Strengthening efforts to integrate mental health into primary health care in Chile: Lessons from an international collaboration process
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(2) 88 INTERNATIONAL JOURNAL OF MENTAL HEALTH. as recognition grows that sound mental health, which includes being free from substance abuse and concurrent disorders, is a fundamental component of people’s overall health and well-being. A more central role for primary health care has also emerged in large part because it provides an opportunity to improve people’s mental health by offering comprehensive care from health promotion to early recognition, diagnosis, treatment, and rehabilitation. Integrating mental health into primary health care has many advantages for improving care and reaching better outcomes, such as reduction of stigma and discrimination, better access to integrated and continuing care, and improvement of social integration. Chile has been a country at the forefront of the process of integrating mental health into primary health care. Reciprocal collaboration and knowledge exchange have been critical to its change process. Canada’s Centre for Addiction and Mental Health (CAMH) has been collaborating with Chile since 2003 to build capacity in primary health care from a system’s approach. This article reviews the process and results of the collaboration between CAMH, through its Office of International Health, and different institutions in Chile aimed at strengthening mental health and addiction services in primary health care. Some key lessons learned and implications for the future are identified and discussed. Addressing mental health, including mental and substance use disorders, through primary health care (PHC) has become a central tenet of international mental health discourses. Like many countries in Latin America and the Caribbean, Chile is working to foster its health system and to better address the population’s mental health needs, strengthening accessibility, quality of care, and health promotion. Chile has acted on the recognition that the community care approach fosters the development of strong health networks and is aligned with internationally recognized best practices for mental health and addiction care. The fact that Chile has initiated a wide range of international collaborative initiatives attests to the leadership role the country is taking in Latin American mental health reform. As such, Chile is a model for other governments in the region that are moving toward integrating mental health into PHC. The Centre for Addiction and Mental Health (CAMH), a Pan American Health Organization/World Health Organization (PAHO/WHO) collaborating center, has recognized a leadership responsibility to share knowledge and expertise with international colleagues, serving those who are most in need of mental health and addiction services around the globe. CAMH established an Office of International Health in 2002 to work with partners around the world with the goal of enhancing mental health care through sustainable capacity building and knowledge exchange. CAMH and various Chilean institutions have been working together for almost 9 years on a capacity-building partnership for mental health in PHC. This collaboration has proven to be ideal as each partner has contributed unique knowledge and skills and gained unanticipated benefits from the mutual learning. Such experience would provide a strong foundation for subsequent international collaborations..
(3) spring 2012. 89. This article reviews the process and results of the collaboration between CAMH and its Chilean partners. The authors base their analysis on a systematic review of the documents produced throughout the partnership, such as collaborative agreements, needs assessments, training agendas, participant evaluations, external evaluations, and symposium reports. The best practice literature is used as a framework for analysis. The background of international mental health work is first outlined. Second, the process and key initiatives of the partnership are described. Third, the overall experience of participating in this collaborative process is discussed, identifying some key lessons learned and their implications for the future. Background Mental Health in Primary Health Care International Focus More than 30 years after the emblematic WHO-UNICEF Conference in Alma-Ata [1], a worldwide movement has developed to strengthen mental health in PHC [2, 3]. A recent report [4], for instance, outlined seven reasons to offer mental health care in PHC, including the interconnection between mental and physical health problems, the significant mental health treatment gap, and the need for increased access, human rights promotion, and cost-effectiveness. This is best delivered in an interprofessional context, given the level of complexity and the need to optimize the expertise of the primary care clinicians [5]. PHC is now considered a critical strategy with which to reduce service gaps in mental health by offering comprehensive care from health promotion to early recognition, diagnosis, treatment, and rehabilitation. In this article, the authors apply a broad definition of PHC reflected in the principles of the Alma-Ata Declaration and consistent with the community-based approach now widely advocated. Many people with serious medical problems who get their regular treatment from PHC also have comorbid mental and/or substance use issues [4]. Although the majority receive regular treatment from their PHC team, few are getting mental health services. Such a pattern is striking given the growing evidence that good mental health outcomes can be achieved, especially when PHC teams work with collaborative care models that include, for example, mental health specialists performing consultation/liaison activities. Focus on the Americas PAHO has also made integrating mental health into PHC a main priority for the Americas. A combination of rapid population growth and globalization has fuelled an increasing need for mental health services across the region that far exceeds local resource capacities [6]. Expectations have also grown throughout Latin America.
(4) 90 INTERNATIONAL JOURNAL OF MENTAL HEALTH. and the Caribbean because of a number of significant agreements that moved the regional mental health agenda forward. The PAHO Caracas Declaration of 1990 aimed to promote the civil and human rights of people with mental illness and to restructure mental health service delivery with a focus on PHC [7]. More recently, PAHO released the Strategy and Plan of Action on Mental Health for the Americas [8] and the Strategy on Substance Use and Public Health [9], each emphasizing the need to integrate mental health into PHC. The process was outlined in a recent PAHO publication [10], and its implications for collaboration were also discussed at a 2011 International Symposium coorganized by CAMH, PAHO, and the Department of Psychiatry at the University of Toronto [11]. International Collaboration/Partnerships International collaborative efforts are becoming increasingly important and prevalent on the global stage, with a focus on the shared learning and the dissemination of best practice principles [12, 13]. CAMH considers five factors as the pillars of effective global mental health work: reciprocity, sustainability, holistic health, cultural competence, and the improvement of overall health and quality of life. Reciprocity and respectful relationships are instrumental in overcoming the challenges of international collaboration. Without these two elements, partnerships are less effective [14]; trust and respect have to be built over time, and the value of each partner must be acknowledged [14, 15]. Chilean Focus Both the opportunities and the barriers for developing effective collaboration are highly context specific [16]. The Chilean context is complex and must be considered when implementing mental health reform. Chile has a high rate of mental health issues [17, 18]. Nearly one-third of the population has had a psychiatric disorder in their lifetime and 22.2 percent in the past year [17]. However, only 38.5 percent of diagnosed patients receive mental health care, either from a PHC team or a specialist [17]. Specific social and environmental determinants of health [19], including poverty, unfair income distribution, social and political violence, and natural disasters among others, have a strong impact on the mental health situation of Chile. The country’s ethnocultural diversity is another factor to consider when providing services in PHC, particularly in Mapuche communities, where traditions of cosmovision are upheld [20]. Stigma and discrimination also pose challenges to the integration of mental health into PHC in Chile [21, 22]. Despite the significant work that has been done, the need for mental health services in Chile still far exceeds the human resources available to deliver them. Not only are professionals highly concentrated in urban areas, but many professionals such as nurses, physicians, and social workers have had limited education in mental health [22, 23]. Nonetheless, training for service providers is rising with initiatives.
(5) spring 2012. 91. such as the CAMH and Chile partnership, and some universities are increasing the mental health content in their health and social services programs [23]. Health Care Reform in Chile In Chile important health care changes began taking hold in the 1990s. By 2000, major changes were happening, as demonstrated by the Chilean Ministry of Health (MINSAL) introduction of the National Mental Health and Psychiatry Plan [24]. Integrating mental health into PHC was a main facet of the plan. In 2005, the government undertook a general health system reform, aimed to guarantee access, opportunity, quality, and financial protection [25, 26], including mental health [26, 27]. Effective and Sustainable Capacity-Building Educational Model Capacity building in the area of global mental health work is an ongoing, collaborative, and systematic process of learning and practical application aimed at strengthening mental health practices, policies, and support structures in diverse contexts. In order to affect long-term and sustainable change, CAMH develops capacity building with collaborative partners at the front-line, managerial, and policy levels with the aim of fostering local organizations and leadership. CAMH incorporates both best practice and action research, where progress depends on the strength of the relationships, the level of knowledge exchange and mobilization, and the communication between partners. Based on internationally recognized best practices for effective capacity building [28–32], the system-based model allows organizations to satisfy their mandates in a sustainable and autonomous manner. It acknowledges and addresses the interplay between the various elements of mental health service delivery, from front-line clinical work to policy development [33]. Furthermore, as partners develop their competencies within the area of mental health, they are better equipped to advocate for services and to influence policy change. Results The collaboration between CAMH and Chilean partners has been a long and enriching process of mutual learning and knowledge mobilization (see Figure 1). From the beginning, both partners prioritized the development of a sustainable partnership based on the principles of reciprocity, equity, shared decision making, and cultural appropriateness. Those features helped to foster respect and understanding. In 2003, the process began as an exploration of possible collaboration and relationship building. Both CAMH and Chilean partners saw the potential advantages of working together with a focus on the integration of mental health into PHC, which was taking hold in both Canada and Chile. CAMH and Chilean.
(6) 92 INTERNATIONAL JOURNAL OF MENTAL HEALTH. Figure 1 Multilayered Process of Collaboration to Foster Mental Health in Primary Health Care. Policy support National and international interagency collaboration. Capacity-building training program for leaders and local decision makers (Focus: management and evaluation). Capacity-building training program for front-line workers (Focus: clinical). partners developed official collaboration agreements at the municipal, district, and national levels in order to outline their common objectives, goals, and understanding of how to improve mental health in PHC. The development of the CAMH and Chile partnership has been an ongoing process, beginning at the local level and scaling-up to the district, national, and international levels. The first collaboration agreement was made in 2003 with the Municipal Corporation of Puente Alto (MCPA). Shortly thereafter, in 2005, a collaboration agreement was made with MINSAL that outlined the intention to work together in the areas of policy development and interprofessional training. In the same year, a similar agreement was made with the Department of Family Medicine at the Universidad Católica de Chile, which has been a key player in the collaboration process. Different Chilean institutions have forged written, and unwritten, agreements with CAMH during the past 6 years as partnerships expanded to meet specific challenges; including the South East Metropolitan Health District (SSMSO), the National Drug Control Commission (CONACE, now SENDA), Fundación Paréntesis—a nongovernmental organization (NGO) providing support to marginalized people with addictions—and the Centre for Addiction Studies at the Universidad Católica de Chile. Thus, multiple relationships have been established, allowing the collaborative capacity-building process to increase in scale. In a number of cases,.
(7) spring 2012. 93. collaborative interagency partnerships are developing within Chile, and recently, certain principles of the programs have expanded to other regions of Latin America, such as Mexico, Nicaragua, Brazil, and Peru. In order to ensure that collaborative efforts are context appropriate, each partnership has conducted its own thorough needs assessment by liaising with local partners, key stakeholders, and service providers. Based on these findings, CAMH and Chilean partners designed multiple training initiatives, consultations, and process evaluations. As needs changed over time, the assessment process became an ongoing activity. A number of evaluations have been conducted by internal and external evaluators. These are discussed in the following section. Key Initiatives Key initiatives have formed at the municipal, national, and international levels. See Table 1 for a list of trainings that took place as a result of CAMH and Chile collaboration. Key Initiatives—Municipal In 2003, the CAMH and MCPA partnership began as a small-scale, local initiative in Puente Alto. The first interprofessional training took place in June 2004 and focused on stigma and discrimination, the fundamentals of mental health and addiction, brief interventions, self-care, and health promotion. Forty professionals attended the training and reported having found motivational interviewing, self-care, harm reduction, and stigma to be the most beneficial topics [34, 35]. In December 2005, a more in-depth and comprehensive training was held in Puente Alto [34]. The Department of Family Medicine at the Universidad Católica de Chile contributed to the organization of each of these trainings. Participants noted the value of the collaborative approach used in the trainings, particularly the mutual learning and respect shown for local knowledge [34–36]. In 2005 and 2008, external evaluations of the CAMH and Chile capacity-building process in Puente Alto were conducted [35, 36]. The results demonstrated a high level of satisfaction among the participants, an increased knowledge of the main topics, and an understanding of the value of developing local mental health models and of participating in international collaboration [35, 36]. In 2006 and 2007, the SSMSO, partners in Puente Alto, and a number of international partners collaborated with CAMH to conduct intensive mental health training programs in Toronto, Canada, aimed at enhancing the implementation of mental health competencies in PHC and optimizing the collaboration and consultation between primary and secondary care. The programs were run twice, in July 2006 and 2007, and were well received. This stage of collaboration was very important because it built confidence and strengthened ties between CAMH and Chilean partners [34]. Although it is still a viable possibility for future work, it was not.
(8) Addictions and Mental Health in Primary Care Addictions and Mental Health in Primary Care—2 Intensive 2-week training on mental health and addiction in primary care at CAMH Intensive 2-week training on mental health and addiction in primary care at CAMH—2 Accelerating the Agenda for Action: Strengthening Mental Health and Addiction Services in Primary Care (Toronto, Ontario) Mental Health Promotion at the South East Metropolitan Health District International Seminar on Mental Health Integration in Primary Care (Chilean Ministry of Health-PAHO-CAMH) Toward Ongoing Health Systems Improvement: Institutional Capacity Building for Evaluating Mental Health and Addiction Initiatives, Version 1. Title of training. Key Initiatives Related to the CAMH-Chile Collaboration. Table 1. 45. March 2008. 2009–10. 45 from 16 institutions from Chile, Peru, Ecuador, Argentina, and Mexico. 92 100. 10. July 2007. September 22, 2008 September 23–25, 2008. 40 40 10. Number of participants. June 14–18, 2004 December 13–14, 2005 July 2006. Dates. 94 INTERNATIONAL JOURNAL OF MENTAL HEALTH.
(9) Notes: * In January 20, 2012, at the end of the on-site component of the training, there was a knowledge exchange workshop where participants of the program “Toward Ongoing Health Systems Improvement: Institutional Capacity Building for Evaluating Mental Health and Addiction Initiatives” (versions 1 and 2) shared the results of the evaluations they implemented.. January–April, 2012. Mental Health and Addiction Capacity Building Program for Primary Health Care in Chile and Peru, Version 3 (Santiago, Chile)*. 40 participants, mainly from the South-East Metropolitan Health District (Chile); 6 of the participants were from Peru 44 participants from the Red Lima Salud, Ministry of Health, Peru 37 participants from Chile and 3 from Peru. January–May, 2011. August, 2011. 51 from 16 Chilean institutions. 2010–11. Mental Health and Addiction Capacity Building Program for Primary Health Care in Chile and Peru, Version 2 (Lima, Peru). Toward Ongoing Health Systems Improvement: Institutional Capacity Building for Evaluating Mental Health and Addiction Initiatives, Version 2 Mental Health and Addiction Capacity Building Program for Primary Health Care in Chile and Peru, version 1 (Santiago, Chile). spring 2012 95.
(10) 96 INTERNATIONAL JOURNAL OF MENTAL HEALTH. repeated after 2007 because of its high costs, difficulties of transferring knowledge back to Chile, and a general preference for on-site training in Chile. Instead, the SSMSO hosted a special symposium in 2008 on similar topics. Key Initiatives—National and International The collaborative process continued to develop, moving beyond a local focus to crossing global concerns. One direct result came in the form of an international symposium at CAMH, held in Toronto in March 2008, where key players from nine countries worked together to forge a common understanding of their diverse challenges for advancing mental health in PHC; the “Toronto Letter” [37] was put forth that identified twelve recommendations for action. Using the Toronto symposium as a model, in September 2008, MINSAL, PAHO, and CAMH held a symposium entitled “International Seminar on Primary Health Care and Mental Health” in Santiago, Chile, which was attended by 100 professionals. The “Toronto Letter” was distributed and discussed at the symposium, and a number of key themes were emphasized, such as integrating mental health into PHC in Chile and Ontario, community care, family support, stigma and discrimination, self-care, and early intervention. According to a report prepared by local partners in Chile, events such as the symposium helped to validate local mental health initiatives, while generating ideas for developing national policies and contributing to the overall understanding of integrating mental health into PHC. CAMH and Chilean partners also identified a need for mental health service providers to develop in-house institutional capacity in the area of program evaluation. In 2009 and 2010, CAMH, with the support of Universidad Católica de Chile, MINSAL, Harry Cummings and Associates, and QUALITAS, facilitated the program entitled “Toward Ongoing Health Systems Improvement: Institutional Capacity Building for Evaluating Mental Health and Addiction Initiatives.” This program consisted of a 1-week on-site evaluation workshop, and 10 months in which students implemented their own evaluations. The program emphasized the interconnection between local, district, and international clinical and managerial mental health work. CAMH ran a second version in 2010 and 2011, co-organized with the Universidad Católica de Chile, Fundación Paréntesis, and MINSAL. Both versions were positively evaluated, and more than twenty “evaluation initiatives” have been implemented locally that provide concrete recommendations for improving mental health and addiction services and programs [38, 39]. A knowledge-exchange event to present the results of the evaluations conducted by the participants was held in January 2012. Similar programs have been implemented in other partner countries such as Brazil, Trinidad and Tobago, and México. The most recent initiative, entitled “Mental Health and Addiction Capacity Building Program for Primary Health Care in Chile and Perú,” started in January 2011 and has taken place in Santiago, Chile (2011 and 2012), and in Lima, Peru (2011). This program is a collaboration between CAMH, the Universidad Católica de Chile, and.
(11) spring 2012. 97. the Universidad Cayetano Heredia (Peru). The international collaboration between Chile, Perú, and Canada is aimed at increasing capacity among service providers, at both the clinical and managerial levels, and at integrating mental health into PHC, which directly aligns with the current goals of PAHO [8]. Other collaborative initiatives in Chile have been influenced by the PHC perspective even when it is not their main focus. Between 2006 and 2007, the CAMH team worked with CONACE to evaluate its pilot program for addiction treatment for children and youth [40]. Also, in 2009 and 2010, CAMH supported MINSAL in its effort to develop a National Alcohol Policy [41, 42]. Discussion From the beginning of the partnership between CAMH and Chile, the respective institutions have prioritized the principles of reciprocity, equity, and shared decision making. Not surprisingly, they have developed a strong and productive working relationship that has evolved through multiple stages: from concrete sharing of knowledge to epistemological, evaluative, and value-based mutual learning. The results of collaboration have been significant and mutually rewarding and have led to sustainable capacity building, specifically in PHC [35, 36]. It is clear from the collaborative initiatives that have been developing within Chile and Latin America that the CAMH and Chile partnership process may serve as a model for others, particularly in light of the PAHO Strategy and Plan of Action on Mental Health for the Americas [8]. It is important, however, to acknowledge that limitations exist in the CAMH and Chile collaborative process. Availability of resources has affected the amount of work the partners have been able to accomplish, despite significant contributions being made by each. Also, the geographic distance between Canada and Chile has, at times, been a barrier because of travel costs. The various institutions have experienced structural and personnel changes, and new relations have had to be built. Differing priorities have sometimes created lag times in the planning process as the attention of the planners was required elsewhere. Language may be also considered a barrier because translation costs are high. Surprisingly, culture itself has not been a challenge, perhaps because of the assumption that cultural screening was essential to identifying relevance and appropriateness of technologies. Some of these challenges have been identified as common in international collaborations [43]. Barriers also exist at the local level. The full integration of mental health into PHC is still a distant goal: funding issues, inefficient management, and lack of proper community or family interventions are considerable challenges (X. Candia, Health Director of Municipal Corporation of Puente Alto, personal communication, August 13, 2011). Staff turnover, especially of physicians, has been a notable barrier to sustainability given the low status and pay that continue to characterize work in PHC. Nonetheless, building relationships with CAMH has improved attitudes toward community-based mental health work and.
(12) 98 INTERNATIONAL JOURNAL OF MENTAL HEALTH. is facilitating change at the organizational level (X. Candia, personal communication, August 13, 2011). Despite the limitations, evaluations of the collaborative process indicate that it has been enriching for all those involved, in large part due to the engagement of motivated and committed local leaders with the unfolding process [35, 36, 38, 39]. The first comprehensive evaluation revealed that participants’ engagement stemmed from the importance they attached to gaining technical skills to better assist clients, such as motivational interviewing and brief interventions for addictions [35]. The 2008 evaluation indicated that participants’ engagement remained strong as they perceived significant changes in their own attitudes toward clients, allowing them to use a more client-centred approach [36], in how they addressed stigma, and in how they integrated both health promotion and self-care—all valuable and novel approaches to their practice and essential reasons for remaining involved [36]. However, it is important that future evaluations focus on longitudinal impact in order to better demonstrate the outcomes of the collaboration. Evaluations also suggest that the capacity-building framework used by CAMH and the Chilean partners draws its sustainability from the nurturing of a strong sense of local ownership. Participants extol the bottom-up approach and contrast it with the common top-down approach with which they were most familiar; it seemed to be a key aspect fuelling commitment to the collaboration [35, 36]. The partners within Chile are continuing to cultivate and implement new initiatives that follow from the mental health in PHC approach [38, 39]. Chile is also taking a leading role in joint efforts to promote mental health in PHC throughout Latin America. The collaboration has been particularly effective in the Chilean context because of the reciprocal process and local strengths. On account of this reciprocal approach, which has been the basis of the partnership, a sense of local ownership of the work has existed from the beginning. Key players in Chile have been at the forefront of the work, taking on leadership roles and joining the international discourse to advance mental health in PHC. At the same time, CAMH’s experience gained from the collaboration with Chile has engendered the development of a strong global health model for integrating mental health into PHC. The key lessons learned throughout the process of collaboration are: 1. Collaborative mental health initiatives are sustainable, particularly when they involve diverse partners, including members from the government, universities, and nongovernmental organizations. 2. Reciprocity, equity, shared decision making, and cultural appropriateness are key values for an effective and sustainable model of international collaboration in the area of health and mental health. 3. Scaling-up is an effective approach. Begin at the local level and move toward national and international work. 4. The systems approach facilitates change at the local, regional, and national levels..
(13) spring 2012. 99. 5. The capacity-building model used by CAMH and Chilean partners facilitates reciprocal learning. 6. Large knowledge-sharing events, such as symposiums, generate creative ideas and help build relationships. 7. Limited resources are challenging and can limit the amount of work that can be done. Initiatives should be designed to reflect the available resources. 8. The model developed through this process may be applicable to other contexts and countries, although it must be adapted to local needs. Next Steps Collaboration between CAMH and Chile is an ongoing process of knowledge exchange and mobilization, support, and mutual learning. In the future, both partners intend to work together to strengthen this partnership. Some key initiatives are planned for the upcoming years, including expanding the collaborative work to other countries in Latin America in the form of evaluation trainings and university programs in mental health. At this point, as Chile takes an increasing leadership role, local initiatives will emerge for which CAMH may act as a support when necessary, while acknowledging the increasing local capacity in mental health. CAMH will continue to work with Chile as well as other countries in Latin America and the Caribbean in order to further strengthen mental health care in the region. As a local leader, Chile will be a key player in this process and will be central to the advancement of mental health in PHC for all of Latin America. References 1. World Health Organization. (1978) Alma Ata declaration for primary health care. Almaty, Kazakhstan. 2. World Health Organization. (2008) World health report. Geneva, Switzerland. 3. Walley, J.; Lawn, J.E.; Tinker, A.; de Francisco, A.; Chopra, M.; Rudan, I.; et al. (2008) Alma-Ata Working Group. Primary health care: Making Alma-Ata a reality. Lancet, 372(9642): 1001–1007. 4. World Health Organization and World Organization of Family Doctors. (2008) Integrating mental health into primary care: A global perspective. Available at http:// whqlibdoc.who.int/publications/2008/9789241563680_eng.pdf, accessed May 13, 2012. 5. Goldman, J. (2010) Interprofessional collaboration in family health teams. Canadian Family Physician, 56(10), e368–e374. 6. Rojas, G.; Fritsch, R.; Solis, J.; Jadresic, E.; Castillo, C.; González, M.; et al. (2007) Treatment of postnatal depression in low-income mothers in primary-care clinics in Santiago, Chile: A randomized controlled trial. Lancet, 370(9599), 1629–1637. 7. Pan American Health Organization. (1990) The Caracas declaration. Caracas, Venezuela. 8. Pan American Health Organization. (2009) Strategy and plan of action on mental health for the Americas. Available at http://new.paho.org/hq/dmdocuments/2009/ SALUD_MENTAL_final_web.pdf, accessed May 30, 2012. 9. Pan American Health Organization, Fiftieth Directing Council: Sixty-Second Session of the Regional Committee. (2010) Strategy on substance use and public health..
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(16) 102 INTERNATIONAL JOURNAL OF MENTAL HEALTH. 40. Rush, B.; Sapag, J.; Chaim, G.; & Quinteros, C. (2011) Client characteristics within the Chilean national youth addiction treatment demonstration system. Journal of Substance Abuse Treatment, 40(2), 175–182. 41. Ministerio de Salud (MINSAL). (2010) Estrategia nacional sobre alcohol [National alcohol strategy]. Santiago: Comité Interministerial. 42. Giesbrecht, N., Marquez Contro, J., & Sapag, J. (2009) A national alcohol strategy for reducing high-risk drinking and damage from alcohol in Chile. Commissioned by Dr. Alberto Minoletti, Ministry of Health, Government of Chile, and provided to the Chilean Ministry of Health. Toronto, Canada: Centre for Addiction and Mental Health. 43. Martin, D.; Craft, A.; & Tillema, H. (2002) International collaboration: Challenges for researchers. Educational Forum, 66(4), 365–370.. To order reprints, call 1-800-352-2210; outside the United States, call 717-632-3535..
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