Libremente

Disasters such as the COVID-19 pandemic  inevitably lead to adverse, and potentially long-lasting,  mental health effects for survivors. This decline is most notable for low-income and isolated communities, who have the least access to mental health support services. Since recovery is only possible when communities are strengthened physically and mentally, Libremente is designed to fill the gap between mental health needs and existing resources. 

We leverage the accessibility and reach of SMS to extend self-care support to underserved communities, providing a toolkit of exercises and resources individuals can use to care for themselves and their community — all delivered in easy-to-implement text messages. Designed to be scalable and broadly applicable, Libremente uses a foundation of Behavioral Activation Therapy and Cognitive Behavioral Therapy to reach communities impacted by COVID-19 on a scale not replicable by traditional mental health resources.

In May 2020, the United Nations characterized the COVID-19 pandemic as having the “seeds of a major mental health crisis,” with the brunt of the impact going to those experiencing psychological distress, including frontline workers, those at-risk for the disease, women, and marginalized communities.  The adverse mental health effects of COVID-19 are already making themselves known. The World Health Organization has called for “substantial investment” in mental health resources for COVID-19 response; to underscore this point, WHO presented  an April 2020 study in Ethiopia that “reported a 3-fold increase in the prevalence of symptoms of depression compared to estimates from Ethiopia before the epidemic.” WHO also highlights adverse effects in healthcare workers in China and Canada, and those with pre-existing mental health conditions in the United Kingdom. Traditional coping mechanisms such as interaction with loved ones, exercising, and maintaining daily routines have either been upended or labelled high-risk. Further, mental health services have paused or changed due to distancing and safety requirements. Given the scope and scale of the pandemic, it is clear that we need a mental resource unlike any other: scalable, accessible, and easily adaptable.

Libremente leverages the accessibility and scalability of SMS to provide self-care support to individuals affected by disaster-like situations. We use a web-based SMS sending platform to send short messages with techniques and activities derived from Behavioral Activation and Cognitive Behavioral Therapy — models widely used by mental health professionals  to treat a variety of mental disorders including anxiety, depression and stress. The messages are designed to help improve positive thinking and physical activity patterns to increase an individual’s sense of support and overall resilience. By sending daily messages, we build and provide a toolkit for participants to improve their self-care and wellness habits.  

Our message design systems and community-based approach are rooted in human-centered design principles to ensure that users feel supported and engaged by participation in the program. We ultimately  aim to create a widely adaptable resource that can be customized and implemented by various non-profit community organizations to best support their individual needs and priorities. To that effect, we have piloted a process in both Peru and Puerto Rico to partner with community organizations while delivering Libremente as a scalable, accessible program available to underserved communities but also to any community that is interested in implementing our approach.

Libremente can positively impact anyone who has access to a basic phone with SMS capabilities. Unlike other mental health resources that rely on in-person interaction, apps or data connections, Libremente’s approach ensures accessibility for  individuals and communities worldwide. 

Since we started Libremente in 2016, we have used a human-centered design approach to ensure that our overall program fits community needs. We have tested Libremente’s concept and messaging in communities impacted by severe flooding in Peru and by Hurricane Maria in Puerto Rico, and have integrated feedback from these communities into our process for sending messages and for working with disaster-affected communities as effectively as possible. By partnering with on-the-ground community organizations we can send messages that are relevant to local concerns and interests. Furthermore, we have worked extensively with mental health professionals to design messages suited to those recovering from disaster-like situations. 

We propose to use SOLVE support to extend our reach and scale by refining our prototype and process as we partner with community-based organizations in Mexico to provide mental health support to women in underserved communities impacted by COVID-19. Our ultimate goal is to make Libremente a resource available to any interested community or individual.

A pandemic like COVID-19 can change lives overnight: lives and jobs are lost, support networks are fragmented, and caution and fear increase.  Mental health is often under-prioritized during life-altering situations such as the one presented by COVID-19, particularly in areas that are already underserved. In such communities, mental health concerns can be a barrier to rebuilding and returning to life as usual. Libremente is designed to address the mental health recovery challenges posed by the COVID-19 pandemic in a unlike other, already-existing mental health resources that are limited by an inability to accessibly scale to vulnerable communities.

Innovation is often thought of as creating the most advanced solution possible to a problem. However, in post-disaster situations, advanced, highly-technical solutions can be barriers rather than opportunities. In actuality, communities of disaster survivors are making do with what is most easily accessible to them. Typically, mental health support is made available through in-person interaction, digital apps or through internet-based data connections. Especially for marginalized and underserved communities, even these solutions are inaccessible after a disaster. 

Libremente is unique because we go where people already are; today, a basic mobile phone with a cell connection is readily available — and far more accessible than a smartphone, a therapist or a stable internet connection in many communities that will be most affected by a disaster such as COVID-19. We designed Libremente by closely working with communities in Peru and Puerto Rico to best understand their specific needs and interests post-disaster. By putting so much emphasis on program design, access, and community input, we have developed a simple yet vital resource that can help individuals learn to manage their mental health and wellness concerns, potentially helping to stave off longer-term problems related to these issues in the future. The emphasis on accessibility and community input ingrained into Libremente also means that our tool can help any interested community, whether they are marginalized, underserved, or simply in need of more mental health support.

SMS messaging has been used in some settings to support mental health. Two models are particularly noteworthy: Crisis Text Line and Khuluma. Crisis Text Line is a U.S.-based  SMS hotline that individuals can text into if they are having a mental health emergency. Crisis Text Line queues messages and shuttles them to trained volunteers who de-escalate the situation and contact emergency services if needed. Crisis Text Line has been largely successful but is limited in scalability by its reliance on trained volunteers. The Khuluma program was an SMS program designed for adolescents with HIV. Participants were put in mentor-moderated SMS groups, where they could support each other and learn about HIV. Participants reported increased feelings of social support and decreased internalized social stigma. These services are limited by their reliance on trained volunteers but both prove that SMS messaging can positively impact mental health and wellness.

We have developed and refined our solution in Lima, Peru, and in Naguabo and Utuado, Puerto Rico. In 2017, in Lima, Peru, we conducted a week-long pilot with mothers caring for their households after a series of devastating floods. 100% of registrants participated in the program and reported an increase in perceived sense of support. In 2019, we conducted a 7-week long pilot in two communities in Puerto Rico. In Utuado, 100% of registrants indicated completion of an activity with an SMS response. In Naguabo and Utuado, participants completed on average 3-4 activities per week and reported enjoying the messages.

Disaster recovery processes are necessarily focused first on immediate concerns such as food, shelter, reuniting families and ensuring livelihoods for survivors. However, once the dust has settled and survivors have started rebuilding their lives and processing what they’ve been through, their mental health and overall wellness can take a severe turn for the worse. Such a turn depends on a number of factors including the severity of the disaster, a survivor’s pre-existing support system, and other factors including whether or not the survivor is a member of a marginalized or underrepresented community.  

After conducting a series of interviews with mental health professionals and disaster relief specialists, we learned that these negative mental health effects can be long-lasting and intergenerational, and that they often go unaddressed. In the absence of robust interpersonal mental health, technological or monetary resources, we realized that a mental health resource for disaster-affected communities is most effective when it meets individuals where they are. 

Through pilot tests in Lima, Peru, we worked with disaster-affected mothers to develop Libremente as it exists today: one simple text message, daily can help spur community interaction, individual wellness and self-care habits, and have a positive impact on anyone in the community who interacts with a program participant. We developed our business model, partnering with on-the-ground community organizations, during our work with two communities in Puerto Rico. Input from these communities helped us understand how to make Libremente customizable by community so communities can apply their priorities and preferences to the program and its implementation.  

We aim to positively impact communities of disaster survivors by providing them with a simple, daily resource to help them address their mental health concerns and wellness habits during a difficult time in their lives. Given the nature of disaster recovery, we aim to work first and foremost with underrepresented and marginalized communities by partnering with community organizations in these communities. Ultimately, we plan to make Libremente available to any interested community that wants to invest more in mental health and wellness in a low-cost, scalable manner.

Within a year, we plan to have developed our own software and  a more consistent evaluation method. We also plan to publish a paper to document the project.

After a year, we want to have a more robust library of messages that can be customized for different profiles of users –mostly age, gender, language, and rural or urban settlement. We are learning that needs within these groups are similar across countries. This library would allow us to have a more decentralized design.

In five years, we expect to be partnering with nonprofits to impact communities in most countries in Latinamerica and the Caribbean, as well as serving underrepresented communities in the US.

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Our three person team has expertise across areas including design, urban planning, public health communications and computer science, making us well-poised to effectively run a scalable program focused on the mental health and wellness of disaster survivors. 

Akemi Sato is an architect and urban planner focused on human-centered design. She is the co-founder of Sustrato, a studio researching, designing and developing community-based projects in Mexico. Her recent work focuses on disaster prevention and recovery in Latin America. Aashka Dave is a researcher, journalist, and project manager. She is currently a researcher/community manager at the Center for Civic Media at the MIT Media Lab. She studied the intersection of media coverage and disease outbreaks as a graduate student in MIT’s Comparative Media Studies program, and has previously worked at the Harvard Kennedy School and The Associated Press. Kari Stromhaug graduated from MIT with a B.S. in computational biology and is interested in global health and international development, and how technology can be used to enhance various aspects of medical care, especially in places where resources and awareness are low.

Our core team has conducted extensive background research with mental health and public health professionals, community-oriented non-profits and disaster survivors to best position the program for success. We follow a human-centered design approach honed through in-house work at La Victoria Lab, a design studio with a close partnership with IDEO based in Lima, Peru, which ensures that we are constantly conscious of impact, social responsibility and ease of use.

We plan to work with non-profit community organizations working to roll out Libremente to disaster-affected communities. Given our emphasis on working with underrepresented and marginalized communities, on-the-ground community organizations have the necessary expertise in their communities to ensure that Libremente is rolled out in the most sensitive, effective manner possible. In this sense, community organizations will be our partners and customers, working with us to apply Libremente to their community contexts. End users will be community members with access to a phone with basic SMS messaging capabilities. Because Libremente is designed to be implemented remotely, we will work with community partners virtually, which is particularly effective when organizing efforts in a time that necessitates physical distancing. 

Background research and interviews with community organizations we have worked with have shown us that community-oriented non-profits are well-aware of scarce mental health resources and support but lack the means to address the problem due to a combination of factors including limited mental health specialists, limited technological expertise  and lack of technology among community members. Libremente fills this gap by pre-establishing messages designed with mental health professionals and operating the technological systems necessary for implementation. Since basic, SMS-equipped mobile phones are now common across all levels of society, the concern about technological access becomes far less significant. Furthermore, SMS messages are low-cost and widely scalable.

We are seeking:

Advice on scaling our model to sustainably reach marginalized or underrepresented communities, while generating revenue to keep the service free of charge to participants and be self-sustaining over time.

Recruit a software engineer interested in public health concerns and social enterprises

Guidance on incorporating as a non-profit or non-for-profit organization.