Expanding established knowledge translation networks to respond to a community in distress
Laura Simich, Centre for Addiction and Mental Health and the University of Toronto
Joanna Anneke Rummens, The Hospital for Sick Children and the University of Toronto
Morton Beiser, University of Toronto
In the wake of the devastating 2004 tsunami, a group of concerned scientists, physicians and community leaders formed a local distress relief network to provide information, referral, and care to the affected Toronto Tamil community. This initiative was made possible by a previous community-based survey of Tamil mental health needs, which produced both valuable findings and, more importantly, resulted in a respectful and enduring university-community partnership. In a time of crisis, these established knowledge translation (KT) networks enabled the rapid development of activities to promote knowledge exchange on culturally appropriate service provision, provider-community networking, and mutual aid among service providers.
The tsunami of December 26, 2004 was a catastrophe for countries rimming the Indian Ocean. It also had a devastating impact on people from affected communities living elsewhere in the world. Not one of the 160,000 Sri Lankan Tamils living in Toronto, watching and listening to the news and worrying about friends and family in their home country, was left untouched.
Over the last few decades, Toronto has become home to the largest Tamil diaspora in the world. Toronto Tamils form a well-educated and civic-minded newcomer community. Often arriving as asylum seekers, most have become Canadian citizens and are enjoying some degree of economic well-being in Canada. However, as is often the case with immigrants and refugees, many Tamils are separated from immediate and extended family for long periods of time, face under-employment and lower than average household incomes, and experience language barriers that hinder their employment prospects and access to public services. Members of the community are also still dealing with the effects of displacement and exposure to traumatic events in Sri Lanka during the country's twenty-year civil war.
This case describes a joint academic-community effort to provide psychosocial support to Toronto's Tamil community in the wake of the tsunami. Our initiative was made possible by a recently completed mental health study with the community. The findings from the study, and the existing university-community research partnership, provided the foundation for effective knowledge exchange, sharing of respective expertise and resources and increased public awareness of local mental health needs at a time of heightened need. The initiative, the Local Distress Relief Network (LDRN), provides an example of effective KT and community empowerment, and contributes to the development of policy and practice guidelines for culturally appropriate health-related interventions with ethnocultural communities in Canada.
The KT initiative
The original mental health study, entitled "A Community in Distress," was initiated when Tamil community leaders, concerned about mental health in their community, approached Dr. Morton Beiser to join with them in an effort to document mental health problems, associated risks, protective factors, help-seeking patterns and perceptions of health care. The epidemiological survey of 1,600 adult Tamils between 2000 and 2004 was planned and overseen by an executive group that included university researchers and Tamil community leaders, and supported by CIHR funding.
The findings from this study meant that when the tsunami hit, we already knew that 12% of the Tamil population was suffering from post-traumatic stress disorder (PTSD)—a rate not unusual for refugees, but considerably higher than for the general population. We also knew that mental health services in Toronto were insufficient and rarely culturally appropriate. Only one-in-ten Tamils with PTSD had received any form of support.1 How could people who had already experienced so much trauma cope with this new tragedy? Could anything be done to prevent re-traumatization?
Jointly initiated and led by Drs. Anneke Rummens and Laura Simich, a group of concerned scientists, physicians, Tamil community leaders, scholars, and service providers formed an informal network of individuals to focus collective efforts on what we called local "distress relief." The network aimed to offer a much-needed forum for information exchange on culturally appropriate service provision, provider-community networking, professional referrals, and mutual aid among service providers in Toronto. The foundation of the network was the partnership between university-based academics and representatives from the many Tamil service organizations that formed the core of the mental health study's community advisory group.
Once launched, the LDRN expanded rapidly. The first face-to-face meeting drew nearly 50 people from diverse sectors, including community health centres, hospitals, public schools, Tamil and multi-ethnic community-based organizations, municipal public health offices, and academia. Bracketing these collective relief efforts, the research team sponsored forums for community members and service providers during which they presented initial findings from the survey of Tamil mental health.
KT was effective because it was community-based and driven by the articulated needs of the community itself, with health researchers and professionals playing a supporting role.
In its first five months, LDRN activities included several collaborative efforts that reached across different sectors. First, we prepared, translated and distributed culturally appropriate mental health promotion materials at an important community vigil, through local service organizations and via the Internet. In collaboration with the Settlement Workers in Schools program, a carefully-prepared letter was directly distributed to teachers in elementary schools with large Tamil student bodies to inform them about the community's concerns and responses to the disaster. Citizenship and Immigration Canada provided $50,000 for Tamil translation and distribution of 5,000 photo-novellas on PTSD and depression previously available only in Canada's two official languages.
In addition, the CIHR Institute of Health Services and Policy Research provided workshop funding to bring together international trauma and mental health experts, Toronto Tamil health and settlement service providers and physicians, and public health agency officials. This group of experts discussed the current international mental health debate over the role of trauma counselling in community-based, culturally appropriate distress relief, and reached consensus on its implications for health policy and practice in Canada. Workshop participant Dr. Jack Saul, founding director of the International Trauma Studies Program at New York University, remarked that the LDRN workshop was one of the most outstanding examples of community-based response to trauma he has ever witnessed.
Results of the KT experience
The network significantly increased the level of information exchange and mutual support among its members. KT was effective because it was community-based and driven by the articulated needs of the community itself, with health researchers and professionals playing a supporting role. The mandate and activities of the network also informed the tsunami response of several other organizations, including university departments and municipal emergency response units.
The LDRN's school-based initiatives were particularly critical and appreciated. The new photonovellas have not yet been evaluated, but they are likely to be a welcome resource because so little mental health literature is available in translation. Proceedings of the expert workshop, containing policy, practice and research recommendations, are currently being prepared for dissemination.
It is too early to tell if there will be systemic infrastructural changes in terms of hospital services or government policies. We recognize that it will take more time to engage wider institutional support in order to ensure that mainstream institutions become more responsive to diverse communities during crisis situations, and also more generally.
Looking ahead, a small working group of mental health professionals from the network have begun to find ways to support Tamil community-based service providers in the long term. They are hoping to develop collaborative funding proposals for more sustained mental health services for Tamils in Toronto. Other members are focused on community and/or institutional capacity building. Several have also become involved in information exchanges and planning for increased mental health worker training in Sri Lanka.
Our original mental health study had, from the outset, created mechanisms to ensure the translation of research knowledge to community members and service providers. The LDRN accomplished its objectives because we were able to rely on those established working relationships.
We did not, however, expect to be taking part in responding to an emergency and there were some disadvantages to a lack of advance planning. As is the case for much KT work, there was very little institutional infrastructure to draw upon. Without dedicated administrative or substantial institutional support, we relied extensively on volunteered personal time and virtual networking and were profoundly grateful for the moral and practical support provided from the departments of Psychiatry and Public Health Sciences at the University of Toronto.
A key challenge faced by the network was identifying community-based Tamil service providers who had the resources to respond to public inquiries that might result from distribution of health promotion leaflets. This again speaks directly to the need for infrastructural support mechanisms—including skilled personnel—for such outreach initiatives.
Conclusions and implications
This case study demonstrates the importance of making the relationships underlying KT a regular part of research, and shows their power to enhance health system responsiveness and to meet both identified and unanticipated health needs. The LDRN helped shape an effective and rapid response to the tragedy, may have helped alleviate individual psychological suffering and created new possibilities for ongoing KT to address public health needs.
The LDRN helped shape an effective and rapid response to the tragedy, may have helped alleviate individual psychological suffering and created new possibilities for ongoing KT.
According to Raymond Chung, executive director of Hong Fook Mental Health Services, "There is no one formula for working with all immigrant communities, but there is a need to grow alongside the community." The development of the LDRN demonstrates the potential of partnerships with transnational immigrant communities in healing, rebuilding, and providing sustainable health care for under-serviced ethnocultural communities. Increasingly, learning to put research to good use requires increased awareness of the importance of global ties both for diaspora communities and for Canada itself.
However, one KT barrier remains: identifying additional partners in the public policy sector. Despite Canada's much-vaunted commitment to multiculturalism, there are few places in government where health and cultural diversity intersect. In this particular case, the researchers' connections with community members and service providers were much stronger than that with policy makers. For systemic changes to occur, decision makers from other sectors will need to be involved in future initiatives.
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