Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD): Study Protocol

Abstract

Introduction:

This study describes the incorporation of an evidence-based mental health intervention, the Youth Readiness Intervention (YRI), into a youth entrepreneurship training program in Sierra Leone. A Collaborative Team Approach (CTA) is used as the implementation strategy to address the human resource shortage and related access to care and capacity challenges.

Methods:

A Cluster Randomized Quasi-Experimental Pilot Trial (N=175) has been conducted in one rural district of Sierra Leone. Pilot data assessed implementation feasibility and clinical effectiveness using this delivery platform. A larger Hybrid Type II Effectiveness-Implementation Cluster Randomized Trial is underway (N=1188) in three rural districts. Findings on feasibility and fidelity, barriers and facilitators influencing the integration of the YRI into the entrepreneurship program, and clinical effectiveness of the YRI are of interest.

Results:

Findings from the pilot study indicated that the YRI can be implemented within the delivery platform of youth entrepreneurship programs with mental health benefits to high-risk youth. Pilot findings informed the ongoing larger Hybrid Type II trial to understand barriers and facilitators of the CTA and clinical effectiveness of the YRI within this delivery platform.

Next Steps:

In fragile and post-conflict settings, innovative approaches are needed to address the mental health treatment gap. Findings from this study will support efforts by the Government of Sierra Leone and partners to address human resource challenges and increase access to evidence-based mental health services.

Editor’s Note:

In partnership with Milton L. Wainberg, M.D., Psychiatric Services is publishing protocols to address the gap between global mental health research and treatment. These protocols present large-scale, global mental health implementation studies soon to begin or under way. Taking an implementation science approach, the protocols describe key design and analytic choices for delivery of evidence-based practices to improve global mental health care. This series represents the best of our current science, and we hope these articles inform and inspire.

Introduction

Data from the 2016 Global Burden of Disease study indicate that globally, 162.5 million disability adjusted life years (DALYs) were lost due to mental and addictive disorders, 6.8% of all DALYs lost in that year (1). In sub-Saharan Africa, where the burden from non-communicable diseases is increasing, total DALYs due to mental disorders increased by 113.9% from 1990 to 2017 (2). As many as 78% of mental health disorders are untreated among adults in low-and middle-income countries (LMICs), and likely higher for adolescents and youth (3–4). Among youth, mental health problems resulting from trauma exposure and psychological distress are often expressed as externalizing (e.g., hostility) and internalizing behaviors (e.g., withdrawal). Emotion dysregulation—difficulties in modulating strong emotional responses—is a major neurobehavioral mechanism operating across a range of mental health problems including traumatic stress, depressive symptoms, and externalizing problems (5–7). Emotion dysregulation can lead to myriad behavioral and interpersonal problems, which can impact one’s ability to engage in healthy behavior and participate in livelihood opportunities (8–20).

Similar to other post-conflict LMICs, Sierra Leone has limited healthcare infrastructure and faces challenges in the delivery of mental health services (21). Since gaining independence in 1961, the country has experienced several social and political upheavals (Figure in online supplement). The Ebola outbreak of 2014–15, which resulted in 3,956 deaths (22), further weakened the healthcare system and exacerbated the mental health treatment gap (23). The formal and informal structures set up to support mental health services across sectors lack coordination and resources which has resulted in a disjointed, ineffective system (24). Sierra Leone’s mental health work force is grossly inadequate (25). The Sierra Leone Psychiatric and Teaching Hospital is the only dedicated mental health facility in the country and there are scant community-level mental health services.

The Government of Sierra Leone’s economic development and health policy plans, including the recently launched Mental Health Policy and Strategic Plan for 2019–2023, underscores the importance of health and mental health to advance human capital. The limited reach of mental health services in Sierra Leone, coupled with strong political will, presents an opportunity for delivering evidence-based mental health interventions via the alternate delivery platform of youth employment programming.

Youth Functioning and Organizational Success for West African Regional Development (Youth FORWARD), funded by the US National Institute of Mental Health, is an implementation science collaboration focused on scaling out evidence-based mental health interventions for youth exposed to war, community violence, and other adversities. During the course of Youth FORWARD’s work, the term “scaling-out” emerged, which refers to the process whereby evidence-based interventions (EBIs) are modified for a new delivery system, a new population, or both (26). We refer to our effectiveness trial as a scale-out study per this recent nomenclature that more accurately captures our approach to delivering a mental health program, the Youth Readiness Intervention (YRI), via youth employment programming.

Youth FORWARD builds on 18 years of research on the effects of war, violence, and post-conflict adversity on the mental health of youth in Sierra Leone. The Longitudinal Survey of War-Affected Youth (LSWAY;1R01HD073349–01), launched in 2002, was the first longitudinal study in sub-Saharan Africa to examine trajectories of psychosocial adjustment and social reintegration among a cohort (N=529) of male and female war-affected youth (27–33). The LSWAY demonstrated how trauma and loss influence emotion dysregulation, interpersonal deficits, and impairments in daily functioning (30–31) while understanding trajectories of risk and resilience with attention to modifiable factors that could be targeted by behavioral interventions (34). Formative intervention research illuminated a gap in mental health services for youth: programs focused on classic symptoms of Posttraumatic Stress Disorder (PTSD) and offered exposure-based PTSD treatment, but few programs focused on the emotion dysregulation and interpersonal difficulties that impeded success in educational/livelihood programs. Focus groups with community leaders, youth, and professionals led to the YRI and its orientation as a transdiagnostic, common-elements based intervention that could be safely delivered with fidelity in community settings by lay workers receiving strong training and supervision (11, 34).

A randomized controlled trial (RCT) in an educational setting demonstrated that youth who received the YRI reported significantly greater improvements in emotion regulation, prosocial attitudes and behaviors, and daily functioning than control youth, with YRI participants six times more likely to persist in school compared to controls (11). Given constraints in Sierra Leone’s health system and high rates of mental health problems within the population, testing alternate delivery platforms like schools and youth employment programs for the integration of EBIs like the YRI is critical.

Youth FORWARD is delivered via a Collaborative Team Approach (CTA) that draws from the implementation science strategy of Interagency Collaborative Teams tested to scale out the SafeCare child protection intervention in California (35) as well as elements of Learning Collaboratives and quality improvement strategies developed by the Institute for Healthcare Improvement (IHI) (36). These approaches emphasize the importance of collaboration and reinforce knowledge sharing, problem solving, and intervention oversight, creating a community of practice among stakeholders. The CTA model is being tested as an implementation strategy for scaling out and sustaining quality in the delivery of the YRI.

Implementation of the YRI is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) conceptual model (37). In this four-phased, multilevel framework, implementation determinants in the outer (system) and inner (organization) context, as well as bridging factors that work across the contexts, pull in the relationships among stakeholders in the implementation process (37). The EPIS framework was used to identify key supports needed within each phase while the CTA model specified the steps to achieve the supports while addressing challenges (35).

Hypothesis

By leveraging investments in youth and economic development programs and using CTAs to facilitate integration of mental health interventions within existing delivery platforms, LMICs with limited mental health care infrastructure can build capacity to address the mental health treatment gap.

There are three aims that guide Youth FORWARD:

AIM 1 (Implementation Impact Evaluation):

To utilize an innovative Collaborative Team Approach (CTA) to scaling and sustaining the YRI in terms of feasibility of this approach, facilitator preparedness and sense of satisfaction and impacts on fidelity and sustainment of delivery of the YRI.

AIM 2 (Implementation Process Evaluation):

To identify internal and external factors influencing the integration of the YRI into a youth employment promotion program (EPP) via a process evaluation documenting barriers and facilitators to effective implementation and integration.

AIM 3 (Clinical Effectiveness):

To compare clinical effectiveness of the YRI when delivered via the EPP platform to results of our previous randomized control trial (RCT) of the YRI as measured by improved mental health and reduced functional impairments among high-risk youth. Emotion regulation will be examined as a major mechanism by which the YRI improves behavior of treated youth and their functioning in the EPP.

Methods

Overview of Implementation Science Framework

The EPIS framework draws on five principles of system-wide implementation: 1) generating shared investment in implementation of evidence-based practices; 2) creating a process for incorporating local expertise within multiple organizations to build institutional knowledge; 3) optimizing resources to address known implementation challenges; 4) focusing on quality assurance and appropriate oversight within systems change; and, 5) developing an implementation structure that focuses on communication and workload sharing (37–39). Youth FORWARD chose this framework because it illuminates the key outer and inner factors within each phase to guide the implementation and sustainment of EBIs (Figure in online supplement). Models that rely heavily on remote expertise for training and ongoing fidelity monitoring have proven to be an obstacle to scaling and sustaining EBIs in LMICs as they fail to develop local expertise. To remove the need for remote expertise in training and oversight, Youth FORWARD uses the CTA to scale, sustain, and integrate an evidence-based mental health intervention into existing employment programming.

The CTA is adapted from the EPIS-guided Interagency Collaborative Team Approach, which focuses on collaboration as a key element for the implementation and sustainment of evidence-based practices into established service delivery systems (35). Within Youth FORWARD, collaboration primarily involves development of in-country expertise and capacity building directed at local service providers. Specifically, the CTA model creates a community of practice around an EBI through development of a Seed Team, a local unit of experts, to provide training, coaching and support as the intervention is scaled out. The Seed Team monitors and supervises new facilitators as they deliver the EBI while overseeing cross-site collaboration to expand institutional knowledge on best practices in EBI delivery.

Key CTA activities include: creation of a cross-site expert Seed Team; cross-site learning and routine communication; collection of process data for monitoring quality and illuminating barriers and facilitators; structured fidelity monitoring and targeted supervision; and, use of Plan-Do-Study-Act (PDSA) cycles to identify, analyze, and solve problems (40). Using collaborative teams and scaling across sites where lessons learned from one site can improve delivery in another site is a strategy to develop a culture of quality improvement and cross-site learning that can enhance inner and outer factors that reinforce sustainment.

Overview of Intervention

Youth Readiness Intervention.

The YRI is designed to assist youth facing complex problems using evidence-based treatments that have been tested and shown to be effective in addressing the mental health of violence-exposed youth in a range of settings and cultures (11, 41–42). The YRI has three goals: 1) develop emotion regulation skills for healthy coping; 2) develop problem-solving skills to assist with achieving goals; and, 3) improve interpersonal skills to enable healthy relationships and effective communication. It integrates six empirically-supported practice elements adapted from Cognitive Behavioral Therapy (CBT) that have demonstrated effectiveness across disorders ranging from major depressive disorder to anxiety and conduct disorders (42–44). The YRI is organized into twelve weekly 90-minute group sessions, delivered by same-gender lay facilitators to gender-matched groups supported by a robust training and supervision structure that can sustain best practices (42). Youth FORWARD’s key implementation partner, Caritas Freetown (hereafter Caritas), employs YRI experts who were trained by the YRI developers and worked as YRI facilitators in the prior RCT. YRI delivery is supported by fidelity monitoring via audio-recorded intervention sessions and direct observation, to bolster YRI facilitators’ skills and reinforce key YRI components, which is then integrated into individual and group supervision.

Youth Entrepreneurship.

Recognizing the challenges facing Sierra Leone and the need for delivery of mental health programming via well-established structures (Box 1), the YRI will be integrated within the youth Employment Promotion Programme (EPP) created by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ). GIZ has been working in Sierra Leone since 1963 and is keenly aware of the issues facing Sierra Leonean youth (45). The EPP responds to market demand within targeted districts through a needs-oriented approach, to ensure that youth can obtain the skills required for employment. The youth capacity development component of GIZ’s EPP includes several module-based focal points, including an entrepreneurship training (ENTR) program. Per input received from local communities, the ENTR program also includes a psychosocial competency module. GIZ uses a competitive bidding process to contract local service providers to deliver their programs in Sierra Leone. The ENTR training is delivered five days per week for three weeks.

Box 1. Key Challenges, Advantages, and Design Solutions of the Study.

Key challenges:

• Contextual challenges: a fragile health system affected by civil war and the EVD outbreak; weak governance structures and limited policy and financial supports for mental health; a fractured funding environment with little coordination of development actors; and, a fragile context that contributes to reticence from donors.

• Implementation challenges: limited human resources for mental health services; need for models to support strong training, supervision, fidelity, and sustainability of evidence-based practices that can be delivered by a lay workforce; and, a culture of short-term contracting for financing of youth employment programs directed at the most vulnerable rather than focused health systems strengthening.

Key advantages:

• Long-standing research in the region on youth issues (i.e. LSWAY) and understanding of culture and context, multi-institutional partnership leverages longstanding collaborative relationships, and shared commitment to expanding access to mental health services for vulnerable youth.

• Youth FORWARD integrated organizational structure fosters synergy, local ownership, and problem solving, which can contribute to sustainability.

• Youth FORWARD will examine elements critical for understanding how to maintain quality and fidelity in alternate delivery platforms of youth employment programs for delivery of evidence-based mental health services.

• Youth FORWARD will examine links between emotion regulation, daily functioning, and performance in employment/entrepreneurship programs as well as longer term economic self-sufficiency which is of high interest to development actors.

Design solutions:

• Flexibility of the intervention allowed for the delivery schedule to be modified to meet an accelerated timeline responsive to the needs of development partners.

• A staggered approach to intervention delivery across the three study sites allowed for the best use of resources between the service provider and research team.

• Cross-site learning strengthened a culture of quality improvement and prevented implementation challenges from being repeated across sites.

• The CTA approach built skills and expertise among a local Seed Team who can continue to train and supervise YRI implementation in new delivery settings.

Study sites

Youth FORWARD operates in rural areas of Sierra Leone given the presence of GIZ ENTR programming. As such, the pilot was delivered in one rural district (Kailahun) while the scale-out study is being conducted in three rural districts in eastern and northern Sierra Leone (Kailahun, Kono and Koinadugu). Districts in Sierra Leone are divided into chiefdoms and four chiefdoms per district have been selected to participate in the scale-out study. There is no overlap between chiefdoms from the pilot and scale-out study. Given their rural nature, study districts have limited internet connectivity, poor road infrastructure that can become impassible during rainy season, and economies that prioritize agricultural production and mining. Youth participating in the YRI may share skills learned with peers and community members, which could make it difficult to determine any differences that exist between the YRI+ENTR and ENTR-only study arms. Thus, study sites are situated at the community level and consider the location of youth clusters to avoid natural diffusion and spillover effects.

Study Procedures

Following the Exploration phase of the EPIS implementation science framework (37), the Youth FORWARD team negotiated with GIZ to use the evidence-based YRI for their psychosocial competency training module. The team established a Memorandum of Understanding for use of the YRI curriculum and training package delivered by the Caritas-based YRI experts to the GIZ contracted ENTR agency. The CTA included the following parties: YRI developers, YRI experts, YRI facilitators, and the Youth FORWARD team. Peripherally, GIZ, the contracted service provider agencies overseeing delivery of the YRI and ENTR program, and Caritas were also part of the CTA.

To prepare for training new YRI facilitators that would deliver the YRI for our pilot and scale-out studies, the YRI experts formed the Seed Team. As part of Seed Team responsibilities, the experts were trained in good practice principles to enhance learning and prepare them to facilitate YRI training and develop strong, competent YRI facilitators. They were also trained on the Youth FORWARD CTA model and EPIS framework. Lastly, they learned about the key CTA activities they would be expected to carry out and planned how they would do this in the field.

Pilot study.

A cluster randomized pilot feasibility trial with a quasi-experimental untreated control group was employed to pretest implementation science aspects of the study (i.e., use of CTA) and refine study assessments. In total, 175 youth (18–30 years old, 62% female) were enrolled. Participants were assigned to clusters stratified by chiefdom and training site location; clusters were randomized into: YRI+ENTR (n=58) or ENTR-only (n=57). A non-randomized, statistically matched untreated control group (n=60) was recruited from chiefdoms outside of GIZ’s current programming in Kailahun. Third-party reporters (n=120) reported on youth participants at two time points for a total pilot study sample size of 295 participants. Results from the pilot study demonstrate that an integrated YRI and ENTR, when delivered within the CTA with robust training and supervision by a Seed Team of experts is both feasible and acceptable (46). Mixed effects models indicated improvements in core mental health outcomes (e.g., emotion regulation, functioning) for treatment youth (YRI+ENTR and ENTR-Only) compared to matched controls (46). As a precursor to a well-powered scale-out study, the pilot also supported measures refinement; updating of study inclusion criteria and recruitment procedures given the rural location and demographic makeup of study districts; and, strengthening our partnership with GIZ, including adapting our communication and engagement structure for before and during program implementation.

Scale-out study.

For the scale-out study, a Hybrid Type II Effectiveness-Implementation cluster randomized three-arm trial is being employed guided by the EPIS framework. A total of 1,188 youth (18–30 years old, 47% female) were enrolled across these three districts, along with two agency leaders, 12 YRI facilitators, and 626 third-party reporters for a total sample size of 1,828 participants. Eligible youth were stratified into clusters based on geographic location and gender.

Clusters were then statistically matched into triads based on the following variables: age, sex, marital status, number of dependents, education, previous skill training, income generating activities, days and hours worked in the past month, WHO Disability Assessment Schedule (WHODAS) score, Difficulties in Emotion Regulation Scale (DERS) score, locality access to highway, characterization as a hub village, and locality population. Matched clusters were then randomized into the three study arms: 392 youth were clustered and randomized to control, 392 youth were clustered and randomized to ENTR-only, and 404 youth were clustered and randomized to YRI+ENTR. Data will be collected at baseline, post-YRI, post-ENTR, and 12-month follow-up. Remaining study activities include the collection of data at 12-month follow-up.

Scale-out study outcomes.

Primary outcomes of the scale-up study focus on intervention process and implementation variables according to the EPIS framework, including a costing analysis; fidelity to intervention protocol; and, the sustained delivery of the YRI within a CTA to enhance intervention delivery, training, and supervision. Secondary outcomes are emotion regulation skills, interpersonal skills, and functional impairment. A comparison of youth who receive the ENTR to those who receive the YRI+ENTR will determine whether the YRI adds value to the ENTR in terms of positive effects on emotion regulation and interpersonal functioning, and whether improvements influence economic self-sufficiency over time (Figure in online supplement; Detailed data collection plan in Appendix B in online supplement).

Scaling-out the YRI

Three YRI experts comprised the Seed Team and worked across each study district to ensure processes related to quality improvement (i.e., cross-site learning, fidelity monitoring) occurred as expected. There was a change in the service provision agency contracted by GIZ for the scale-out study which meant the Seed Team members added during the pilot study could not be part of the scale-out and a new cohort of YRI facilitators were trained.

During the Preparation phase, GIZ utilized community sensitization and newspaper and radio recruitment efforts to recruit youth to participate in the ENTR. Applications submitted to GIZ district-based offices were transferred to Caritas for review and digitization by research assistants (RAs). Caritas RAs then contacted and consented youth to be screened for eligibility. Criteria for youth eligibility included: male or female aged 18–30; disengaged from school; not pregnant; and elevated t-scores on the WHODAS and DERS. Locations of participant residence and ENTR training sites were used to determine arrangement of clusters. Statistically matched clusters of youth were randomized into one of three arms: control, ENTR, or YRI+ENTR (Figure in online supplement).

To evaluate post-YRI outcomes, a subsample of youth from the ENTR-only and YRI+ENTR study arms were administered a reduced assessment battery immediately post-YRI. We randomly selected clusters of youth from each treatment arm until we reached our desired sample size of 400 youth (200 youth from each treatment arm).

As the scale-out study utilized a staggered YRI roll out across study districts, YRI experts engaged in within-district problem solving and supervision to enhance YRI delivery. Seed Team members and other stakeholders including GIZ, Boston College (BC), and the implementation agency utilized a structured Terms of Reference to outline roles and responsibilities. This structure supports a community of practice around the YRI that prioritizes the use of problem solving processes such as PDSA cycles and cross-site learning that allow best practices to be shared and a culture of quality improvement to be institutionalized as part of YRI scale out. A process evaluation collected data on the implementation of the CTA and potential for sustaining quality improvement over time. Facilitators worked across training sites and participated in face-to-face and phone-based supervision. Facilitators also collected process data throughout the intervention and utilized supervision to engage in troubleshooting to create a feedback loop that, over time, enhances YRI delivery.

Analysis Strategy

Quantitative data will be analyzed using a multilevel modeling approach. To determine the effect of the YRI as delivered by facilitators within the ENTR, standardized mean difference between treatment conditions of approximately 0.3 for youth outcomes was assumed. An effect size of 0.3 is similar to what was observed in the YRI RCT (11). The scale-out study includes 1,188 subjects clustered and randomized into three arms (Control, ENTR-only and YRI+ENTR). Each arm included 20-clusters, for a total of 60-clusters. The power calculations assume two sex-segregated sub-groups of 10-participants each per cluster. A multilevel modeling approach (level one: time-point; level two: individual; level three: intervention group, level four: site) will be used to accommodate the potential loss of precision due to attrition (estimated to be a maximum of 20% at last follow-up). Power is estimated accommodating 10% attrition at the study midpoint. Under intent-to-treat, all subjects initially observed will be included in all analyses regardless of their participation in ENTR or YRI+ENTR. Multilevel models will investigate how youth outcomes differ between the YRI+ENTR group and the ENTR-only and control groups over time. A four-level multilevel model will be used to compare YRI+ENTR participants to those in the ENTR-only and control groups to assess whether there is greater change in mental and behavioral health outcomes in the YRI+ENTR groups.

Qualitative data will be analyzed using grounded theory (47) and an analytical strategy derived from thematic content analysis (48). Both qualitative and quantitative data will be synthesized to understand barriers and facilitators to using the CTA to deliver evidence-based mental health programming in Sierra Leone. These methods will allow us to examine areas of convergence or divergence in the data. If contradictions arise, we may examine qualitative/quantitative data on hypothesized associations to establish relationships that may be tested further (see Online Supplement for more detail).

Ethics Committee Approval

All participants provided informed consent prior to participation. Study approval was granted by the Institutional review board at BC, the Sierra Leone Ethics and Scientific Review Committee, with study monitoring oversight by an independent Data Safety and Monitoring Board.

Results

Analysis of data from the Hybrid Type II Effectiveness Implementation scale-out study includes three primary evaluations. An implementation impact evaluation guided by the EPIS framework will assess the use of the CTA to scale and sustain the YRI with a focus on feasibility, facilitator satisfaction and support, and fidelity to core YRI practices. An implementation process evaluation also guided by EPIS will identify internal and external factors influencing the integration of the YRI into the youth ENTR program via a process evaluation documenting barriers and facilitators to effective implementation and integration. A clinical effectiveness evaluation will compare YRI clinical effectiveness when delivered via the GIZ employment platform to results of a previous RCT of YRI as measured by improved emotion regulation and reduced functional impairments among high-risk youth.

The implementation and testing of the YRI as integrated into the GIZ-supported ENTR program via the CTA strategy is intended to improve the mental health and functioning of vulnerable Sierra Leonean youth while demonstrating the capacity for an EBI to be integrated into an alternate delivery platform. By demonstrating that the YRI can be delivered with fidelity and quality improvement by lay workers linked to ongoing employment/entrepreneurship programming and supported by the CTA strategy will provide evidence for further adoption and scale-out of the YRI using alternate delivery platforms in Sierra Leone and other LMICs.

Next steps

An opportunity exists to build capacity in fragile and conflict-affected regions by leveraging investments in youth economic development programs to integrate evidence-based mental health interventions therein. In such settings, innovations are needed to address the mental health treatment gap. Study findings will support efforts by the Government of Sierra Leone, development actors, local universities, human services agencies, and other partners to address human resources challenges and increase access to mental health services for youth.

Should the YRI as implemented under the CTA and linked to youth entrepreneurship programs demonstrate effectiveness on emotion regulation and functional impairment as well as follow on effects on ENTR program participation and economic self-sufficiency, this will strengthen the case for evidence-based mental health interventions in fragile settings. Data from this study can be used to identify elements of the EPIS framework and CTA influencing integration of the YRI into the ENTR and possible pathways for sustainment. Lessons learned can be applied in future efforts to scale out EBIs in post-conflict settings.

Supplementary Material

supplement

Figure: Social and political upheavals since gaining independence)

Figure: Application of EPIS Framework in Youth FORWARD)

Figure: Scale-out study aims and associated primary outcome measures)

Figure : Description of study arms)

Highlights:

• Innovative approaches, like alternate delivery platforms, including the integration of evidence-based interventions into youth entrepreneurship and employment programs, are needed to address the mental health treatment gap in fragile and post-conflict settings.

• A Collaborative Team Approach that utilizes targeted supervision and routine fidelity monitoring is a feasible way to ensure evidence-based interventions are delivered with fidelity to evidence-based components.

• Challenges faced in low- and middle-income countries require novel and creative approaches to problem solving that can inform the implementation of evidence-based interventions in less fragile, higher income countries.