Developing Research Capacity for Mental Health Interventions for Youth in Haiti
>> 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
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
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
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
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
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
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
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
And we engaged in a high level of community
outreach around providing mental healthcare,
both embedded with other teams such as the
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
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
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
which will include physicians prescribing
and we have built our psychopharmacologic
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
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
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
in Mental Health Research Retreat.
It was a three day meeting of over 30 leaders
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
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
On day two, looking specifically at the grants or
aims, design and timeline.
Talking about reliability, validity and mental
review of mixed methods, developing valid
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
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
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
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
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
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
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
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
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
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.
>> 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
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
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
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
which we expect over the next couple years that
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
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.
So thank you. I think with that we'll be signing
Thank you everybody.