Thread by @rnsoicher

Live tweeting #SIRC2019 again Today. Plenary is "Overcoming Implementation Challenges in Low-Resource Communities: Methods and Solutions from Western Kenya" - Dorsey & Whetten, MPIs; Wasonga, Kenya PI

Related to this talk: Ace Africa (ace-africa.org), UW, Center for Health Policy & Inequalities Research at Duke University, and Center for Evidence and Implementation. #SIRC2019

The team from Ace Africa have traveled a long way to talk to us today. Truly an honor to hear from them. #SIRC2019

.50-2% of budget in "low-resource" countries is spent on mental health. Most of that goes to adults, not children. Around the world, the ratio is typically 2 psychiatrists: 100,000 people. #SIRC2019

The strategies discussed today are not just relevant in Kenya - the challenge of low-resource areas is widely applicable. Even in high-income countries, only 1 in 5 people receives minimally adequate care (e.g., for depression). #SIRC2019

EPIS framework is a good start for thinking of the stages of implementation and each stage has their own challenges. How do we address them in low-resource communities? #SIRC2019

One strategy is task-sharing - lay people with no formal counseling training can be trained to deliver service with fidelity and with great outcomes. Barnett et al. (2017) and Hoeft et al. (2018) #SIRC2019

Long line of work (10 years) around improving mental health for children subsequent to the death of a parent in Tanzania and Kenya. (Dorsey & Whetten) #SIRC2019

Groups of up to 8 children experienced parental death and mental health impact, grouped by age. Children and a guardian receive 8 concurrent group sessions. 2-3 individual sessions for exposure, talking individually about death and difficult events. #SIRC2019

Clinical outcomes in O'Donnell et al. 2014 #SIRC2019

A challenge to this was that, although the intervention was successful, there wasn't much of a formal system for integrating the intervention. So, in the last steps, the goal was to figure out what systems existed where children could be served - urban and rural #SIRC2019

Colleagues at Ace Africa thought the best two places were Ministry of Education (teachers) and Ministry of Health (community health volunteers). What do orgs need to do to successfully deliver, scale-up and sustain mental health txs? #SIRC2019

What would be necessary from an implementation perspective? What would be feasible? And how do we do that without grant funding? #SIRC2019

Weiner has a theory on org effectiveness in implementation. From this, we want to know what are the implementation policies and practices that could be useful/helpful? These might be overlapping and also unique for the two sectors. #SIRC2019

e.g., teachers would be excited but busy & have quite a workload. Community volunteers would need transportation to get to delivery areas. Transportation is not cheap there, esp in rainy season. Everyone would need training, supervision, leaders expectations, and resources.

Building and Sustaining Interventions fro Children (BASIC) - identify policies and practices that predict TF-CBT adoption, fidelity, and sustainment. Examine child outcomes, cost in each sector. Counselors from experienced sites would coach/support subsequent sites

Stepped wedge, cluster RCT design with over 1,000 children enrolled (age 11-14). #SIRC2019

Use findings from first 10 sites in each sector (schools/communities) to help build a future implementation plan. This is what the team is going to share today. #SIRC2019

Built up greater local TF-CBT expertise and implementation leadership. All the expertise is in the community leaders. Some themes: cascading implementation, org theory of imp effectiveness, imp facilitation, iteragency collaborative teams...#SIRC2019

Fidelity to Function v. Form (IS strategies), specification and reporting of implementation strategies. #SIRC2019

Good resource: Lewis, Scott, Marriott (2018) method for generating a tailored implementation blueprint #SIRC2019

(Jan 2018) experienced lay counselors trained new lay counselors in 10 sites in each sector. Delivered TF-CBT in both sectors to 256 kids. (Oct 2018) Mixed methods approach to learning from sites in both sectors. BASIC Collaborative Meeting. #SIRC2019

As of Sept 2019, 20/40 schools, 20/40 communities...60 teachers, 60 community volunteers, 490 youth have been trained/reached with TF-CBT. (tagging @SD_RISEMHLab) #SIRC2019

@SD_RISEMHLab Step 1 of Initial Implementation of BASIC: 40 schools randomly selected, site leaders sensitized then identified counselors. Counselors trained, first 10 sites in each sector delivered the intervention. #SIRC2019

@SD_RISEMHLab 1st training ever was led by supervisors: 60 newly trained counselors - 30 teachers (3/school), 30 community health volunteer counselors (3/community). Training involved using easy to follow guided manuals (Step-sheets) #SIRC2019

@SD_RISEMHLab Teaching, Role Play, Small Group Practice, Feedback [Steps of the training] #SIRC2019

@SD_RISEMHLab During observation where counselors deliver two 8-week groups (1 girl/1 boy; groups separated by gender), counselors are rated on a scale for their skills. 257 children served. #SIRC2019

@SD_RISEMHLab Learning form Step 1: Original plan - compare successful & unsuccessful sites...but they were all successful!

New plan: look at ways different sites made an enabling context. Variation in leadership, urban/rural context, size/population of school, more influential counselors

@SD_RISEMHLab All initial sites had quantitative interviews. Based on the variations, 6 sites in each sector also had qualitative interviews for counselors and site leaders. #SIRC2019

@SD_RISEMHLab Some counselors could get people to arrive on-time, practice, excite the community. So interviews helped the team to learn these important variations. Counselors found the intervention to be acceptable, feasible, appropriate, and effective. THE CHILDREN FELT BETTER! #SIRC2019

@SD_RISEMHLab One strength of the program was the school and community cross-sector collaboration. CHVs supporting recruitment and family sensitization for both teachers and CHV groups.

@SD_RISEMHLab Schools provided space for delivery of intervention and also supervision meetings. Schools provided materials for teachers and CHVs. Schools and facilities were always welcoming fo ACE Africa staff. Trained leaders covered for counselors if they had to miss a session.

@SD_RISEMHLab BASIC Collaborative Team (BCT) meeting goals: share findings from interviews with CHVs, teachers, head teachers, extension workers about the intervention. Before, they developed a lay language for implementation constructs. #SIRC2019

@SD_RISEMHLab example: implementation leadership = leaders who are passionate, positive, supportive #SIRC2019

@SD_RISEMHLab 3 day meeting w/ both joint discussions from both sectors and separate discussions to address concerns specific to each sector. There were 11 CHVs, 11 teachers, 2 community health extension workers, 4 head teachers, 1 rep from Ministry of Health, 1 rep from Ministry of Ed

@SD_RISEMHLab Lessons Learned: Workload Adjustment - need to change existing duties to accommodate intervention activities. Teachers had to plan lessons earlier, delegate some duties to fellow teachers. CHVs have more flexibility. #SIRC2019

@SD_RISEMHLab Lesson learned: Leadership - supportive, passionate leaders resulted in effective delivery of the intervention. Leaders rewarded counselors by acknowledgment in public forums. 89% of teachers, 83% of CHVs reported leaders were encouraging and talked positively about the program

@SD_RISEMHLab Lesson Learned: Resources - Training was a resource - step sheet was important. Supervision was a resource. Schools providing materials (chalk & blackboards, space for delivery). Head Teachers, schools, and facilities were always welcoming. #SIRC2019

@SD_RISEMHLab Coaching guides were made in the BCT meeting based on stakeholder feedback. Coaching experience done by ACE supervisors and experienced lay counselors to help with expectations, delivery, leadership development, increasing resources, improving attendance for kids & guardians

@SD_RISEMHLab The project (intervention?) has been referred to as "Pamoja Tunaweza" during the presentation, which sounds simply beautiful and also has a beautiful meaning: Together We Can #SIRC2019

@SD_RISEMHLab Challenges: transport for CHVs, communication - phone calls effective for supervision but not coaching, Workload adjustment - teachers in smaller schools or w/fewer teachers or unsupportive fellow teachers - now coach helps teachers create a plan for lost time while in training

@SD_RISEMHLab Next Steps: lay counselors can be trained and this reduces the cost of hiring professionals. Lay counselors can be respected as trainers, supervisors, and imp coaches. Learning from the sites so that whatever is recommended is feasible.

@SD_RISEMHLab Next steps (cont'd) - Other sharing experiences (e.g., in church) can help accelerate future sites. Coaching is easy to deliver and is helpful!

@SD_RISEMHLab Want to know more? Listen to the podcast! bit.ly/2mggo4j #SIRC2019

@SD_RISEMHLab @Rsbeidas points out during Q&A that 100% implementation success is outstanding and no one ever sees it. Can't wait to see more about how this was achieved. Also, would be great if they could publish how they de-jargonized the implementation vocab. #SIRC2019

@SD_RISEMHLab @Rsbeidas Another Q from the audience - is mental health a concept in the culture there? A: no. This is why it is important but also very hard. Q: What is mental health? A: A feeling that isn't helpful, that can be changed so people can feel better.

@SD_RISEMHLab @Rsbeidas Q: Where there guardians who were not interested and how did you encourage them to participate? A: Yes, many parents think the skills won't really help their child. But you can get the leaders to help convince the parents & encourage them to take time to see the effects

@SD_RISEMHLab @Rsbeidas E.g., advice is go home and praise your child and see the results. Normally a child would be expected to do something so praise feels weird (on both ends) and can't just be used once. Try multiple times and wait to see what happens. #SIRC2019

@SD_RISEMHLab @Rsbeidas Also CHVs encouraged to go into homes, leave reminders, and have children experiencing improvement share about their experiences. Experienced guardians also coach others about how to benefit from the program. #SIRC2019

@SD_RISEMHLab @Rsbeidas Q: How will the work continue after the end of the grant? A: Working on that now. They have the resources (which are minimal) and can give them out freely. Leaders are given ownership - ability to identify at-risk children, creating "clubs" where they can discuss the program

@SD_RISEMHLab @Rsbeidas Q: What is most surprising from when the program started? Maybe what you thought wouldn't work but did? A: When we started, we were doing the therapy. It didn't cross my mind that it would be so big (multiple sectors, many leaders).

@SD_RISEMHLab @Rsbeidas A: Also surprising - CHVs don't have much education and we weren't sure if we could create the resources to educate them or if they would "get it". But they've been wonderful resources. #SIRC2019

@SD_RISEMHLab @Rsbeidas Q: Do children and caregivers participating view this as an opportunity or was there stigma attached to it? A: No stigma because children were randomly selected and unselected children would watch through the windows, wanting to participate. #SIRC2019

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