Asia Pacific Research for Mental Health Services (ASPIRE-MHS)

This program is led by faculty from the Johns Hopkins Bloomberg School of Public Health (JHSPH) together with collaborators from the University of Public Health Yangon, clinicians and academics from private clinics, international and national non-governmental organizations.

The goal of this program is to help different types of service providers in Myanmar successfully integrate an evidence-based mental health talk-therapy into their ongoing services in order to provide sustainable community-based mental health services to adults suffering from common mental health problems including depression, anxiety, posttraumatic stress, and general distress.

Through this program, we will gain a greater understanding of the road to implementation and sustainment of a mental health program in Myanmar across a range of organizations. We will also understand barriers and facilitators to mental health service integration at the organizational level. Barriers are increasingly being understood and addressed at the consumer and provider level of services; this program will begin to address our gap in knowledge of organizational-level barriers and methods for addressing them to achieve intervention implementation and sustainability. Generating a road-map to scale up and sustainability for different organizational types will facilitate future organization’s prediction of barriers and the tools to proactively address them.

The mental health intervention being implemented as part of the ASPIRE project is the Common Elements Treatment Approach (CETA), a community-based transdiagnostic talk therapy that the JHU team tested among adults from Myanmar in a randomized controlled trial (2010-2013) and found to be effective at reducing the burden of depression, anxiety, and trauma symptoms and improving functioning. CETA is not a new psychological treatment, rather it is a new way of combining components of common psychotherapies in different ways to be able to treat individuals with any of these common mental health problems or combinations of these problems. The treatment is being implemented for this program as a one-on-one talk therapy that includes an average of 8 to 12 one-hour treatment sessions.

Primary Aims

To identify the resources (time, financial and human) that are needed for organizations to plan for, implement, and sustain an evidence-based mental health program:

• At the organizational level we will be monitoring the process each organization goes through in terms of activities, amount of time, and human and financial resources used, to move through the planning, implementation and sustainability phases of program implementation.
• At the provider level we will be monitoring how environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, communications and strategic planning affect how an organization moves through the planning, implementation and sustainability phases of program implementation.

Secondary Aims

• To identify mediators and moderators factors associated with sustainability in order to facilitate implementation success: Moderators include type and dose of organization intervention, size and type of organization, and type of provider. Mediators include acceptability, reach, feasibility, willingness to change and organizational climate.
• To characterize paths to sustainability: Case studies of individual organizations will identify barriers and solutions used to overcome these barriers for selected organizations as they go through the phases of implementation. 

Organizational Interventions

As this program is one of technical support to help organizations through the process of integrating CETA into their ongoing services, the interventions that are provided as part of this program are organizational support activities that are designed to improve the process of implementation and sustainability of this mental health program. Each intervention is designed to help achieve a goal or solve a problem at the organizational level. To this end, we have designed two sets of organizational interventions, Basic and Enhanced. Basic interventions are activities that address key areas that most organizations would need to uptake and implement a new evidence-based practice and thus will be provided to all ASPiRE organizations. Enhanced interventions are activities that provide extra doses of the basic interventions or provide new skills that may be needed by some organizations to move through the stages of implementation.

Included in the Basic Interventions are best practice information on:

• Human resource planning
• Workplan development
• Establishing safety and referral systems
• Systems for program monitoring and evaluation  
• Planning for structural, logistical and financial resource needs

Included in the Enhanced interventions are:

• Additional dosing of the above elements (example: if an organization needs additional time and/or support in these areas)
• Organizational buy-in advanced areas: Challenge Model, SMART, Root Cause Analysis (5 whys), Brainstorming priority actions
• Effective leadership
• Work planning: Priority matrix, Developing a work plan, Monitoring work plans
• External stakeholder engagement
• Identification of target population, local and recruitment
• Worker incentive programs
• Enhancing community partnerships
• Evaluation planning
• Principles and practices of supervision
• Quality improvement (PDSA cycle training)
• Internal communication (roles, stakeholders, organogram)
• Funding sources and planning
• Sustainability planning

Program Monitoring System

To address the primary aims and inform what organizational interventions may be needed by the participating organizations, data will be collected at the level of the organization and CETA providers. Monitoring data will be collected bi-monthly at the organizational level using the Stages of Implementation Completion (SIC) and bi-annually at the provider level using the Program Sustainability Assessment Tool (PSAT).   

The SIC, developed by colleagues at the Oregon Social Learning Center, is an electronic checklist that allows program staff to regularly monitor the different activities and milestones that are considered necessary for each stage of implementation. The checklist will record the date that the activity or milestone was completed and will allow for a rating of the quality of the product. From this measure, we will have a record of all the activities and milestones completed by each organization as they go through the implementation phases allowing us to assess how much time it took and how many resources (human and financial) were needed during each phase for each organization. 

The PSAT is a monitoring tool that the JHU team adapted for use in Myanmar to regularly monitor a program’s current capacity for sustainability and identify potential barriers and facilitators to success across a range of organizational and contextual factors. The PSAT is completed bi-annually by organizational leaders and CETA providers and gathers information on environmental support, funding stability, partnerships, organizational capacity, program evaluation, program adaptation, communications, and strategic planning.

To address the secondary aim and provide additional information on selecting appropriate organizational interventions we will use a series of implementation science tools developed by our team, based on prior qualitative and quantitative research and testing. These measures have been adapted for Myanmar, will be completed annually by organization staff and providers to monitor how, over time, their perceptions change of the acceptability, adoption, appropriateness, and feasibility of the CETA intervention. We will also look how their perceptions of their organizational climate and leadership evolve and how the reach of the program changes as CETA is integrated into ongoing services for the communities they serve.   

Monitoring data will also be collected on the characteristics of the organizations, including year registered, location (urban, peri-urban, rural), number of staff and type of each staff, type of organization, target population served, number and demographic/educational background of providers, size of the client population (across all services), and funding sources. 

Capacity Building

In addition to providing program monitoring assistance, the NIH has given us a mandate to work collaboratively with clinicians and experts in Myanmar and other Asia-Pacific countries (Viet Nam and Papau New Guinea) to conduct trainings and provide mentorship in implementation research for mental health services. The capacity building activities will vary over the years of the program based on the collaborators involved and their needs, but will be based on the program monitoring design and activities being conducted in Myanmar as part of this  intervention. The capacity building activities will be done in collaboration with experts at the University of New South Wales in Australia (Drs. Derrick Silove and Zachary Steele) as well as Dr. Brandon Kohrt (Duke University) and Wietse Tol (JHU).