're beginning that process of training and the manuals are being completed this
    week actually.
    So that has been exciting and interesting and
    that's our thinking.
    That we want to be able to provide evidence-
    based services over the long term.
    And so this is our team a couple of months
    The team is very dynamic, very committed, very
    And we identified soon after the earthquake
    that child mental health needs
    and school-based mental health would be a
    priority for us and the opportunity to apply
    for the Brain Disorders in the Developing
    World Grant was very exciting.
    Fundamentally, three major aims for this
    One, evaluating the perceived burden of
    mental illness in school-going Haitian youth,
    the associated unmet need, and relevant
    school and community-based priorities and
    And we will do that through community based
    participatory research
    with educators, parents and youth. Aim two, deliver didactic training specific to
    epidemiologic, social science
    and implementation research on mental
    disorders in Haiti.
    And Zanmi Lasante will host its first Haiti-
    and Haitian-led mental health research
    workshop in January of 2013.
    Aim three, applying this didactic research
    training to development, implementation
    and evaluation of a novel school-based pilot
    mental health intervention in Haiti.
    And that will include educator training,
    epidemiologic assessment and case finding,
    and implementation of school-based
    navigation to mental health services.
    And so in January, we had our first
    Implementation Science
    in Mental Health Research Retreat. It was a three day meeting of over 30 leaders
    at ZL.
    There were six or seven psychologists and
    social workers but we had people --
    physicians, we had nurses -- we had people
    from a range of roles and sites, all very
    so it was very exciting to be able to bring you
    know sort of a general review and
    of implementation science through the mental
    health program
    to a broader audience as well within ZL. And so we spent time discussing mental
    health challenges in Haiti,
    introduction to implementation research, epidemiologic study designs, qualitative
    research methods.
    On day two, looking specifically at the grants or
    aims, design and timeline.
    Talking about reliability, validity and mental
    health assessment,
    review of mixed methods, developing valid
    mental health
    measures, examples of quantitative
    measures, sampling and recruitment
    ethical considerations for research on mental
    health in youth.
    And then informed consent, types and
    examples of error in epidemiologic studies,
    development of group presentations and
    actual group presentations.
    And so here's Anne Becker who is one of our
    And so there's a lot of excitement. I'm just going to finish right now with my part by
    providing just the basic introductions
    of the people who are in this room. So here's Professor Anne Becker from Harvard
    Medical School.
    Here's Father Eddy Eustache, our PI here at
    Father Eustache is a psychologist and a priest. I'm not sure, do you like that picture up here,
    And so Anne and Pierre, Eddy have been a very
    dynamic and excellent team.
    As I said, there's been not only just a lot of
    excitement but a lot of sophistication
    and thinking around the issues that have been
    brought up.
    Here's Ermaze Louis providing an overview of
    the mental health situation in Haiti.
    Here's Weslow Wambare [phonetic], who is
    actually the director --
    the clinical director of ZL right now who has
    gotten a background in public health --
    a Master's in public health who gave the talk on
    and you know some of our various team
    So this is Elysee Noesil who is a psychologist
    in Mirebalais.
    This is Emmeline Affricot, a psychologist in
    This is Tatiana Therosme, our psychologist in
    And I'll just say that these are three excellent
    As we build the hospital in Mirebalais, all three
    of them will be moving to serve
    at Mirebalais and will be filling in their spaces
    at the other sites as we have tried
    to have a psychologist at each of the 11
    hospital sites.
    And Tatiana, as I mentioned before, is going to
    become our director of training and curriculum
    at ZL for the community health worker trainings
    that we're going to be doing
    and essentially task shifting work. This is Dr. Fils-Aime who is a star physician at
    ZL, who has directed the MDR-TB Program
    based here
    in Cange, who really in his spare time has
    been doing home visits and providing backup
    medical backup to the mental health team. So he is formally moving to our team in the
    next month.
    And this is Dr. Jennifer Severe who is also a
    star physician at ZL,
    who runs our program in Dominican Republic. And she will be moving to our team as well
    and aspires to be a psychiatrist.
    And we're talking about five -- generally, about
    five to ten psychiatrists
    in Haiti serving ten million people. This is Ermaze Louis Pierre, a social worker. Did I mention also directs the social
    assistance program at ZL?
    And here in the back raising his hand, there's
    Ernst Origene,
    our social worker from Mirebalais. And this is Marie Floye Chipps, a teacher and
    educator in Cange.
    She is also one of the Cange investigators on
    this grant.
    And here's Erick Alexis Georges, who is our
    coordinator for the study.
    And this is Gregory Adolphe, who is our more
    general mental health program coordinator.
    And this is Joel Malebranche, who is our PIH
    coordinator working with the team.
    And here is Dr. David Grelotti who is a PIH
    And also future scientist, very interested in a
    whole bunch of things
    but who actually has spent some time with our
    in Wauzutzu [phonetic] doing this assessment
    for around orphans and vulnerable children
    because Partners in Health fundamentally is
    facing a crisis around orphans
    and vulnerable children in Wauzutzu so we're
    hoping that he will be staying on essentially
    as a full-time researcher next year with us. And then this is me. There's not many pictures of me in existence
    and I look a little too sly here but --
    so I direct mental health to Partners in Health
    and I also direct the program
    in Global Mental Health and Social Change at
    And I also work half-time at Children's Hospital
    Boston and direct the quality
    and improvement program in child psychology
    at Children's.
    And fundamentally just to close, this R21
    process has been a wonderful experience for
    and an opportunity to enhance the quality of
    research and care.
    But also, it's been interesting in terms of
    raising the profile of mental health means.
    We had a recent visit with Secretary of Health
    and Human Services,
    Kathleen Sebelius, really thanks to this grant. And we were able to arrange a focus group for
    her with some of our patients
    and with the members of the team in this room
    and so that also was very exciting.
    So maybe now, I've taken about 26 minutes. Why don't -- I can open it up to questions and I
    can also hand the mic over to Anne and Eddy
    who are over -- I can push here on the screen
    and who are on video.
    And so I'm going to turn off the -- so I'm going
    to sit here now and manage the microphone.
    Thank you. >> Anne Becker: In the meantime, we just want
    to say hello on behalf of the team,
    some of whom are still on their way up here
    this morning and actually caught us on a
    landmark day
    for the study because just as we were listening
    to Giuseppe's wonderful presentation here,
    Eddy got a text that our final, final, final IRB
    approval was received which was
    to add all the training personnel to the study. So we're excited and actually I'm expecting to
    run two focus group discussions today.
    >> I appreciate it. >> Anne Becker: So and also just to build on
    what Giuseppe said,
    as you heard him explain very nicely and pretty
    thoroughly, the mission here is Zanmi Lasante
    and all the Partners in Health is to leverage all
    service delivery --
    all clinical service delivery with research and
    And that was really the large point or the
    foundation of our collaboration
    between Harvard Medical School, the
    Department of Global Health and Social
    and the mental health team here at Zanmi
    And also as you heard, Haiti is in an unusual
    situation where after the devastating losses
    of the earthquake, the vast mental health
    needs in the country were suddenly more
    to [inaudible] -- they were suddenly more
    visible and there was tremendous political will.
    And so the resources for mental health delivery
    were actually built,
    you know as you heard from Giuseppe, quite
    There was a rapid response but part of what
    we worried about was that there wasn't
    yet a culture of help-seeking or truth-finding
    and so the grant really was designed to involve
    the voices
    of the community, both the clinicians, the
    teachers, and the parents and the youth
    to learn how we could help youth at-risk for
    PTSD depression, other kinds of distress,
    much of the earthquake related, some of it not. How we could help them navigate, possibly
    through teachers accompagnateur
    to the services that now are fit. >> Father Eddy Eustache: In addition to what
    Anne just said, that the most interesting part
    of the project to me is for staff in the benefit
    Sorry -- the research culture is being
    And that would be a good plus gravy. Because in the past years, we have not been
    used to this idea of looking
    to what maybe a source of knowledge are the
    Now, we are slowly but surely implementing
    this kind of mentality
    and I think it will be a good plus for our future in
    >> Giuseppe Raviola: So there was a
    What is your mental health outcome metric? How are you measuring your impact? That's a great question. Our goal is to be able to measure our impact. So fundamentally, we have a quality
    and monitoring evaluation team both at ZL and
    We are working with them right now to really -- fundamentally, our mental health services have
    not truly been integrated into the sort
    of the core package that is offered by PIH and
    ZL, and so that has been part of our goal.
    And so that has required a lot of collaborations
    with multiple groups within PIH
    and ZL which include MNE, EM -- electronic
    medical record people,
    the training and curriculum folks, the
    community health team.
    And so that's been an ongoing process. What we've done is we've tried to provide our
    psychologists and our social workers
    with as much supervision around the care of
    patients at the hospital level.
    And we've been careful about bringing
    community health workers into the provision of
    until we feel that we have the tools to follow
    And so what we decided was that we would
    start with depression as a priority condition
    and that we would use both that depression
    screening tool
    as one outcome metric for the care of
    But the goal over time is to add true care
    pathways for psychotic disorders and epilepsy.
    And also for child and adolescent mental
    health disorders,
    which we expect over the next couple years that
    this --
    that the tools that come out of this project will
    be important to informing that process.
    >> Anne Becker: And -- so in addition to some
    of the broader outcome goals
    within the clinical services here, I do just want
    to speak too some
    of the narrow outcome measures in this
    particular study just to clarify.
    So the study is envisioned as -- we set it up
    essentially as a process so that it begins
    with a committee processing and identifying
    the best intervention.
    In order to get that started, our model has
    proposed a school day of teacher training
    so teachers would be equipped with basic
    skills to assist with navigation
    of troubled youth to care services. Our specific outcomes will be right now and
    we'll see if that's ratified
    by the focus group that's going to be connected
    today is to do predisposed assessments
    of training of the teachers and then the t
    outcome will be once we've done case finding
    will be whether or not we were able to
    successfully pair youth identifier at-risk
    with a trained P2 and whether or not they were
    able to complete the recommended follow-up
    which would be either a clinic visit or a certain
    number of meetings with a teacher.
    And then of course, the post assessment
    where we would not just be
    on what knowledge they obtained but also
    what their experience of the process was,
    whether or not it was per diem, whether or not
    it added a burden,
    whether or not it imposed a burden on the
    children or families
    and we'll be debriefing these as well. >> And what we’ve been developing we’ve got
    an opportunity in the future.
    For instance, when we have the most active
    youth who have been exposed to some kind
    of trauma or horrible conditions, we may actually refer them to the psychologist
    -- try to measure the impact of the quality of
    services they have been receiving.
    >> Anne Becker: Indeed. Our guests have arrived from focus groups so maybe we have time for one more person? >> Thank you. I just wanted to thank you for a
    really interesting presentation.
    It's just amazing all the work you're doing there
    and I wish you the best of luck with that.
    This is just -- you know, obviously you can see
    this system works really well.
    And we did it just really a lot for this purpose so that people could communicate and
    collaborate internationally.
    And we had a really good team that works on it
    and a lot of support.
    So you can read a little bit about the purpose of
    it and what it does.
    And hopefully it will be there to help you with
    this project in the future.
    >> Giuseppe Raviola: Thank you. >> So Kathy, did you have any closing words
    and then I think we're done.
    >> Kathy: Just to say thank you to everyone. This was, you know, on the part of, you know,
    the team that, you know,
    International Collaboratory and the team here
    and everybody here is waving.
    I mean this was just -- it actually -- those of you on the call don't realize it actually
    took a lot just to get
    to this point and it worked out great. And just thank you to everyone. And this is a wonderful program. I'm really privileged to have been able to come
    here and see it and participate.
    So thank you everyone for participating. Again, it will be archived so if you want to go
    back and look at any part of it
    and see the presentations, you will be able to
    Thank you very much. And Anne, did you want to say something? >> Ann: Yes. I just wanted to -- I didn't want to close without
    on behalf of all of us,
    just saying our huge thanks to Kathy for her
    support of this project and also
    to LeShawndra Price, who is our program
    And I don't know if she had a chance to be on
    today but we really really appreciate everything
    and I know everyone on the team sends their
    messe on peut.
    Thank you. So thank you. I think with that we'll be signing
    Thank you everybody.