Evergreen: Creating a Child and Youth Mental Health Framework for Canada

Approximately one million young Canadians experience a mental disorder requiring professional care, although most do not receive needed services (1,2). Barriers to care include inadequate quantity, type, and distribution of mental health services; lack of appropriate services in primary care; long waiting lists for specialty care; and lack of child and youth mental health policies (3–5).

Lack of a national mental health strategy has contributed to a patchwork of services across Canada’s provinces and territories (5,6) and has hampered Canada’s ability to gather national data related to access, common care processes, and outcomes (6). Cognizant of these challenges and in order to help inform and assist policy makers, the Child and Youth Advisory Committee (CYAC) of the Mental Health Commission of Canada (MHCC) created the Evergreen Framework (7), a mental health framework for Canada’s children and youths.

Evergreen: purpose and overview of development process

Evergreen is a mental health framework designed to be a resource for policy makers across Canada to help inform and assist them in their development of child and youth mental health care. Evergreen is the first national mental health framework to be developed in Canada. Different from a national strategy, the Evergreen framework does not prescribe what provincial and territorial child and youth mental health policies must contain. Rather, it provides a set of values and strategic directions that can be adapted to various locations and fiscal realities to inform the development, implementation, and review of child and youth mental health policies, plans, and services across Canada (7). This distinction is important in the Canadian context because health care is primarily a provincial responsibility, whereas the role of the federal government is limited to the terms of the Canada Health Act, including the provision of transfer payments to the provincial and territorial governments (8,9).

Evergreen was developed by integrating public input with expert opinion developed outside usual jurisdictional authority (that is, outside provincial and territorial government health policy development processes), with the aid of a variety of novel online technologies. In phase 1 of development, several working committees were created and technologies were harnessed to enable input to be sought nationwide and to enable documents to be drafted online. An online resource library of materials relevant to child and youth mental health policy was developed and posted to help inform public and committee input.

Phase 2 identified and confirmed Evergreen’s values. These were elicited by seeking input from the Canadian public and through committee interactions and focus groups conducted at two national conferences. Six values emerged from this phase, labeled in Evergreen as “human rights”; “dignity, respect, and diversity”; “best available evidence”; “choice, opportunity, and responsibility”; “collaboration, continuity, and community”; and “access to information, programs, and services” (7). A summary of Evergreen’s six values, including a description of what each value entails, can be accessed online at www.mentalhealthcommission.ca/SiteCollectionDocuments/family/Evergreen_Framework_Summary_ENG.pdf.

Phase 3 involved online public input, intercommittee interactions, and an expert review of mental health policies at provincial and territorial, national, and international levels to identify strategic directions (strategies, initiatives, unique programs, services, and activities) that were consistent with Evergreen’s values and deemed relevant and possibly useful to policy makers’ development of child and youth mental health policies, plans, and activities. These strategic directions were organized into categories, which included promotion, prevention, intervention and ongoing care, and research and evaluation (7). A complete listing of the strategic directions, including example strategies, can be accessed in the online version of the full Evergreen Framework at www.mentalhealthcommission.ca\SiteCollectionDocuments\family\Evergreen_Framework_English_July2010_final.pdf.

All online input provided by the Canadian public was made available to Evergreen’s committees as raw data (verbatim, from online responses to the survey) and as a synthesized thematic report produced by Evergreen’s coordinator. This synthesis was informed by qualitative research methods drawing upon grounded theory (10,11) and used N*Vivo, qualitative research software to organize and manage narrative inputs. A full discussion of these methods is beyond the scope of this Open Forum and is described elsewhere (McLuckie A, Alaggia R, Kutcher S, unpublished manuscript, 2012). A Youth Advisory Committee (YAC) solicited input from young people through a youth-specific engagement strategy primarily utilizing social media.

Evergreen’s development process

Committee recruitment, composition, and functions

A multiwave recruitment process was used to form Evergreen’s committees. The Drafting Committee (DC) chair and CYAC members nominated potential committee members. After a search of youth mental health institutions and organizations for possible candidates, snowball recruiting procedures were used to recruit diverse committee membership (in terms of age, culture, place of residence, professional background, and personal and parental experience with mental illness). Potential International Advisory Committee (IAC) members were recruited through the DC chair’s contacts with the World Health Organization and the Pan American Health Organization. Members of Evergreen’s YAC were recruited from similar committees from mental health services across Canada, including the MHCC National Youth Advisory Council.

Evergreen was written by the 25-member DC with input from the 100-member National Advisory Committee (NAC), the 25-member IAC, and the eight-member YAC. Committees comprised individuals with national or international expertise in child and youth mental health, health care, child welfare, human rights, culture and media, economics, First Nations issues, and education. Young people, parents, and individuals with personal mental health experience (for example, an individual living with a mental illness or a diagnosed mental disorder) were included in each committee apart from the IAC, which was composed of international professionals with expertise in child and adolescent mental health. DC members cowrote drafts of Evergreen using a Wiki within Socialtext, a Web-based computer program well suited for online collaborative projects. NAC, YAC, and IAC members could post comments on the various drafts visible to all members within the Socialtext online Wiki workspace and could read the public inputs in raw and synthesized formats, as described above. However, NAC, YAC, and IAC members were not provided access to directly alter the document within the online Wiki workspace; this ability was reserved for members of the DC.

Communication among DC, IAC, NAC and YAC members was facilitated with the tools available in the Socialtext online workspace, including discussion board functions (that is, posting comment threads), Twitter-like functions (allowing short messages to be shared between committees or between specific committee members), and a Facebook-like function that allowed group members to post their pictures, areas of interest, affiliations, and contact numbers and that showed a history of interactions with the group and contributions made to the Evergreen document.

An online library was also created within the Socialtext workspace, where documents could be easily uploaded by committee members and downloaded to help inform their writing or commentary regarding Evergreen. This library was cocreated within the Socialtext workspace with seminal publications suggested by committee members and documents relevant to child and youth mental health policy and obtained from national and international sources. Committee members could easily upload and download items to the online library to help inform their writing or commentary regarding Evergreen. The library was also made available to committee members and the public via Box.net (a file storage and sharing Web site) and can still be accessed through www.teenmentalhealth.org.

Public input

Input was sought from the public through requests sent to various mental health and human services organizations (such as the Canadian Mental Health Association), professional associations (such as the Canadian Academy of Child and Adolescent Psychiatry), parent groups (for example, the F.O.R.C.E. Society for Kids’ Mental Health [Families Organized for Recognition and Care Equality]), youth groups (including the Boys Club and the Girls Club), Web sites relevant to child and youth mental health (www.mindyourmind.ca), a Facebook group (Help Canada Create a Youth Mental Health Strategy), traditional media (such as Today’s Parent magazine), and networks known to committee members. Links to an online survey were embedded in all requests to participate so that individuals could provide input regarding Evergreen directly, without involving the organization or portal through which they had received the invitation.

The youth-specific input strategy for Evergreen included hiring a youth engagement coordinator, who contacted mental health youth groups across Canada and established with the YAC a “community champions” approach to engaging Canadian youth in the development of Evergreen. Specifically, the youth coordinator and members of the YAC would engage with young people in or near their home communities and with youths in online communities (that is, through a Facebook group) to inform them of the opportunity to provide input to Evergreen. The YAC also suggested specific popular youth-friendly Web sites (including www.mindyourmind.ca) where online survey links could be hosted to garner youth input. The YAC coordinator also made regular Facebook posts that included embedded links to the survey to engage youths and emphasize their opportunity to provide input via the survey.

Over 2,000 Canadians (N=2,196) from all provinces and territories provided online input (rural, 28%; urban, 70%; First Nations communities, 2%). Online participants included family members, parents, caregivers (13%), health and social service professionals (40%), educators (16%), government officials (2%), youths (13%), and a category referred to as other (16%) that represented a range of participants. Of the 13% of youth respondents, 68% reported personal experience with mental illness. Participants were invited to provide their e-mail addresses to receive a copy of Evergreen, which they had helped create with their input, and to build a public distribution network for the document.

Research-informed mental health framework development

Public input into mental health policy development often includes substantial input from organizations and institutions. We specifically sought input from individuals rather than organizations and institutions because persons not represented by such interests can experience considerable barriers to participation in traditional public consultation processes (such as capacity to prepare written briefs and attend hearings).

Evergreen also aimed to decrease potential bias in data collection and analysis by drawing on qualitative research methods consistent with a grounded theory approach (10,11). For example, raw data entered by the public into Opinio, an online survey program, were exported verbatim into N*Vivo, qualitative research software useful for conducting thematic analyses. The raw public input and synthesized documents (that is, raw materials distilled into key themes) were made available to members of all committees, not only to those charged with drafting the document. In addition, the distribution of a draft version of Evergreen’s values component for public endorsement demonstrates an iterative process that respected public participation.

Novel technologies and framework development

Our experience suggests that current online technologies, such as Socialtext and online survey programs, allow for meaningful and cost-effective public input into development of health frameworks and health policy. Online technologies such as Wiki offer policy and program developers tools for an informed, transparent, and time-efficient iterative drafting process.

Online technologies such as Socialtext and Box.net may allow for immediate, wide, and cost-effective access to documents. Evergreen’s use of these online tools demonstrates the feasibility of providing the public with easily accessible information that it can use to shape the input into mental health framework or policy development. For example, through Box.net, participants were able to immediately access numerous human rights documents endorsed by the Canadian federal government that could be used to help inform input into Evergreen’s values related to human rights.

Use of these technologies also may increase individuals’ access to health care policy and program consultations, especially for those residing in rural or isolated communities. For example, about one-quarter of those who participated in Evergreen’s online consultation resided in rural, remote communities (7). This proportion closely matches Canada’s demographic makeup, with 80% of the population residing in an urban setting (12). This process also demonstrated that qualitative research methods, such as grounded theory, and research tools, such as N*Vivo, can guide the analysis of public input. Use of such methods may reduce the bias within policy development processes compared with traditional methods of analyzing public input. Policy makers may wish to consider these approaches in the future because they harness new technologies that will, over time, be consistent with novel but increasing online methods of public discourse.

Conclusions

To our knowledge, Evergreen is the first national child and youth mental health framework developed largely online and informed by qualitative research methods. It is also Canada’s first national child and youth mental health framework. Evergreen was developed in a manner that took steps to decrease bias in the interpretation of public input by using established qualitative research methodologies; by engaging a broad spectrum of document drafters, including experts in child and youth mental health from a diverse range of professional backgrounds and parents and youths with personal experience with mental illness; and by using transparent and collaborative document development, including the use of a Wiki writing process involving national and international input.

A variety of novel online communication and document development tools were used, including Socialtext. Evergreen’s online consultation process not only encouraged diverse public input but also provided for public confirmation of its values and created a built-in public distribution network so that those who participated in the online consultation would receive the completed document.

Evergreen was also financially responsible; its development cost was less than $125,000 CDN, including staff salary, Socialtext and N*Vivo software, teleconference calls, translation, and travel to two national conferences. Although the process described above was applied to the creation of a national child and youth mental health framework, we propose that others may consider a similar process, to inform the creation of many different types of health and social policies.