Child Study Center Grand Rounds 11.16.2021

December 14, 2021

School Mental Health, Suicide Prevention, and Wellbeing: Lessons Learned from the Last Ten Years (And Wisdom for the next 10)

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00:00Uh, man, I'll mention a few words
00:02about the early Childhood peace
00:03consortium at the end, but let me be
00:06as quick and as brief as possible.
00:08Uhm, it's really been a pleasure
00:10and an honor to know. Teresa.
00:12I first met her in Sierra
00:14Leone five years ago,
00:16and I've also had the opportunity
00:18to go up to Boston to help celebrate
00:22her new endowed professorship,
00:24which wisely was offered by Boston College
00:27after she spent so many years at Harvard.
00:30My goodness.
00:32But what can I say?
00:36Congratulations and it's wonderful
00:38that she has this child Health and
00:40Human rights program that she's been
00:42running up at Boston College and
00:44she's really been an inspiration
00:46for me and I guess the other really
00:49wonderful news is that she's recently
00:51agreed to join the early Childhood
00:53Peace Consortium Leadership Group.
00:56And I'm really optimistic that she's
00:58going to help us move forward,
00:59and one of the big issues that we want
01:02to focus on is how to engage the youth,
01:04how to help them become leaders in our field,
01:07and to really make a difference in the world.
01:09And so we're really very fortunate
01:11to have Teresa,
01:12but I'm going to be as quiet
01:14and as brief as possible.
01:16So I'd just like to also thank
01:18you because one of her priorities.
01:21Is actually helping young people
01:23make a difference in the world by
01:26becoming scholars and clinicians?
01:27And she's an inspiration to all of us,
01:30and we certainly need the next generation.
01:32And it's wonderful that she just
01:34had lunch with our colleagues in
01:36terms of our training program,
01:38so it's wonderful to see here in action.
01:40And we'll be looking forward to
01:42hopefully having an opportunity to
01:44raise a few questions at the end.
01:46But thank you for coming, Teresa.
01:53Thank you so much, Jim and
01:54Karen and everyone here for
01:56the warm welcome and it's so fun
01:58to be able to do this in person.
02:00It's a great honor and I can take
02:03off my mask. That feels really.
02:05It's so cold in here.
02:08It was like a facial scarf, but, uh,
02:10but I thought you know I gave grand
02:12rounds right before the pandemic here and
02:14talked about my work in Sierra Leone.
02:16And then I thought, oh goodness, you know,
02:18that's really the mechanistic child
02:19development stuff that they yelled child.
02:21Study center wants to hear
02:22about and I just gave that talk,
02:24but I'm doing something new here,
02:26which is to share with you a little
02:28of my work in implementation, science,
02:30and especially to go into how we
02:34develop partnerships in Rwanda.
02:36To begin to think about the scale up.
02:38Of evidence based home visiting and
02:40it builds on work that we did with
02:43Bill Beardsley on a family based
02:45preventive intervention that now
02:46we're in the process of moving from
02:49little mini pilots and mixed methods.
02:52Work on the culture and adaptation to
02:54Rwanda to a randomized control trial.
02:57But the big issue for all of us in
02:58the field is you can't just stop
03:00at the randomized control trial.
03:01What do you do after that?
03:02After you have the evidence that this works,
03:04how do we address the challenges
03:07of scale and sustainment?
03:09I also wanted to say something
03:10about your work in Boston. They say
03:12nothing is working today. If you have
03:14yes, absolutely. And actually the
03:16intervention I'm talking about today.
03:18The family strengthening intervention
03:19which comes out of billboards work
03:22we've adapted to refugee families
03:23and have a community based,
03:25participatory research project in Lewiston,
03:27ME and Springfield,
03:28MA with Bhutanese and Smelly Bantu refugees.
03:31And now we're talking about adapting it
03:33to the Afghan refugee population with a
03:35very larger settlement as anticipated.
03:37So I'm very happy to talk about that.
03:39So as I mentioned,
03:40I'm gonna discuss implementation science
03:42strategies for scaling out a home
03:43visiting program to promote the CD,
03:45but also prevent violence in post genocide,
03:47Rwanda and the partnerships that
03:49sort of work takes so to go forward.
03:51It looks like I should just click.
03:54What is the OK?
03:54I'm going to give you a little
03:56background on our research program.
03:58Overall,
03:58the evolution of the intervention itself
04:01are our findings from early trials.
04:04But also now we've had to push beyond
04:05those early trials to think about
04:07strategies for scaling out and actually.
04:09The science of scaling out
04:11and implementation science,
04:12which I'd like to focus on today
04:13and the opportunities of integrating
04:15evidence based interventions into new
04:17delivery platforms and in low resource
04:19settings that really matters because
04:21oftentimes we don't have the systems
04:23that we do in more developed settings,
04:24and we're hoping to go next,
04:26so I wanted to give you a little bit of
04:28background on my motivation in doing
04:29this kind of work in the first place.
04:31It can be said that I'm from
04:33a low resource setting.
04:34This is my hometown of Bethel,
04:36Alaska, population 3000.
04:38This is an Alaska's interior.
04:40You see here the little red dot.
04:42This is the Yukon Kuskokwim Delta,
04:44mainly native Yupik Alaskan population.
04:49I was born there and lived there
04:50all the way through high school
04:52and then my parents were teachers
04:53so they knew college Prep was not
04:55really what was happening out there.
04:57So we moved into another part of Alaska,
04:59but it was really an amazing place to
05:01grow up because you see extremes both
05:04of hardship but also of collective
05:06iti in overcoming adversity.
05:08And so I've experienced 90 degrees below 0.
05:11When the town power generator caught
05:13on fire and everyone had to take
05:15others into their homes and those
05:16of us who had a fireplace and could
05:18heat our homes without electricity,
05:20took in others.
05:22And I've seen some of the highest per
05:24capita rates of violence in families
05:26because of this toxic influence of the
05:28loss of the culture and subsistence
05:30ways of living with alcohol and
05:32firearms coming into the state.
05:34And so my parents were very involved.
05:38My father was the math teacher,
05:40the science teacher.
05:42And the Fire Chief.
05:43My mother worked for the Instant
05:45Learning program and started the first
05:48early Childhood Development Center in
05:49the region that was named after her.
05:51The Norma Jean center.
05:52I grew up in the Yupik culture
05:55had babysitters.
05:55I used to speak cubic because I,
05:58you know, grew up around people who
06:00were speaking the language and I think
06:01as somebody who grew up in this study
06:03and I really learned to respect other
06:05cultures to slow down, to listen,
06:07to recognize when you're an outsider.
06:10But someone who really wants to.
06:13Engage in a respectful way and honor the
06:16culture and the power of collective iti
06:19to get through extremes and so this is
06:21really something a thread that I hope
06:23to carry over to my work everywhere.
06:25Including the work in Rwanda.
06:26Then I'm going to talk about today so
06:28when I'm presenting and if we could,
06:30we'd have the whole Rwandan team here.
06:32This is not just my work,
06:33this is this work with this amazing
06:35team of collaborators in Rwanda.
06:36These are just some of our expert
06:38home visitor cell mentors in three
06:40districts across for Wanda who are
06:42involved in this scale up study.
06:44And I want to acknowledge our
06:45team at Boston College.
06:46My postdoctoral fellow, Sarah Jensen,
06:48assistant research Professor Jordan Fair,
06:51associate director,
06:51as well as our team in Rwanda or Slug
06:54Abeo day and our amazing collaborator, Dr.
06:57Vincent,
06:57says Ibarra at the Center for Mental
06:59Health at the University of Rwanda and our
07:01Mutual learning coordinator, Joseph Kulesa.
07:03This is really a work that takes a whole
07:06team, and I wish they could all be here.
07:08I'm sharing with you today
07:10and so just to set the scene.
07:12This was the shot.
07:13Heard round the world.
07:14For many of us and child development,
07:15this is from The Lancet series on early
07:18childhood Sally Granthan McGregor.
07:19The statistic that over 200 million
07:22children this is covered by zoom
07:24are not fulfilling their full
07:27developmental potential globally,
07:28and so if you look at children ages
07:3036 to 59 months who are not on track
07:33and some of the domains like literacy,
07:35numeracy, physical development,
07:37social emotional development and learning
07:39that these are worrisome statistics
07:41for human capital and also human rights.
07:44And this statistic has now been
07:46updated in 2017 to be even higher.
07:48It's now estimated about 249 million
07:50children in low and middle income
07:53countries who aren't meeting metrics for
07:55appropriate progress on these domains.
07:57And a lot of this is Cohen Co
08:01occurring in areas of the Middle
08:03East and Sub Saharan Africa.
08:04So these are big policy issues when it
08:07comes to the advancement of populations.
08:10And Jim talked about violence
08:12and issues of peace.
08:15Globally at the same time that
08:16you know we're contending with
08:18underdevelopment and children,
08:20especially concentrated in places like
08:21the Middle East and Sub Saharan Africa,
08:24we are in our lifetimes witnessing
08:27the largest humanitarian crisis
08:28since World War Two due to wars
08:31raging around the world.
08:32Massive displacement of population
08:33statistics are at the end of 2019.
08:35There were nearly 80 million
08:38forcibly displaced nearly 46 million
08:40internally displaced people,
08:4126 million refugees and a large number
08:43of these are under the age of 18.
08:45And UNICEF estimates now that
08:46the number of children living
08:48in conflict zones has risen by over 74%.
08:50So if you think of the Co occurrence
08:52of these different vectors of risk,
08:54it's it's real issue for
08:56thinking about human rights,
08:57human capital and peace and stability
09:00in societies around the world.
09:02And so World Bank and people like
09:04Jim Heckman and others have really
09:06drawn attention to the important
09:08the importance of early investment,
09:10and we know that disruptions in child
09:13development and early mental health.
09:15Are costly for societies and individuals,
09:18and if you just look at some of
09:20the data and this is from a World
09:22Bank workshop summarizing some of
09:23what we know from the literature.
09:25Young children who are physically stunted,
09:27so that's a blunt indicator or or falling
09:30behind and indicators of cognitive,
09:32linguistic or socio emotional development are
09:34much more likely to enter first grade late,
09:37perform poorly in school,
09:38repeat grades,
09:39drop out of school before even
09:42completing primary school experience.
09:44Poor physical and mental
09:45health throughout life.
09:46And we know this from a range of studies
09:48like the Aces work here in the United
09:49States engaged in high risk behavior,
09:50especially in adolescence,
09:51and be less productive and
09:53have lower earnings.
09:54So this is a wake up call
09:56to governments to say,
09:57OK,
09:57we this you've got our ears now we've
09:59got to invest in early childhood,
10:02has been an area where globally
10:03there's increasing political will,
10:04and I think this goes back to people
10:07who are great leaders and transforming
10:09public policy like Julius Richman,
10:11who had the honor of getting
10:12to know at Harvard.
10:13And as you probably know, Julius Richman.
10:16A former U S surgeon general,
10:18the mastermind behind the scale of
10:20the Head Start program in the United
10:22States and he wrote very cogently that
10:24policy reform and services implementation
10:26requires a strong evidence base.
10:28We need to show that things work
10:29and we need to have the data.
10:31But you also need social strategies to
10:33build political will to ensure that we
10:35get these effective services invested
10:37in and implemented at greater scale.
10:39And so this sort of virtuous
10:41cycle between the knowledge base,
10:43the political will and public policy
10:44is so important to keep in mind.
10:46As we think about questions of scale.
10:48So there's a lot of evidence even
10:50from early U S studies on the long
10:53term effects of ECD interventions
10:55in low resource settings.
10:56And when I say low resource,
10:57I'm talking about in the United
10:59States as well as globally.
11:01And so the Perry Preschool project
11:03very famous, starting in 1967,
11:04which provided high quality preschool
11:06education and a randomized controlled
11:08trial with a relatively small sample
11:10of three to four year old African
11:12American children in poverty,
11:14they found that by age 40 there were
11:15large effects on educational attainment,
11:17income, criminal activity.
11:18And it's one of the longest running
11:20longitudinal studies that really
11:22demonstrated the importance of
11:23preschool education, Absa, Darien,
11:25similarly starting in 1972,
11:27looked at full time,
11:29high quality educational
11:30intervention in a child care
11:31setting from infancy through age 5,
11:33and they had follow up all the way to age 35.
11:36Again seeing positive long term effects,
11:38especially to counteract some
11:40of the disadvantages of poverty
11:42related to education and attainment.
11:44And now, globally, you've probably heard
11:46we were talking about this at lunch
11:48about the reach up study in Jamaica.
11:50Very influential, a play based home
11:53visiting and nutritional supplement.
11:54Intervention given weekly to infants,
11:57again stunting being a very galvanizing,
11:59blunt indicator of underdevelopment that
12:01catches the attention of policymakers.
12:04And here they were focused on
12:05the first two years of life,
12:07they saw substantial improvements in
12:08child language, cognitive outcomes,
12:10fine motor and social emotional skills,
12:12but when they looked at adult outcomes,
12:14they also saw very important
12:16effects many years later,
12:18on educational attainment.
12:19College participation.
12:20Employment and this program is now
12:22scaled up in about 10 countries,
12:24including Peru,
12:25Jamaica in Bangladesh and other important
12:28program out there in the world and
12:31Roxio Atanacio who may be joining online,
12:33has done very important
12:35economic analysis of CUNA MAS.
12:37More than a cribbed the home visiting
12:40program in Peru and their evaluation
12:42showed robust and significant
12:44impacts on child development,
12:45cognitive development,
12:47communication with some exciting
12:49effect sizes, and this has been.
12:51Also scaled up within
12:52the Peruvian government,
12:53providing care to more than 170 minors.
12:56Age 0 to 36 months.
12:58So again there is emerging evidence.
13:01There are models.
13:02There's willpower and excitement,
13:03what about Sub Saharan Africa?
13:05Where is Sub Saharan Africa?
13:06And all of this given what I just
13:08showed you on the risk profiles?
13:10So in our own little teeny way,
13:12we're trying to contribute to this ecosystem.
13:15And so our research program on children
13:17in adversity is really dedicated to
13:19understanding what are the leverage.
13:21Points what do we know from longitudinal
13:23data about how we can influence
13:25trajectories of risk as well as
13:27resilience and life outcomes for children
13:29and families that face adversity?
13:31And some of this is trying to close this
13:33gap that we have about the knowledge
13:36of early adversity and its impact on
13:38child development and mental health,
13:40and what's actually done on the
13:41ground and very low resource
13:43settings including Bethel,
13:44Alaska,
13:44including you know so many parts
13:47of Sub Saharan Africa and support
13:49the development of high quality.
13:51And effective programs and policies
13:53in low resource settings and
13:55as Jim talked about,
13:56we work domestically and globally.
13:57So here's just a little synopsis of that,
14:00probably our best known study,
14:02and I talked about that when I
14:04gave grand Rounds previously here
14:06in child psychiatry was this,
14:08and is this ongoing 20 year intergenerational
14:11study of war in Sierra Leone,
14:13West Africa,
14:14where we've been following a cohort
14:16of 529 more affected individuals.
14:18They were 10 to 17 when we
14:20first started the study.
14:21We've had data collection.
14:242002, 2004, 2008 and then 2016 and
14:27now we're negotiation. Wish us luck.
14:29That maybe will be able to come back
14:31and have a fifth wave of follow up
14:33in the last wave funded by NCH D.
14:36We added the intimate partners and
14:38the biological children of the index.
14:41Participants in, you know,
14:42a majority of them are former child
14:44soldiers with very high trauma histories
14:46that we know from you know their
14:48childhood reports and also this brought
14:50us into this focus on intergenerational.
14:52Violence, just from what I
14:54presented last time about the
14:55associations between parental trauma,
14:57history, emotion,
14:59dysregulation and parent child interactions.
15:01And beginning to think about what our
15:04intervention models that can work in
15:05low resource settings and some of our
15:07earliest family based work was funded
15:09by NIH in the context of HIV and AIDS,
15:12and that started in Rwanda.
15:14We adapted Bill Beardsley,
15:15family talk intervention,
15:17which is a very well regarded
15:19evidence based preventative
15:21intervention that's been done by late.
15:23Years from Native American communities have
15:25been scaled up in Costa Rica and Finland.
15:27We adapted that to the context of HIV
15:29and AIDS in Rwanda and had this strength
15:32based parenting intervention that we tested.
15:35And now I'm going to talk today
15:36about how we kept that core of the
15:38strengths based parenting intervention,
15:39but moved it into not an HIV
15:41specific domain anymore,
15:42but looking at adversity and
15:44looking at early childhood.
15:46And then, as Jim mentioned,
15:47the same core of family based
15:48prevention is also work for now.
15:50Doing in New England and community
15:52based participatory research.
15:54With Somali,
15:55Bantu and Bhutanese refugees,
15:57with the idea of a home visiting
15:59intervention done by refugees for refugees,
16:01so by community health workers,
16:03peer counselors who are from the
16:05refugee experience beginning to work
16:07with families in a prevention lens.
16:09And this is really exciting to think
16:10about with the Afghan resettlement,
16:12I hope we'll be able to pull this out
16:13for in discussions with Office of Refugee
16:16Resettlement and other partners about that.
16:18So we were talking a little earlier
16:20about qualitative and quantitative
16:22research and mixed methods,
16:24and again that cultural humility
16:25comes into play here that we
16:27recognize ultimately through the
16:28partnerships we're developing that
16:30were coming in as outsiders.
16:31We don't know the language.
16:32We don't know the culture and
16:33we have to start by listening.
16:35And really from the ground up understanding
16:37constructs of how do people think
16:40about good parenting around here?
16:41How do people think about childhood?
16:43What are non stigmatising ways to
16:45discuss mental health and children?
16:47What are those terms?
16:48How can we learn about that?
16:50And we use this kind of data to select
16:52our measures to adapt standard measures
16:54or even create new measures when
16:57we don't find that construct being
16:59captured well from what's out there.
17:01And a standardized tool because
17:03we're asking about what works
17:05locally and also when children have
17:07these forms of adversity.
17:08What helps them do well,
17:09despite those sorts of experiences we now
17:11have the active ingredients to think about
17:14for strength based interventions too,
17:16so we want to measure protection
17:18and protective processes.
17:19But we also want to learn about what
17:20are the ingredients that we can have
17:22in our intervention models that really
17:24matter here locally and culturally.
17:26And now we come back and implement this
17:28culturally informed model and evaluate it
17:30using the most rigorous designs possible,
17:32including randomized control trials
17:33and now implementation science.
17:35But it's this cycle that we've used in
17:38many different settings around the world.
17:40Now to talk about implementation science.
17:42This is another extremely influential
17:44article in the field by Balasan,
17:47born in 2000,
17:48and they looked at the leaky pipeline
17:50of NIH research that by the time
17:52you conceptualized the thing,
17:53get your early pilot grants,
17:55get the intervention developed,
17:58do your randomized control trial,
18:01get your publications out there,
18:03get it into national registries.
18:05It's taking about 17 years on average
18:08to turn just 14% of original.
18:10Research to the benefit of patient care,
18:13so we're not doing a good job.
18:14We have a massively leaky pipeline
18:15when it comes to translation of
18:17science to policy and practice,
18:19and so implementation science is a
18:22field has really grown in attempt to
18:24address these this leaky pipeline,
18:26and this is the study of methods to
18:28promote the integration of research
18:29findings and evidence into health care
18:31policy and practice and thus implementation.
18:33Research is the scientific study
18:35of the use of strategies to adopt
18:37and integrate evidence based health
18:39interventions that include some behavior.
18:41Health interventions into clinical and
18:42community settings in order to improve
18:44patient outcomes and also benefit
18:46population health and so ultimately
18:48I'm a public health person all the way.
18:50How do we shift that distribution of risk
18:53so that more young people are starting
18:55out on better footing and so that means
18:57designing for implementation a lot earlier?
18:59As we think about intervention models,
19:01thinking about who's ultimately
19:03going to deliver this,
19:04especially at scale.
19:05What's the delivery platform
19:06that could have reached?
19:08How do we design an intervention
19:09that will be feasible and acceptable?
19:11What's its fit?
19:12The ultimate patient population,
19:14given cultural issues,
19:15given the contextual issues,
19:17can we build in little mini tests
19:19rapidly of training of supervision
19:21of adherence and also questions
19:23of mediators and moderators?
19:25What works for whom,
19:26under what circumstances and begin
19:27to think about that a lot earlier?
19:29And that often means hybrid designs,
19:31so we're designing studies that are
19:34implementation and effectiveness.
19:35Hybrid designs were asking questions of
19:37implementation from the very beginning,
19:38not just effectiveness questions,
19:40and so that means that you get.
19:42Your standard kind of client
19:44outcomes symptoms functioning,
19:46but you might ask questions
19:47about satisfaction.
19:48You know how well did this intervention fit
19:51or service outcomes such as efficiency,
19:53patient centeredness.
19:54This is where we get into Co creation and Co.
19:57Ownership of the kind of intervention
19:59models we're designing and
20:00then implementation outcomes
20:01like adoption, the cost.
20:03How does this you know
20:04who's going to pay for this?
20:05What does it cost?
20:06How do we scale this issues of
20:09feasibility and then sustainment?
20:10What's the policy ecosystem?
20:12Are we able to look at mechanisms
20:14that can contribute to this being
20:16done at scale and go back to Julius Richman?
20:18That's my model, you know.
20:20Head start is widely scaled up and
20:22it's bulletproof administration
20:23after administration.
20:24That's an example of a program that's
20:27achieved this so an evidence based
20:28intervention is only as good as
20:29whether or not it's actually adopted.
20:31The providers are actually trained
20:33with competence to deliver it.
20:34They actually deliver it with high
20:36quality and people who are supposed
20:37to get it actually receive it.
20:39And so if we assume at 50%
20:41threshold drop at each step.
20:43Again,
20:43we're talking about very little benefits,
20:45so these questions of quality,
20:46especially as we move into new delivery
20:49platforms and lay worker delivered models,
20:51they really matter.
20:52So we have this question of voltage drop.
20:54It's a challenge in our field,
20:56especially as we move out to fragile
20:58and low resource settings that we have.
21:00You know,
21:01the drift that comes with expanded use.
21:03We have staff turnover after you've
21:05trained everybody we may not have
21:07mechanisms to track and report on
21:08quality or fidelity of delivery.
21:10Maybe people don't even think
21:12about fidelity or quality.
21:13And then we have these dynamics
21:14all the time of train in hopes that
21:16you train the thing and you just
21:17hope that everybody is going to
21:18do it in the way it was intended
21:20within early childhood development,
21:21we're starting to see more attention
21:24to implementation science.
21:25I draw your attention to this
21:27special issue on implementation,
21:28research,
21:28and UCD some big names like I showed you,
21:31those I who's a good friend and pia Brito,
21:33who actually came out of the Yell
21:35Child Study Center beginning to write
21:37about the importance of attending
21:39to quality and implementation
21:40and global ECD work.
21:41And now she's doing amazing work in Pakistan.
21:44So this brings us to Rwanda and our
21:46little contribution that we're trying
21:48to make you see here were in East Africa,
21:50neighboring Uganda,
21:51Tanzania,
21:52Burundi and the Democratic Republic
21:54of Congo and Rwanda is a very
21:57geographically tiny but mighty nation.
21:59You know, 13.4 million inhabitants.
22:01Again,
22:02these issues of children youth really matter.
22:05You have 53% of the population less
22:07than 20 years of age and ramant Rwanda
22:10is making great strides forward.
22:12It's really making progress in addressing.
22:14Like under five mortality,
22:16infant mortality,
22:17maternal mortality bringing
22:18those numbers down,
22:19but is very vexed by these high
22:21rates of under 5 stunting,
22:23which continue to be some of the
22:24highest in Sub Saharan Africa.
22:26And then you have compound adversities.
22:28You have the after effects
22:29of the 94 genocide,
22:31intergenerational trauma and loss you have,
22:33the HIV and AIDS epidemic that
22:35I worked on with our family,
22:37strengthening intervention,
22:38pockets of extreme poverty
22:40and now COVID-19 on
22:42top of all of that.
22:43But strengths of working.
22:44In a place like Rwanda are a political
22:47stability of very strong government
22:50that has a real effort at fiscal
22:52and administrative decentralisation
22:54and strong political will.
22:55So going back to that Julius Richmond model,
22:57they've written ECD policy goals
22:59into their economic development
23:01and poverty reduction strategy.
23:03So there's already this recognition
23:04that if we want to develop economically,
23:06we have to invest early and you've
23:08got initiatives on youth gym you'll
23:10like this generation unlimited the
23:12youth initiative to ensure that
23:14all young people ages 10 to 24.
23:15In school training employed by
23:172030 and expanding attention to
23:20violence such as the Assange,
23:21one stop centers to provide
23:23support for children and families
23:24who've experienced sexual assault
23:26and other forms of violence.
23:27So political will is a real window
23:29of opportunity and I think for me,
23:31that's why I've really enjoyed and had
23:33the pleasure of working in Rwanda.
23:35So I mentioned that work with Bill
23:36Beardsley on family based prevention
23:38and promoting mental health and
23:40children affected by HIV and AIDS.
23:42So we had the bones of that intervention and
23:44we were starting to write with colleagues.
23:45At the World Health Organization about
23:48integrating prevention of violence
23:49and early childhood development,
23:51they're often the same kids we talk about.
23:52Who's at risk?
23:53It's the same service systems.
23:54It's the same sort of service providers.
23:57Why are we not bringing these
23:58two worlds together better,
23:59especially in the context of
24:01a place that survived genocide
24:03and intergenerational violence.
24:05So we jumped at the chance to work
24:07with UNICEF and the government on
24:10a baseline ECD assessment before
24:12they rolled out these beautiful one,
24:14you know, stop ECD centres.
24:16In every district of the country,
24:18and so we sampled 884 caregiver,
24:21child pairs,
24:21and the focus was household characteristics,
24:23caregiver characteristics,
24:24caregiving practices and then child
24:26development, nutrition and health.
24:28And see this extremely cute Rwandan
24:30child being measured for length
24:33so some of the data we found
24:35from that baseline study.
24:36You get a sense of what
24:38early learning looks like,
24:39availability of children's
24:40books in the household,
24:421.6% playthings just under
24:4420% primary caregiver.
24:45Engaging in three.
24:46Activities to promote learning or
24:48school readiness in the past week,
24:49just 8.6%.
24:50Infants under one year of age attending
24:54any ECD programming just over 3%.
24:58Those you know two to three years of
25:00age to attend an ECD program still
25:03under 10% households with a child,
25:0546 who attended nursery or pre
25:07primary school is still under a third.
25:10And then you come to issues of
25:12violence and harsh punishment.
25:14Children under one year of age
25:16exposed to any violent discipline.
25:18About 20% children two to three years.
25:21Of age exposed to any violent discipline,
25:23now you're up in the 80% tiles.
25:25Caregivers who believe that physical
25:27punishment is necessary to raise a child.
25:30Well,
25:30it's well over a third of the sample.
25:32So these issues of violence reduction
25:34in intergenerational violence need
25:36to be matched up.
25:37And as we also think about the
25:38political will around early childhood
25:40development in the home environment,
25:41and so that was the genesis of what we call
25:44SU Guitarra Jango or strengthen the family.
25:46And this is a home visiting intervention
25:49that's done by lay workers.
25:51Some important. Features of it.
25:53I spent my sabbatical at the Harvard Center
25:54on the developing child with Jack Shonkoff
25:57and others developing this intervention.
25:58It used to be 25 modules 'cause you look at
26:00the literature and their one and said that's
26:03not going to be sustainable or affordable.
26:05You got to bring that down.
26:06So in the end we brought this down to 12
26:09modules that are focused on active coaching.
26:12So it's not about the home visitor bringing
26:15fancy toys or playing with a child.
26:16It's about coaching the parents in
26:18those serve and return interactions.
26:20Did you see when the baby
26:21thumped the ground and you thump?
26:23Back you followed her lead
26:24and she took joy in that.
26:26And then she served you another
26:27opportunity to follow her lead and
26:29seeing that and parents understanding
26:30that because there's a lot of you
26:32know children play with children.
26:33The parents don't.
26:34You know aren't a part of,
26:35you know what's considered
26:37playful interactions.
26:38That's what kids do,
26:39so it's starting to change that narrative.
26:40And then if we want to prevent violence,
26:42you can't just focus on mothers,
26:44so the intervention is intrinsically
26:46father and male, caregiver engaged,
26:48and we can work with any kind of
26:50family we can work with Grandma,
26:52Grandpa, Auntie Uncle, Mom, dad.
26:54Just dad,
26:55just mom.
26:55It's meant to be flexible and
26:57the home visiting model really
26:59allows that and so it's done in.
27:01Come in home with active coaching we
27:03call our home visitors coaches and
27:05we had the bones of this strength
27:07based parenting intervention that
27:09focused on conflict resolution,
27:11emotion regulation,
27:12stress management,
27:13problem solving to reduce violence
27:15in the home.
27:16And then we brought in The Who
27:18care for child development.
27:19Standard content on the importance
27:21of early stimulation,
27:22but that can look like in a coached way,
27:24nutrition.
27:24Looking around the house at UM dietary
27:28practices and high hygienic practices
27:30and so it's meant to be flexible.
27:33Work with all family types and at
27:35every session we have a 15 minute play
27:37activity and for parents that can be,
27:38you know,
27:39something they're not used to doing,
27:40and we're making homemade toys
27:41just with stuff that you have
27:43around the house banging on a pot,
27:44making a rattle with a plastic bottle.
27:46And it's meant to be complementary
27:48to the ECD centers and community
27:51sensitization campaigns in the country.
27:53So how to reach those that are
27:55hard to reach and so our platform
27:57for delivery is linking this to
27:59the cash for work program?
28:01The vision,
28:02new merengue social protection
28:03program in Rwanda and like here
28:05in the United States.
28:06It's a very difficult political
28:09argument to have cash transfers
28:11which we know are highly
28:13evidence based, but in Rwanda their poverty
28:15reduction strategy is a cash for work model.
28:18But we know that when you have really
28:20poor families with really small children
28:21and they have to go build a road.
28:23Or dig a ditch there often times leaving
28:25the small children and care of other
28:27children or neighbors and those issues
28:29of who's monitoring the nutrition area.
28:31The nutrition needs a safety
28:33issues are all problematic,
28:34and so the government was starting
28:36to more family friendly model.
28:38This was the time at which we
28:39were able to come together around.
28:40Let's use the vup that vision,
28:42merengue cash for work program,
28:44poverty reduction strategy as the platform
28:46because they have a ranking system so
28:48they have the Uber hey system in Rwanda,
28:50which ranks families by level
28:51of poverty so bad.
28:53Hey one is.
28:53Considered extreme poverty and we know
28:55that all those problems I just showed you.
28:57And if you look at our UNICEF data,
28:58they all coalesce even higher
29:00rates in the poorest of the poor.
29:02And so the goals of the program
29:04are to reduce extreme poverty
29:05to promote gender equality.
29:07Great, you know,
29:07because we're really taking up
29:09some of these issues of gender in
29:10the intervention and to increase
29:12attention to social safety Nets.
29:13So the win win is we're offering
29:15something that already supports
29:16the most vulnerable families.
29:18We can build capacity of community
29:21based workforces,
29:22and we also can help them generate.
29:23Data on impact and so for us,
29:25we want to support responsive parent team,
29:28Pramod prevent violence.
29:28So now we have a way to identify and
29:31recruit who's most at risk because
29:33they already have a ranking system
29:35we can latch onto that and find
29:37a shared vision with government,
29:39including links and referrals to
29:40other networks such as the National
29:43Health Insurance program or violence
29:44reduction or mental health systems.
29:47And think about sustainability
29:48by integrating this within the
29:50government structures.
29:51So this has been a long.
29:53Process I started working in Rwanda in 2007.
29:56We had early pilots support from
29:58the World Bank to with the strategic
30:01Impact Evaluation Fund to look at.
30:03Can we reduce it?
30:04Can we get it down from 25 to 12?
30:06Can we still have impact two different
30:08open trials to look at safety issues
30:09when it's done by lay workers and
30:11then the randomized controlled
30:12trial and now the scale up study.
30:14So I mentioned parent child
30:16interactions are so important.
30:18Active coaching using locally sourced
30:20materials to enrich the home environment.
30:22So you see here some of
30:24the homemade materials.
30:24Soft toys rattles,
30:26pull toys,
30:27and to iterate these with the
30:28developmental age of the child
30:30and help parents think about that,
30:32what can they use that's already
30:34available in their environment?
30:35Male caregiver engagement is so
30:37important and through showing up
30:38when dads are around having imagery
30:40and messaging and proverbs that talk
30:42about importance of males and life
30:44of children and everyone thriving,
30:46we found that on average we had
30:48males competing,
30:49completing 70% of all modules.
30:51And that statistic still blows my mind.
30:53And that's a testament to our local team.
30:55And I've had them checked this one million
30:57times and they say 70% of all modules
31:00and you see this in our materials.
31:03Male engagement is threaded throughout,
31:05it's it's about everybody having
31:06a role to play in the child,
31:08thriving and doing well.
31:09And we use local proverbs.
31:11We had a nice talk about this with
31:13the trainees when you're working with
31:14populations that haven't had a lot
31:16of access to education that often.
31:18There's a long literary literary tradition
31:20of ways that people talk about coming
31:23together and connectivity just like EU pick.
31:26Families I grew up with so these
31:28proverbs like nothing, can defeat.
31:29Combined hands are very powerful and
31:32help people internalize the content
31:34of the intervention.
31:35And we do a lot around thinking of
31:38nonviolent disciplinary practices,
31:40reducing stress and problem solving to think
31:42about alternatives to harsh punishment.
31:45And.
31:45So here's our theory of change.
31:46We're targeting the most vulnerable
31:48classified within the other day.
31:49Hey,
31:49system with a child under the age of three,
31:52we have all the formative work that you know.
31:54We learned about the risk factors,
31:56limited information.
31:57The children's developmental
31:58needs and stimulation.
31:59You'll hear people say things like,
32:01why would I talk to an
32:02infant who's not talking yet,
32:03or a baby who's not talking yet.
32:05I look like a crazy person,
32:06so just like not understanding the
32:08importance of early exposure to
32:10language and labeling and taking
32:11pleasure in those interactions
32:13for many families in poverty,
32:15poverty is a crisis and you see this
32:17with executive functions and you know,
32:19families affected by violence and
32:21poverty here in the United States,
32:22they become very now focused survival, focus.
32:25Instead of thinking of a future and what?
32:27This could mean for graduating
32:28out of poverty and the child doing
32:30better in the future and getting into
32:32formal education and livelihoods.
32:33There's a tremendous amount of family,
32:35social and economic stress,
32:36and all this brings risk of family violence.
32:38So our core active ingredients are
32:41this active coaching with father and
32:44male figures engaged on nutrition,
32:46health, and hygiene.
32:47'cause you're at the home you can
32:48look at all those issues together
32:50in responsive parenting.
32:51The importance of play and modeling.
32:53You know having the parents
32:54they're playing with their child
32:5615 minutes every time?
32:58Building those coping skills and we
33:00actually had a family narrative.
33:02A strengths based narrative
33:04in the HIV intervention.
33:05About these are families
33:06who've lived through Genesis.
33:07You know?
33:08What are the things along the way in
33:09your family story that helped you
33:11make it through difficult times in
33:13the past and we've taken that out
33:14because this is early childhood.
33:15We told the narrative like we do
33:17in the refugee version from the
33:18perspective of the children and the family.
33:20These are young kids in the Rwandan
33:23advisory boards and our staff said no,
33:25you needed in.
33:25We want that strength narrative.
33:27The family story.
33:28Family story focused on strengths
33:29and so I think that's a big part of
33:32also helping people honor their own
33:34unique capabilities and every family,
33:36building skills and
33:37sequential problem solving.
33:38Breaking things down into baby steps.
33:40And because you have a home visitor,
33:42they can help with navigation.
33:43So what are the informal
33:45supports around here?
33:46So when it comes to violence in the home,
33:49there are elders in the community who
33:51oftentimes know the families already.
33:53That's the system,
33:53and being able to with the home visitor
33:56be able to get help from elders to.
33:58Problem solved when there's
33:59conflicts in the family,
34:00and then there's also more formal
34:02systems there wanting governments really
34:04making big investments in health.
34:05So there are programs for acute
34:08malnutrition feeding programs.
34:09There are increasingly referrals
34:11you can make for treatment for
34:13depression and mental health care,
34:15so the home visitor can help
34:18with navigating those systems.
34:19And then lastly just building
34:21skills with the parents,
34:22the adult capability and emotion regulation,
34:25stress management,
34:25learning those alternatives
34:27to harsh discipline.
34:28In conflict resolution and so pre to post,
34:30we'd hope to see parent behavior
34:33improving both on engagement and
34:35stimulating activities and play also
34:38health promotion and a safer home
34:41environment including reduced violence.
34:43We have a one year follow-up study that
34:44will also show you we hope to sustain.
34:46And now you know this is only 12 modules,
34:49so it's about four months on average.
34:50To deliver it,
34:51you don't expect stunting to improve,
34:53but could we see something along
34:55the lines of child development
34:57outcomes one year later?
34:59That is starting to be influenced
35:01by the intervention and then sustain
35:03those reductions in violence and
35:04then actually now we're planning
35:06a three year out longitudinal
35:07study of the intervention effects.
35:09Looking at the transition to
35:11formal schooling.
35:12So I mentioned the 12 modules you see here.
35:14Some of our different themes that move
35:16across the core content I just discussed,
35:18and so the cluster randomized trial
35:20was a little complicated because we had
35:22these clusters around home visitor.
35:23They could each have a caseload of
35:25about five families and these are
35:27lay workers that we got to select.
35:28And then I'll tell you what happens
35:30when you don't get to select them.
35:31But we had the cast for work
35:34program that was the standard.
35:36So you see,
35:36classic PW's classic Public
35:38works program and then we have
35:40expanded public works program.
35:42So these are far fewer clusters
35:44were getting that expanded program.
35:46Then we had some regions that had
35:47both programs operation operational.
35:49So we had that within their randomize
35:51either to services as usual or the
35:53home visiting being built into
35:55those clusters.
35:56And that's our cluster randomized
35:57trial design.
35:58Here's just an overview of our measures,
36:00ages and stages questionnaire.
36:02We wanted to open source Malawi.
36:05Developmental assessment is what
36:06we ended up using.
36:07Although that's a Screener and
36:08it turned out to be
36:09a bit of a blunt instrument in terms of
36:12sensitivity to change Hopkins symptom
36:13checklists for caregiver mental health,
36:15we have the home inventory,
36:16which I'm sure many of you know.
36:18I'm observation of mother child interaction.
36:20We didn't have a father,
36:21one which is ridiculous, but that was
36:23going to be a lot of formative work,
36:25and that's something I hope to do.
36:26Rwanda Parenting Questionnaire
36:28adapted from a standard measure,
36:30and this is based on our
36:32qualitative work and then.
36:33From the UNICEF multiple
36:34Indicator Cluster survey,
36:35we have a child discipline module.
36:37We have health and hygiene module.
36:39We have your standard anthropometrics
36:41dietary recall and then health indicators,
36:44fever, diarrhea, cough,
36:45as well as help seeking for those problems.
36:48So in global health,
36:49global mental health global child
36:51development this concept of task
36:53sharing has been really transformative.
36:55When you don't,
36:56I mean you have just a handful
36:57of highly trained professionals
36:59in any of these countries,
37:00including just, you know, under 10s.
37:03Psychiatrist in all of Rwanda.
37:05So you can't look too highly trained
37:07professionals to be the delivery platform,
37:09but if you're working with lays specialists,
37:11we're now seeing in emerging evidence
37:13base and a range of countries.
37:15That behavior change interventions,
37:17mental health, parenting,
37:18early childhood can be effectively
37:20delivered with impact by non specialists.
37:22And so that's really a lot of
37:24what's influenced our work.
37:25But then you've got to think of how do we
37:27ensure quality and do no harm principles.
37:29So in terms of our home visitors,
37:31when we did the trial we had
37:33a 3 tiered community.
37:34Based volunteer selection.
37:35The community would nominate people
37:37in good standing in the community
37:38who could do this kind of work
37:40oriented towards vulnerable families.
37:42We had telephone interviews and
37:43then in person interviews a three
37:45week intensive training and how to
37:47coach how to help you know in live
37:49in that parent child interaction
37:51the servant return interactions
37:52and then supervision in person,
37:55group and also telephone checkins.
37:57Here's our intervention sample.
37:59So on average the parents are
38:01about 30 just over 3536.
38:04Years of age,
38:05a lot of single headed households and
38:07we wanted to make sure the intervention
38:09worked in both dual headed and single headed.
38:11So in our sample about 36% are single,
38:16separated,
38:17divorced,
38:17widowed and then 63% cohabitating or married.
38:21And you see here the range of caregivers
38:23were working with a lot of biological
38:25mothers also fathers and then other
38:27family members also involved in
38:29the trial as primary caregivers.
38:31Very low levels of access to education.
38:33Remember we're targeting Uber day once.
38:35These are the poorest of the poor.
38:36So you see 23% with no school and
38:424748% under six years of schooling.
38:45The children,
38:45on average are about 22 months of age,
38:47half female.
38:48And then again,
38:49this is where you see the poorest of the
38:51poor over day one coming in 48% stunted.
38:54Remember,
38:54Rwanda is already really
38:56challenged by that number of
38:5829% stunted.
38:58But when you go to the other day one,
39:00it's even more extreme.
39:02Even 3% wasted, 18% underweight.
39:04And then we had this UNICEF Screener.
39:07I don't know if any of you have ever used it,
39:09just it's a very blunt tool
39:11looking for any delay and certain
39:13indicators of early development.
39:1530% of kids would screen positive for some
39:18delay and then violent punishment 47%.
39:21So these are the kind of families
39:23that we really want to focus on,
39:25and so if you look at caregivers
39:27participate in the study,
39:28those who would meet criteria for
39:30being in the likely clinical range
39:32on the Hopkins symptom checklist
39:34for depression like problems.
39:3545% and then for the PTSD checklist?
39:3819% so this is post genocide
39:40or Wanda many years later.
39:41So these issues of trauma and what it
39:43means for parent emotion regulation
39:45and functioning are really important.
39:47And then it's not just the trauma,
39:49it's the daily hardships of poverty.
39:51So if you look at frequency of
39:53daily hardships in the past month,
39:5512 months, very high rates,
39:57including both cumulative as well as
40:02specific daily hardships in the sample.
40:05Trauma prevalence also very
40:07high in the sample.
40:08Looking at a checklist and it was
40:10sensitive what we could ask about,
40:12but we found that about 52% of the
40:15sample had experienced at least one
40:16trauma likely related to the genocide.
40:18So this is this is the backdrop
40:21in which we're working,
40:22and so in terms of the intervention effects,
40:24I'll show you the effects pre to
40:26post and then 12 months out 'cause I
40:28want to talk about getting to scale.
40:30So this is our first study
40:31published in BMC Public Health.
40:33We saw significant increases
40:35and stimulation in the home.
40:36Umn,
40:37playful activities and dietary diversity,
40:40and also care seeking both
40:42for diarrhea and fever,
40:43and then a decrease in use
40:45of violent discipline.
40:45So we're having the impact on the
40:48family level two and on mothers
40:50reports of intimate partner violence.
40:52So significant effects on mothers.
40:54Intimate partner violence.
40:55Unexpectedly,
40:55we also saw significant decrease
40:57in mothers and fathers showing
40:59symptoms of depression anxiety,
41:00so that's with very non specific elements
41:02that we've seen in the intervention.
41:04One year later we did see on
41:05the ages and stages.
41:07Questionnaire higher scores and treatment
41:09children for gross motor development.
41:11No impact on fine motor on the communication.
41:14Z Score is a significant effect on
41:16problem solving and on the personal
41:18social Z scores and then the
41:20violence effects held one year later,
41:22which is really exciting.
41:23The decrease in harsh punishment
41:25and the decrease in intimate partner
41:26violence and we talked about the
41:28importance of qualitative data.
41:29I won't be able to read all of these quotes,
41:32but this is very much triangulated
41:34by the qualitative data and proud
41:36everyone saying.
41:37My child is sharp due to severe mango,
41:40so get him Jango boosted my child's
41:41communication and how to behave and
41:43having conflict with one another
41:44now in
41:44the child sick I immediately go
41:46to Health Center. I used to be
41:48forgive them traditional medicine.
41:49It also helps build our hope for the
41:51future people saying I can recommend it.
41:53I love this quote from the father.
41:54We normally have stress
41:55caused by our daily hardship,
41:56but through the intervention we learned
41:58how to manage stress caused by poverty.
41:59Personally I couldn't hit
42:00my wife for my child.
42:01When I'm stressed I either go look for a
42:04friend or talk instead of shouting at home.
42:06So if you look at,
42:07you know with just 12 sessions compared
42:08to some of the other interventions,
42:10which are many more sessions to get impact.
42:14We're right in the range of impact
42:16perception of some of these big interventions
42:19that have done weekly for a year,
42:21which is really exciting 'cause
42:22we've got to think about scale.
42:23And we've also got to think about
42:26cost and we can bring down the
42:27costs if you go from the research
42:29to manage it with an NGO.
42:30But even better if we can have
42:32it managed by the government.
42:33So that's really where the traction is.
42:36And so the question is,
42:37how do we sustain impact and quality
42:39when the home visitors are largely
42:41volunteer workforce in Rwanda that
42:43gets some stipend ING and and the
42:45workforce we're working with is
42:47called the Friends of the Family or
42:49the into German Jango and Rwanda.
42:51Like many countries,
42:52the institutionalized so in closing the
42:54orphanages there are in every village
42:56two people the friends of the family
42:57workers who are big part of that movement,
43:00home of kids who've been in
43:02institutions and those friends of
43:03family workers are available and
43:05so in working with the government.
43:08Uh,
43:08we negotiated an MO U could we
43:09train them in doing this home?
43:11Visiting intervention because it's
43:12aligned with their goals around
43:14child protection in the first place?
43:16And so the play collaborative is now
43:18this really ambitious implementation
43:20science effort to scale up this
43:22intervention using the embedded
43:24friends of Family workforce or we
43:26call them the ICU's in Judaism and
43:29Jango across 10,000 households.
43:313 districts in Rwanda,
43:32putting them all into cross
43:34site learning and collaboration.
43:36And so this has taken.
43:38Implementers have fixed fee.
43:39Rwanda University ever won the
43:41Lego Foundation, USAID,
43:42oak and many others to come
43:44together and then very close.
43:45Work with government partners,
43:47including the National
43:48Child Development Agency.
43:49So the whole intention here is
43:51to transition the evidence based
43:53practice to the local workforce in
43:55collaboration with government and
43:57local leaders and civil society,
43:58so women's associations,
44:00Mens associations and shift ownership
44:02away from us in Boston to the Rwandans
44:05and to do this by having an expert C team.
44:08All the people who are the best
44:10interventionist in the prior
44:11trials become cell mentors.
44:12Become experts on the seed team who
44:14could now be the source of training
44:16and supervision and across the three
44:18districts we have a shared charter.
44:20We actually had a signing ceremony
44:21for the Charter that everyone
44:23commits to this cross site.
44:25Learning and quality improvement as we go.
44:27We're using techniques like plan,
44:28do study, act cycles.
44:29I'll show you what those look like.
44:31Continuous training,
44:31learning and the use of technology
44:34to track our quality indicators.
44:36So the Play collaborative is
44:38targeting the national level.
44:39We have a we have routine national quarterly
44:42government Advisory Board meetings,
44:44but we also have play collaborative
44:47meetings twice a month at the district
44:48level and also at the sector level.
44:50These are just like States and counties in
44:53Rwanda all the way down to village level.
44:55Champions for the play collaborative and
44:57this is guided by an implementation science
45:00framework from Greg Arends, Epist model.
45:02There are hundreds of implementation
45:04science frameworks if you're interested.
45:06Oftentimes, they're looking at these
45:08stages of exploration, preparation,
45:09implementation, sustainment,
45:10and looking at inner context features
45:13like how complicated is the intervention,
45:15who's it for, who can do it,
45:17and then add our context of
45:19policy environment, the financing,
45:20the funding environment,
45:22the political dynamics around
45:25intervention and quality improvement.
45:27We had a great talk about this earlier today,
45:30has really been a focus.
45:32How do we monitor fidelity and
45:34have improvement in quality we?
45:36For audio taping sessions,
45:37having experts listen to them.
45:39It was clunky to get back to the home
45:41visitor in time for their next session.
45:43Now we're doing spot checks for an
45:45expert will go and sit in and watch a
45:47newly trained and to determine young
45:48go do the intervention and we've also
45:50done some sample videos where with
45:53permission from the family the issues
45:55are recorded at two different time points.
45:57Then they get targeted feedback on
45:59their practice and we're really feeding
46:01that back and looking at quality
46:02indicators with the play collaborative.
46:04Now we've been able to train.
46:06Come nearly 2600 and Schumer,
46:09Jango around the country in Rwanda.
46:113 rounds of training at 124 sites
46:13and they're learning through role
46:15play to do the intervention.
46:17You know you can't just learn
46:18this through a lecture.
46:19There has to be actual practice
46:21and how do you coach?
46:22How do you truly follow the parents?
46:24And then using some of the tools
46:26on screening and referrals and
46:28especially infusion of gender concepts.
46:30And we also train the government
46:32stakeholders because we want there
46:33by and we want them to own this
46:35and so in every district.
46:36We've now had trainings of
46:38involved nearly 65.
46:39Hundreds government stakeholders
46:41across those three districts,
46:43and they're not learning to coach
46:44and do the direct role play that
46:45they are learning about the basics
46:47of early childhood development.
46:48The important of those investments
46:50and reducing violence.
46:52PSA cycles,
46:52I don't know if you've heard about these.
46:54They come from the Institute
46:56for Healthcare Improvement.
46:57The idea is when you hit a barrier,
46:59you should study what is that barrier about?
47:01Let's come up with a strategy
47:03to overcome the barrier.
47:04Let's implement that strategy and see
47:06if we change anything about how we're
47:08doing on our metrics of reach and impact.
47:10And so it's a PSA cycle is a very
47:13systematic way to engage in quality
47:15improvement and bring evidence to bear on.
47:17Looking at that, and really encourage a
47:19cultural problem solving, it's not raining.
47:21Hope we're going to actively tackle.
47:23Barriers and engagement facilitators as
47:25we go and COVID-19 was a huge barrier.
47:27As you can imagine,
47:28we're out there implementing and then
47:30all of a sudden you couldn't have group
47:31meetings and group trainings anymore.
47:33We had to pivot.
47:34We started WhatsApp training and
47:35support groups for our staff.
47:37WhatsApp is highly used in Sub Saharan
47:39Africa, becomes a great platform.
47:41We had to work with the government and our
47:44donors to get PPE and follow at every step.
47:47The government policies about coming
47:49together in groups and hygiene practices
47:51and make sure that we could overcome that.
47:54We also saw from our qualitative data a
47:57real investment in raising awareness and
47:59getting investment from the stakeholders.
48:01An opportunity for us to problem solve
48:04together including refresher trainings
48:05when people had challenges in following
48:07the evidence based practice and find
48:09solutions and then share them one
48:11district when they innovate they'd
48:13share it with the other districts
48:14rather than letting everyone recreate
48:15the wheel every time so they're in a
48:17community of practice and this has
48:19really helped us generate political will.
48:20So we have these beautiful letters
48:23of appreciation from.
48:24Each of the districts that we can now
48:26take back to the national government and
48:28we can take back to the international
48:30donor community.
48:30We've also been thinking a lot about
48:33technology since those early WhatsApp
48:34experiences and with the University
48:36of Rwanda,
48:37we've developed a digital dashboard
48:38project and this is a way that we
48:41could start to track the quality
48:42indicators by district.
48:43And it's it's almost gamification,
48:45you know, have healthy competition.
48:47Can ingoma see in neons as
48:50quality improvement data?
48:51How are we doing on getting fathers
48:53engaged when they're in the household?
48:54Are we making referrals?
48:56What's the timeliness of those referrals?
48:58And one day we could even envision
49:00having the whole manual be more
49:02digital and having embedded videos.
49:04You can see how do you do a
49:06session on conflict resolution?
49:07What does it look like when you're
49:09teaching deep breathing or other
49:10emotional regulation skills?
49:11How do you do that?
49:12Well, we really,
49:13as you heard from Jim,
49:15were very invested in bringing up
49:16the next generation of researchers.
49:18It shouldn't be me here.
49:19Talking about Rwanda should be Rwandans
49:20talking about Rwanda and people coming
49:23from lived experience in the role of P.
49:25And so we do a lot around building
49:28research capacity and the next generation
49:30of researchers interested in this
49:32field from social work to psychiatry,
49:34to psychology, nursing and etc.
49:36Learning about research skills and
49:38being embedded in our research.
49:39So I wanted to make sure we have
49:41enough time
49:42to talk a little bit about the project,
49:45but I hope I've been able to convince
49:47you that we have an emergence of
49:49evidence based models out there in
49:50the world to promote early childhood
49:52development and prevent violence.
49:54But we really need to be
49:55thinking about these.
49:56Questions of scale.
49:56The numbers are huge and they're daunting
49:59and implementation science is such a
50:00big part of how we need to ship beyond
50:03just the randomized controlled trial,
50:04and there are real opportunities
50:05for integration.
50:06Just like I've showed you today,
50:07bringing violence prevention and DCD
50:10promotion into poverty reduction.
50:12Integrating into nutrition programs,
50:14we're doing education and employment
50:16programs meet evidence based
50:17mental health and Sierra Leone.
50:19So there are real opportunities
50:21to innovate and from scarcity.
50:22We can really learn a lot.
50:23And to do this, policymakers need evidence.
50:26And they didn't.
50:27Information on costs and return on
50:29investment to make those arguments,
50:30and success requires these partnerships.
50:32Long term partnerships where
50:34you go deep and you stay long.
50:36But if we can innovate in these
50:37contexts if you can do it in
50:39these situations of scarcity,
50:40you can do it anywhere.
50:41So I hope you'll join me and contributing.
50:44And thank you very much is an honor.
50:53A little.
50:58And we just have a couple of
50:59questions on chat already.
51:01Just real quickly.
51:02First of all, Dr. Betancourt.
51:04You're a real powerhouse and and and
51:06you know there's so much research
51:08about these programs needing someone
51:10to spearhead it and then take off and
51:12they could see why it's been successful.
51:14Just one thought on the 12 session.
51:17This server in our.
51:21Close, yes, very close
51:22program and I was wondering,
51:25you know, it just seems like
51:26the family support workers.
51:27The family in home workers.
51:29Sorry that was 40 and slip were were
51:32you know so connected with the families.
51:34If that was one of the differences that
51:36doesn't occur in a lot of the other programs,
51:38you know that you you so selected
51:40carefully and then got them
51:41really connected the families.
51:43If you think that's what did it,
51:44you know the importance of
51:46that relationship along with
51:47all the other interventions.
51:48Just your thoughts on that. Oh
51:49yeah, I mean.
51:51The the beauty of there.
51:53There's tensions, right?
51:54'cause there's confidentiality,
51:55but these are collective cultures
51:57where everybody knows everybody.
51:58These are already people with a mandate
52:00from the government to be the friends
52:02of the family social protection point.
52:04People in the village, right?
52:06So they're already living in the
52:07village and doing this kind of work.
52:09When we did the trial, they were imported,
52:11so they're from the village,
52:12but they're not yet with that mandate,
52:14so it could be in the play collaborative.
52:16We're now doing it with the
52:17friends of the family workforce.
52:18Those issues are all the more potent.
52:19But even with the importing they
52:21weren't really that imported,
52:23they're from a neighboring village.
52:24They had to be able to get there.
52:25So I do think that there's a lot to say
52:28about people being from the community.
52:30And then you have your 12 actual visits,
52:33or at least you need to cover
52:34the content of the 12 modules.
52:36So you may break it up over more
52:38than you know it's 12 modules.
52:39It's not 12 visits,
52:40but you're going to see the people again
52:42and you're going to say how's that going?
52:44You know,
52:45hey,
52:45does that tippy tap we made at your
52:46house to wash your hands still work?
52:48You need me to come over and fix it house.
52:51Yeah,
52:51they know you care and you're a part
52:54of the community and I think you
52:57know we struggle with issues of you
53:00know who can be the mental health
53:02provider confidentiality issues.
53:03But even here when we're doing this,
53:05United States with refugee populations,
53:07I think it's some of the same power.
53:09And when you look at our qualitative data,
53:11they say nobody else could do
53:13that intervention except somebody
53:15from this lived experience.
53:16And that's the power of getting,
53:18you know,
53:19the access to work with refugee families.
53:21'cause there was a version of an
53:23intervention where it was done in a clinic.
53:24And people were just supposed to show up
53:25and it was the mental health professional.
53:27Nobody came.
53:27But when we shifted it to home,
53:29visiting done by appear from the
53:31lived experience were able to really
53:34start to have much more access and.
53:36And that's about getting to reach, right?
53:38Yeah, yeah.
53:39So there's a lot of comments,
53:41very positive comments coming in on the chat,
53:43and thank you for a wonderful talk.
53:44And there's a question
53:45from Doctor Amanda Calhoun,
53:47one of our fellows here in the Child
53:49Study Center asking about and you touched
53:50on this towards the end of your talk,
53:52navigating issues of perceived
53:53colonialism as a non or wand and
53:56researcher working in Rwanda.
53:58And what are the strategies you're
53:59implementing to overcome that?
54:01Or maybe to raise up UM researchers
54:02of color here in the United States?
54:05They may want to get involved
54:06in this type of research
54:07absolutely now as I see it,
54:08it's my job to put myself out of business.
54:10You know, like I should not be,
54:12the person leading up and
54:14being the Pi of this research.
54:16In these different settings
54:17here we own Rwanda.
54:18I come from that, you know,
54:20background myself.
54:20Being in a low resource setting and
54:23approaching these through partnerships.
54:24And you know, throughout the years
54:26like we now with our refugee study,
54:29have a young man who's in a masters program
54:31who was a youth Community Advisory Board,
54:34meant you know, member,
54:35he's now applying to PhD programs.
54:37One of our Community advisory
54:39partners is now in a PhD.
54:41Program in public health and in Rwanda.
54:43Vincent says the bear and the
54:45Center for Center for Mental Health.
54:46We've been able to work with
54:48our funders to make sure that
54:50we had an entire funding focus,
54:52and that's Oak Foundation.
54:53Very generously on mutual learning,
54:55and we don't see it as capacity building
54:57like we're the experts were going to,
54:59you know, bring expertise to you,
55:01but we have a lot to learn
55:03from their wantons,
55:04and again,
55:04getting back to the stance of listening.
55:07It only deepens our science to have those
55:10partnerships and have mutual learning.
55:12As well as we know some things about
55:14how to design studies and how to write
55:16up research for publications and we're
55:18in it with you for the long haul.
55:19And I would say in Rwanda and Karen,
55:22I think you said you were.
55:23You saw the real investment
55:25in the academic system.
55:27The commitment to rigor and training.
55:30It's really exciting and I would
55:33hope that eventually it's the
55:35Rwandans here giving this talk.
55:37And normally when we do it on zoom,
55:38that's been fun.
55:39We can do it all together so I.
55:42I do think that it has to be
55:44a part of your stance.
55:46You know that you do
55:47this through partnership,
55:48and ultimately it's about bringing up
55:49the next generation and transforming
55:51who's really sitting around the table
55:52and who's writing the grants and
55:53getting funded and leading this stuff.
55:56Another quick question from Christine Dr.
55:58Christine Edmonds, wondering about
55:59the volunteers and whether or not
56:01they could be paid for this work,
56:03and if that could be factored into the
56:05cost analysis for these programs. Yeah,
56:07no. We would love I.
56:09I just I feel in Rwanda.
56:11It may be that in Rwanda because of the
56:14spirit of volunteerism and the organizational
56:16structure that quality and pay.
56:18But it's the same thing with you know,
56:19early childhood services here.
56:21When we underpay people and they're not
56:24adequately compensated for their time.
56:27Questions of quality are
56:28always going to come in,
56:29and so this has been a constant
56:31negotiation with us through one
56:32in government and the World Bank
56:34about how to think about the the
56:37investments required to scale up.
56:38Because Rwanda has a lot of these
56:41community based volunteers,
56:43they also have community health workers
56:44which are widely scaled up in the country.
56:46They've started to iterate with
56:48different incentive program,
56:49so it's not really volunteer per say,
56:51but like collectives where they may be
56:53given a small loan where they can start
56:55a business and then keep the profit.
56:57From that that business,
56:58I think at least again we have to
57:00align with government priorities.
57:02We can't be pitching things that
57:03are outside of what the government
57:05sees is feasible and sustainable,
57:06but I think some of that innovation around.
57:09How do you compensate?
57:10And some of the small group loan programs
57:13that they're experimenting with those would,
57:15I think,
57:16be much more exciting and palatable than
57:18just expecting people that you deserve
57:19a younger have been doing their jobs.
57:21Still as volunteers,
57:22we have to think about ways to
57:24professionalize and and compensate
57:26people for their professional.
57:27Work
57:28and just to pass it back to
57:30Doctor Lichtman to closeout
57:32a really inspiring session.
57:33Thank you so much. It's such
57:36a pleasure and honor and my goodness
57:38we didn't have a chance to talk about
57:40the reality in Sierra Leone and all
57:42the work that you've been doing there.
57:44But you're really an inspiration for
57:46all of us and there's so much more that
57:48needs to be done around the world.
57:50And also here in New Haven.
57:52And fortunately we do have a number
57:54of programs here, and I guess one of
57:57the other things about Teresa is that.
57:59She's present.
58:01If you try and reach out and make a
58:03contact with Teresa, she's there,
58:06and even if you invite her to come down
58:07to New Haven in the midst of a pandemic,
58:09she's here.
58:12So,
58:14and we do have a number of
58:15things that we'll be talking
58:16about later on this afternoon,
58:18and chances are there might
58:19be an opportunity for people
58:21who have questions to sort of.
58:23Stick around for a little bit,
58:24although we probably need to
58:26formally close the grand rounds.
58:32OK yeah, so I
58:35think we have some more time, but I'd
58:36like to give this lady a standing.
58:45Thank you. Never gonna put my mask on.