Our quantitative research has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial. Service transformation is being evaluated across all 14 study sites via a minimum evaluation protocol (MEP). The MEP collects longitudinal data on service user outcomes, service context, processes and impact as well as service user and family outcomes over 3.5 years. It is designed to answer 6 hypotheses (outlined below).
Six of the 14 sites are participating in a stepped-wedge trial whereby the intervention (a service transformation along the key objectives) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves (randomization was stratified by population size).
Given the breadth of issues addressed, strategies deployed and populations targeted, we ask the following main questions in this study:
- How and to what extent does ACCESS Open Minds work to identify youth in need and improve their access to high-quality mental healthcare?
- Among which youth groups and in which contexts is the service transformation most and least beneficial?
These research questions are operationalized through well-defined primary and secondary objectives and related hypotheses.
To determine if the ACCESS Open Minds model:
- Increases early case identification
Hypothesis 1: There will be a significant increase in the number of youth seeking help at, or being referred to, study sites over the course of the project.
- Reduces systemic delay in responding to referrals/help-seeking
Hypothesis 2: The proportion of youth being offered an initial assessment by a trained clinician within 72 hours of referral/help-seeking will increase and be sustained at or above benchmark levels (once attained) over the course of the project.
- Reduces treatment delay (i.e., the delay between the initial evaluation and the commencement of appropriate treatment)
Hypothesis 3: Over the course of the project, a higher proportion of youth seeking services at sites will be offered appropriate care and/or interventions within 30 days (the Canadian Psychiatric Association’s benchmark) . For urgent cases, the guidelines recommend commencing treatment in less than 30 days. This will be examined separately for youth with and without serious mental illnesses.
To determine if the ACCESS Open Minds model:
- Simplifies pathways to mental healthcare
Hypothesis 4: Over the course of the project, youth will make fewer help-seeking contacts in the previous 12 months before accessing services at project sites.
- Improves outcomes for youth served at project sites
Hypothesis 5: The clinical, social-vocational and subjective functioning of youth will significantly improve over the course of their follow-up. An additional objective is to determine which outcome domains are most impacted by treatment. The lengths of follow-up will vary depending on youth’s needs, severity of illness, etc.
- Satisfies youth and their families
Hypothesis 6: At least 75% of service users and their families/carers will be satisfied with services and service providers at all completion time-points.
The aim of the qualitative study for ACCESS OM is to understand the implementation of youth mental health services across its sites. The study consists of a case study based on the ACCESS OM model which will explore how:
1) The ACCESS OM model was drawn upon in enabling stakeholders to define appropriate care in response to the mental health needs of their community,
2) Ties and relationships were forged between site staff members and service providers in their community,
3) Community-based practices were harnessed with the aim of transforming services and
4) The relationships and practices developed through the ACCESS OM initiative are being sustained.
Semi-structured interviews are currently being conducted with site staff members, ACCESS OM clinicians, site leads, community members, service providers, policy-makers, youth council members and family council members. Recruitment is on the basis of their role within their respective site and in implementing services at the site. In addition, documentation is being analyzed alongside stakeholder interviews. Youth and family members are also being interviewed in order to understand their experiences accessing services, in particular the ACCESS OM site in their community. We estimate that 120 interviews will have been conducted by April 2021, along with approximately between 20 to 30 interviews with youth and family members/carers. Interviews, which began in 2019, are still being conducted and analysis will be complete in late 2021-early 2022.
Qualitative Research: Photovoice study
Co-led with the ACCESS OM National Youth Council and National Family and Carers Council, ACCESS OM is also conducting a photovoice study in conjunction with the qualitative study. Photovoice is an arts-based methodology that allows participants to express themselves through photography. Members of the youth and family councils received research and photography training to work with youth participants at each of their ACCESS OM sites to take pictures that reflect the youth’s story and lead discussion groups on the meanings behind the images. The images will be presented in an online art exhibit to highlight the work and stories of the participants from across Canada.
Economic evaluations are being undertaken at three sites that represent different facets of the Canadian landscape: urban (Edmonton, AB), semi-urban (Chatham-Kent, ON), and Indigenous (Eskasoni First Nation, NS). The aim of these studies is to place the project’s goals of bringing more youth into appropriate care, faster, alongside the additional costs involved in the service transformation. The hope is that these analyses will provide the youth mental health community, funders and policy-makers with additional knowledge regarding what can be achieved with additional, sustainable investments in this area.
Youth Mental Health Services: Promoting Wellness or Treating Mental Illness?
Authors: Ashok Malla, Alyssa Frampton and Bilal Issaoui Mansouri
In this report, we argue that promoting wellness is very different from treating emerging and prevalent MHSU disorders among youth, that each requires a special system equipped with a set of disciplines and skills for their operations, and that each must involve evidence-informed practices to be supported as different funding envelopes. It is not our intention to engage in a philosophical or scientific discussion around the concept of wellness but to focus on its practical implications for mental health services. We also acknowledge that the indigenous concept of wellness may be quite different and more inclusive than the one we address here.
Experiences of stigma related to mental illness among youth in three New Brunswick communities
Authors: Carole C. Tranchant, Penelopia Iancu, Anik Dubé, Laure Bourdon, Lacey Clair, Danielle Doucet, Anne Dezetter, Sophie Robichaud, Julie Malchow, Aduel Joachin and Ann M. Beaton
This study aims to understand how youth who receive mental health (MH) services perceive stigma related to mental illness and how this was experienced during their trajectory toward care and recovery. Discussion groups were carried out with 25 youths in three New Brunswick communities (remote Indigenous, rural Francophone and urban Anglophone). Thematic analysis reveals that youth’s experiences of stigma reflect various forms of discrediting as well as differential, dehumanising treatment, which lead them to look for stigma-free alternatives that better meet their needs. This shows that youth actively select their options for MH support depending on the stigma they perceive. Results also show important socio-cultural nuances with regards to youth’s experiences and to the strategies and factors that enable or mitigate stigma. Their accounts hold valuable lessons for destigmatizing mental illness and the access to youth MH services for different cultural groups.
A minimum evaluation protocol and stepped-wedge cluster randomized trial of ACCESS Open Minds, a large Canadian youth mental health services transformation project
Authors: Srividya N. Iyer, Jai Shah, Patricia Boksa, Shalini Lal, Ridha Joober, Neil Andersson, Rebecca Fuhrer, Amal Abdel-Baki, Ann M. Beaton, Paula Reaume-Zimmer, Daphne Hutt-MacLeod, Mary Anne Levasseur, Ranjith Chandrasena, Cécile Rousseau, Jill Torrie, Meghan Etter, Helen Vallianatos, Adam Abba-Aji, Shirley Bighead, Aileen MacKinnon & Ashok K. Malla
Many Canadian adolescents and young adults with mental health problems face delayed detection, long waiting lists, poorly accessible services, care of inconsistent quality and abrupt or absent inter-service transitions. To address these issues, ACCESS Open Minds, a multi-stakeholder network, is implementing and systematically evaluating a transformation of mental health services for youth aged 11 to 25 at 14 sites across Canada. The transformation plan has five key foci: early identification, rapid access, appropriate care, the elimination of age-based transitions between services, and the engagement of youth and families.
The ACCESS Open Minds Research Protocol has multiple components including a minimum evaluation protocol and a stepped-wedge cluster randomized trial, that are detailed in this paper. Additional components include qualitative methods and cost-effectiveness analyses. The services transformation is being evaluated at all sites via a minimum evaluation protocol. Six sites are participating in the stepped-wedge trial whereby the intervention (a service transformation along the key foci) was rolled out in three waves, each commencing six months apart. Two sites, one high-population and one low-population, were randomly assigned to each of the three waves, i.e., randomization was stratified by population size. Our primary hypotheses pertain to increased referral numbers, and reduced wait times to initial assessment and to the commencement of appropriate care. Secondary hypotheses pertain to simplified pathways to care; improved clinical, functional and subjective outcomes; and increased satisfaction among youth and families. Quantitative measures addressing these hypotheses are being used to determine the effectiveness of the intervention.
Data from our overall research strategy will help test the effectiveness of the ACCESS Open Minds transformation, refine it further, and inform its scale-up. The process by which our research strategy was developed has implications for the practice of research itself in that it highlights the need to actively engage all stakeholder groups and address unique considerations in designing evaluations of complex healthcare interventions in multiple, diverse contexts. Our approach will generate both concrete evidence and nuanced insights, including about the challenges of conducting research in real-world settings. More such innovative approaches are needed to advance youth mental health services research.
Special Issue: ACCESS Open Minds: Transforming Youth Mental Health Services Across Canada
Supplementary Articles from ACCESS Open Minds Sites
Improving mental health services for homeless youth in downtown Montreal, Canada: Partnership between a local network and ACCESS Esprits ouverts (Open Minds), a National Services Transformation Research Initiative
Amal Abdel‐Baki, Diane Aubin, Raphaël Morisseau‐Guillot, Shalini Lal, Marie‐Ève Dupont, Pasquale Bauco, Jai L. Shah, Ridha Joober, Patricia Boksa, Ashok Malla, Srividya N. Iyer
Transforming child and youth mental health care: ACCESS Open Minds New Brunswick in the rural Francophone region of the Acadian Peninsula
Anik Dubé, Penelopia Iancu, Carole C. Tranchant, Danielle Doucet, Aduel Joachin, Julie Malchow ,Sophie Robichaud, Martine Haché, Isabelle Godin, Laure Bourdon, Jimmy Bourque, Srividya N. Iyer, Ashok Malla, & Ann M. Beaton
Improving youth mental wellness services in an Indigenous context in Ulukhaktok, Northwest Territories: ACCESS Open Minds Project
Meghan Etter, Annie Goose, Margot Nossal, Jessica Chishom‐Nelson, Carly Heck, Ridha Joober, Patricia Boksa, Shalini Lal, Jai L. Shah, Neil Andersson, Srividya N. Iyer, & Ashok Malla
Eskasoni First Nation’s transformation of youth mental healthcare: Partnership between a Mi’kmaq community and the ACCESS Open Minds research project in implementing innovative practice and service evaluation
Daphne Hutt‐MacLeod, Heather Rudderham, Arnold Sylliboy, Mallery Sylliboy‐Denny, Linda Liebenberg, Jeannine F. Denny, Matthew R. Gould, Norma Gould, Margot Nossal, Srividya N. Iyer, Ashok Malla, & Patricia Boksa
Transforming youth mental health care in a semi‐urban and rural region of Canada: A service description of ACCESS Open Minds Chatham‐Kent
Paula Reaume‐Zimmer, Ranjith Chandrasena, Ashok Malla, Ridha Joober, Patricia Boksa, Jai L. Shah, Srividya N. Iyer, & Shalini Lal
ACCESS Open Minds at the University of Alberta: Transforming student mental health services in a large Canadian post‐secondary educational institution
Helen Vallianatos, Kevin Friese, Jessica M. Perez, Jane Slessor, Rajneek Thind, Joshua Dunn, Jessica Chisholm‐Nelson, Ridha Joober, Patricia Boksa, Shalini Lal, Ashok Malla, Srividya N. Iyer, & Jai L. Shah
Canadian response to need for transformation of youth mental health services: ACCESS Open Minds (Esprits ouverts)
Authors: Ashok Malla, Srividya Iyer , Jai Shah, Ridha Joober Patricia Boksa , Shalini Lal, Rebecca Fuhrer, Neil Andersson, Amal Abdel-Baki, Daphne Hutt-MacLeod, Ann Beaton, Paula Reaume-Zimmer, Jessica Chisholm-Nelson, Cécile Rousseau, Ranjith Chandrasena, Jimmy Bourque, Diane Aubin, Mary Anne Levasseur, Ina Winkelmann, Meghan Etter, Jill Kelland, Caroline Tait, Jill Torrie, Helen Vallianatos, ACCESS Open Minds Youth Mental Health Network
Aim: Youth mental health is of paramount significance to society globally. Given early onset of mental disorders and the inadequate access to appropriate services, a meaningful service transformation, based on globally recognized principles, is necessary. The aim of this paper is to describe a national Canadian project designed to achieve transformation of mental health services and to evaluate the impact of such transformation on individual and system related outcomes.
Method: We describe a model for transformation of services for youth with mental health and substance abuse problems across 14 geographically, linguistically and culturally diverse sites, including large and small urban, rural, First Nations and Inuit communities as well as homeless youth and a post-secondary educational setting. The principles guiding service transformation and objectives are identical across all sites but the method to achieve them varies depending on prevailing resources, culture, geography and the population to be served and how each community can best utilize the extra resources for transformation.
Results: Each site is engaged in community mapping of services followed by training, active stakeholder engagement with youth and families, early case identification initiatives, providing rapid access (within 72 hours) to an assessment of the presenting problems, facilitating connection to an appropriate service within 30 days (if required) with no transition based on age within the 11 to 25 age group and a structured evaluation to track outcomes over the period of the study.
Conclusions: Service transformation that is likely to achieve substantial change involves very detailed and carefully orchestrated processes guided by a set of values, principles, clear objectives, training and evaluation. The evidence gathered from this project can form the basis for scaling up youth mental health services in Canada across a variety of environments.
Take a look through our complete list of publications in our Resources section here.