In this Papers Podcast, Dr. Christina Cruz, Dr. Michael Matergia, and Priscilla Giri discuss their co-authored CAMH journal Short Research Article ‘RESEED – the perceived impact of an enhanced usual care model of a novel, teacher-led, task-shifting initiative for child mental health’ (https://doi.org/10.1111/camh.12673).
There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include:
- Introducing RESEED (Responding to Students’ Emotions through Education), and Tealeaf (Teachers Leading the Frontlines).
- Definitions of ‘stepped levels of care’ and ‘task-shifting’ in terms of teacher-led care.
- Research gaps that this study aimed to address.
- Surprising results from the study.
- Implications for policymakers, and researchers.
- Advice and implications from a practice and intervention perspective for teachers working in low- and middle-income countries (LMICs).
In this series, we speak to authors of papers published in one of ACAMH’s three journals. These are The Journal of Child Psychology and Psychiatry (JCPP); The Child and Adolescent Mental Health (CAMH) journal; and JCPP Advances.
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Christina M. Cruz, MD, EdM is a child global mental health and school mental health researcher, a practicing inpatient child and adolescent psychiatrist, and a mental health systems consultant. Her research program centers on increasing access to child mental health care through alternative systems. Currently, she is focused on task-shifting indicated mental health care to teachers in Darjeeling, India for children in primary schools, scaling this care to the public schools of Manila, Philippines, and adapting this care to the middle school age group for a rural State of North Carolina context in the United States. She is also now working to extend the care in Darjeeling to adolescents, as well as using tenets of the care to address mental health and climate change concerns among Darjeeling farmers.
She is an Assistant Professor of Psychiatry at the University of North Carolina at Chapel Hill (UNC) School of Medicine with a joint appointment in School Psychology at the UNC School of Education. She also serves as the Associate Head of the Division of Global Mental Health within UNC Psychiatry. She additionally serves as founder and Principal of Ligaya, LLC a mental health systems consulting firm. She completed her Bachelor of Science in Economics at the Wharton School of the University of Pennsylvania, her Masters in Education at the Harvard Graduate School of Education, and her MD from Harvard Medical School. She completed her general psychiatry residency and child and adolescent psychiatry fellowship at UNC.
Dr. Matergia completed his medical education at Harvard Medical School. He trained in family medicine at Saint Joseph Hospital where he continues to see patients and teach residents. He is passionate about full scope family medicine, medical education, and the design of healthcare delivery systems in resource-poor settings. Together with his wife, Dr. Matergia co-founded a non-profit dedicated to providing innovative health and education programs in the rural Eastern Himalayas. Currently, he is focused on implementing a lay fieldworker led school health program and developing a community-based care system for child mental health. Dr. Matergia is also interested in the delivery of primary care to adult laborers on the tea estates of Northeast India. (Image and bio from Colorado School of Public Health)
Priscilla Giri is a research administrator with DLR Prerna, leading a research program TeaLeaf (Teachers Leading the Frontline) Mansik Swastha in Darjeeling, India. Experienced in project designing, implementation and evaluation. She has worked with the schools in rural communities in Darjeeling for the past eight years and involved in the mental health program for five years. Priscilla Giri has completed her master’s degree on Medical and Psychiatric Social Work from St. Joseph’s College, Bangalore, and a one-year course on Narrative Therapy from Ummeed’s Mental Health Training Program, Mumbai. (Image and bio from Health, Ethics, and Law Institute)
Other resources
- Featured paper ‘Short Research Article: RESEED – the perceived impact of an enhanced usual care model of a novel, teacher-led, task-shifting initiative for child mental health’ by Setareh Ekhteraei, Juliana L. Vanderburg, Choden Dukpa, Priscilla Giri, Surekha Bhattarai, Arpana Thapa, Catherine Shrestha, Bradley N. Gaynes, Molly M. Lamb, Michael Matergia, Christina M. Cruz
- Video Abstract ‘RESEED – the perceived impact of an enhanced usual care model of a novel, teacher-led, task-shifting initiative for child mental health’ with Setareh Ekhteraei and Choden Dukpa
Transcript
[00:00:00.080] Mark Tebbs: Hello, and welcome to the Papers Podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Mark Tebbs, and I’m a Freelance Consultant. If you’re a fan of one of our podcast series, please subscribe on your preferred streaming platform, do share with friends and colleagues.
Today, I’m delighted to be interviewing Dr. Christina Cruz, Dr. Michael Matergia and Miss Priscilla Giri, who are the lead authors of a paper entitled, “REESEED – The Perceived Impact of an Enhanced Usual Care Model of a Novel, Teacher-Led, Task Shifting Initiative for Child Mental Health,” recently published in the Child and Adolescent Mental Health Journal. Welcome. It’s been lovely speaking you – to you today.
[00:00:48.650] Dr. Christina Cruz: Thank you for having us.
[00:00:50.150] Mark Tebbs: Good stuff. So, could we start with some introductions? If you could introduce yourself and introduce – there was other authors in the paper. If you could introduce them, as well, that would be great.
[00:01:01.149] Dr. Christina Cruz: Sure, I can start. So, my name is Dr. Christina Cruz. I’m a Child and Adolescent Psychiatrist. I am Faculty at the University of North Carolina, at Chapel Hill in the United States, and I have a degree in medicine, as well as in education.
[00:01:14.380] Dr. Michael Matergia: So, I’m Dr. Michael Matergia. I am a Family Medicine Physician and Associate Program Director at a family medicine residency at Intermountain Health, an Investigator at the Colorado School of Public Health and Co-Founder of the non-governmental organisation, Broadleaf Health and Education Alliance, all here in the United States.
[00:01:37.700] Priscilla Giri: Hi, everyone. My name is Priscilla Giri, and I work for a non-government organisation in Darjeeling, India, and my background is a Psychiatric Social Worker.
[00:01:49.320] Mark Tebbs: Thank you. There were other authors in the paper. Could you tell us who they were and their roles?
[00:01:55.280] Dr. Christina Cruz: Absolutely. So, our first author is Setareh Ekhteraei. She is a medical student at the University of Colorado, Denver and will soon be pursuing residency. Juliana Vanderburg, who just graduated from UNC, where I’m Faculty, in School Psychology, with her PhD. Choden Dukpa, who is one of our Lead Mental Health Researchers in Darjeeling, alongside Priscilla, at the organisation, Darjeeling Ladenla Road Prerna, or DLRP. Surekha Bhattarai, she is one of our Researchers, as well as an Interventionist in Mental Health, as well as Arpana Thapa, both of them at DLRP. Brad Gaynes is a Global Mental Health Faculty at UNC, who worked with us on this, and Molly Lamb is an Epidemiologist out of the University of Colorado, Denver, as well.
[00:02:42.900] Mark Tebbs: Brilliant. Thanks for the introductions for you, yourselves, and the team. So, let’s turn to the research article. Could you start with just giving us a brief overview of the paper?
[00:02:54.349] Dr. Christina Cruz: Absolutely. So, in this article, we were studying REESEED, which stands for Responding to Students’ Emotions Through Education. It was designed as an enhanced usual care comparator to our broader intervention, named Tealeaf: Mansik Swastha, or Teachers Leading the Frontlines – Mental Health. So, in general, these are task-shifting interventions, having Teachers be the folks delivering care, and we’ll get into task-shifting in a moment, but essentially, task-shifting is where folks in the community, learn how to deliver parts of care because access is poor throughout the world.
So, Priscilla, Mike and I thought that Teachers would be a great medium through which kids could get mental health care, and they already informally support their students with mental health needs in the interactions they have with them every day, whether actually in crisis or to support positive behaviour. So, we created Tealeaf to equip them with therapy skills to turn those moments of informal support into moments of formal care. We created Tealeaf with and for Darjeeling, to improve access to the care there, but it had to be an alternative system because of the lack of mental health specialists globally.
So, I say all of that to then introduce REESEED as being part of Tealeaf. REESEED is the first part of Tealeaf where they are introduced to mental health concepts, behaviour theory and then, some of Tealeaf therapy tools, but they don’t get the in-depth training in the therapy skills or coaching throughout the year. It’s more meant as an introduction. And again, I alluded to this, but REESEED was created as an ethical comparator to Tealeaf.
When we were first going through the Tealeaf trial, it was clear from our ethics review that having what is typically a true control, which is no intervention, was simply unethical, in an area where identifying children with mental health needs would then leave them without absolutely no care. That standard of care, essentially, is no care. So, we created REESEED, as in this paper, in order to be able to provide something to children who might be in the comparator part, which is, you know, not quite as intensive.
In this paper, essentially, what we learned and what we focused on is that REESEED served an incredibly important role for Teachers as a mental reframing. And there’s a bit of mental health literacy that comes in, but also, it turns out just even introducing the tools got them thinking differently. So, in this paper, we learned these findings through ten focus group discussions across 29 Teachers. We found the findings to be robust and a bit surprising, as we’ll get into later, but we were happy to see that it’s – it didn’t back-serve the role that we had intended for it to have, which was to provide something to children who were identified, but it – I think it went further than we anticipated.
[00:05:31.680] Mark Tebbs: Brilliant. Thanks for that overview. It’d be really useful to clarify whether there are any technical terms, or any definitions, that would be useful to unpack a little bit more.
[00:05:42.509] Dr. Michael Matergia: Yeah, so, I think there’s a few terms that we use in our paper that we could clarify, and one is we allude to Stepped levels of Teacher-led care, and the other is this notion of task-shifting. So, the first one we’re talking about Stepped levels of care. Step Care is a model for mental health delivery where the most effective, yet least resource-intensive treatment, is prioritised for delivery first, and then, from there, programme can – intensity can either be stepped up or stepped down, depending on need and available resources. So, within the context of Teacher-led mental healthcare, REESEED is – it may be viewed as that first level and then, it can be stepped up to the more intensive version of Teacher-delivered therapy, which is Tealeaf.
The second concept is task-shifting. So, task-shifting, formally, is defined by the WHO as “The rational redistribution of tasks among health workforce teams.” And in terms of global mental health, this often involves the training of non-specialist health workers or lay Counsellors, individuals with little or no prior formal training or background in mental healthcare, to deliver actual care, such as brief low intensity psychologic treatments or talk therapy.
In our work, it’s a little bit different because we’re working with a specialist, just a different type of specialist, Teachers. And Teachers are experts in child development, and we are working to leverage these strengths, to have them then take on, or task-shift to them, mental health care tasks that may, more traditionally, be viewed as the domain or purview of mental health professionals.
Those are the two technical terms that I think give a good basis for understanding the work that we’re going to talk about today.
[00:07:28.150] Mark Tebbs: Brilliant, yeah, that’s really, really helpful. Thank you for that. So, let’s turn our mind, really, to the start of your work. I’d be really interested to understand what your original research aims were.
[00:07:40.490] Dr. Michael Matergia: I think even – we’ll step back to before we even considered ourselves Researchers and how we got involved in mental health at all. So, the three of us began this journey, Priscilla, Christina and I, along with our colleagues, when we were working in the context of school health promotion, or trying to figure out how do you deliver school health in rural Darjeeling primary schools? And this is around the time, at least in Darjeeling, that there was that epidemiologic transition from infectious disease, diarrhoea and waterborne illness, to more starting to think about is the burden of those illnesses felt more chronic diseases? And in children, we were seeing children in these schools with behavioural health challenges, and we felt like let’s help those children, and that was unintentionally ambitious thing for us to think about and started us on this path towards mental health.
And so, for several years, we were trying to figure out, how do you support children in rural Darjeeling who are facing mental health challenges? And ultimately developed a model for Teacher-delivered mental healthcare that we thought was, like, and this is quite novel and quite promising. We had some pilot data that was pretty impressive, that we’d presented in some other papers, and then, we’re like, “Okay, we got to rigorously evaluate this within a randomised controlled trial.” And as Christina alluded to, you know, we started thinking about, okay, a controlled trial involves a control arm. Control arms in mental health trials we usually think of as usual care, but in the environment we’re working, like, usual care really means no care at all, which is quite ethically challenging.
The idea that we would identify a child in need, but then, not have any care provided to them, was, ultimately, ethically and morally distressing to us and gave birth to what is REESEED. You know, we, basically, said, “We need to think about what would care in this environment look like without a significant increase in resource investment, but still be viable?”
So, Tealeaf requires, at full intensity, requires a certain level of resources and so, we designed a comparator as something that we felt was viable, without significant additional resources, and then, that became REESEED. The first year, because of the way we designed our initial trial, was designed to be a stepped wedge cont – randomised controlled trial, in which all schools started out in the control arm. And so, in 2019, we had a cohort of schools all receiving REESEED.
We had a sense that this isn’t just a research tool, it’s not just a tool to complete a trial. Like, REESEED, in and of itself, is a form of intervention and it’s really important that we develop a deep understanding of it. And so, we designed a protocol to generate this understanding in the findings that we’re presenting in the manuscript and discussing today.
I think, ultimately, just to round that out, you know, this was 2019. The second year, when some of the schools would’ve entered the Tealeaf intervention was 2020 and then, obviously, things changed quite dramatically in 2020, and so, that particular version of our trial was suspended during the COVID-19 pandemic and school shutdown period. But had a really robust year of experience that we’ve gone back to, and I think have some interesting findings to share with the world.
[00:11:18.310] Mark Tebbs: Great stuff. It’s really helpful to understand that journey. Were there any particular research gaps that you were trying to address?
[00:11:25.370] Dr. Michael Matergia: You know, the core of our work is this. We’re inspired by Teachers. We’re inspired by the potential Teachers in Darjeeling and really, around the globe, to improve the mental wellbeing of children, and I think it’s pretty widely recognised that Teachers can deliver social emotional learning and supports and that they can also identify struggling children and refer them to further professional services.
However, when we start talking about Teachers delivering mental healthcare, serving themselves as forms of mental health professionals, that’s when we, you know, we run into much more doubt. And as our paper highlights, there are certainly barriers that Teachers face, academic pressures and all these other requirements that are stretching them to their limits. Through our research, what we want to understand is if and how Teachers cannot only recognise a child in distress, but then respond with the delivery of therapeutic care.
In this particular aspect of our research, we’re looking at one version, REESEED, that we think is potentially a viable approach to task-shifting care to Teachers.
[00:12:34.579] Mark Tebbs: Thank you. Let’s turn to the methodology. You use a qualitative approach. Could you tell us how you conducted the study and whether there are any particular challenges to the work?
[00:12:46.209] Priscilla Giri: Yes, sure. So, we conducted around ten FDGs, focus group discussions, at the end of the intervention, to learn about how the Teachers’ experiences were about REESEED. So, the programme itself aligns with the school year here in Darjeeling, where we start with the training in the beginning of school year and the end of the training, we do these FDGs and qualitative interviews with the Teachers and the networks that we build. So, by the end of December, that is when the school year ends, we conducted these FDGs with Teachers and these FDGs are usually conducted in the school setting or in community setting, which is more convenient for the Teachers itself.
So, as we know that in Darjeeling these schools are spread out in a very large landscape, travelling to these communities take a long time. Having all the Teachers come and sit for these FDGs was another challenge that we experienced. So, we had to host multiple FDGs to have engagements or have understanding of the Teachers’ perspectives and experiences. So, also, to understand the cultural context of different schools that we partnered with, we had to conduct these ten FDGs to have an individual, as well as the contextual, perspective of the area.
[00:14:13.801] Mark Tebbs: Thank you. Yeah, that geography sounds challenging. You mentioned that a context and the setting. Could you just describe a little bit more about the context for the study?
[00:14:22.890] Priscilla Giri: Yes. So, Darjeeling lies in the Eastern Himalaya part of India, and most of the communities in the Darjeeling Himalayan region are natural resource dependent. So, mostly small-scale agriculture, tea and Cinchona plantation is very huge and also, we are dependent on the forest. But the issues that we ho – we all experiences are low remuneration of all the three main resources, natural resources. So, we have limited infrastructure, we have limited market space and also, exposure to knowledge and skills. We are – kind of, have had experiences and difficulties because of human-wildlife conflicts, climate change impacts and also, there is a huge low employment opportunities, which has led to outmigration.
So, all these factors, especially with the im – which impacts the mental health and also, the general impact of the global pandemic, has affected the economy, the politics, as well as the whole area or the region itself. So, the need to work on the issues of mental health is more progressively being seen, even after the global pandemic.
[00:15:36.680] Mark Tebbs: Thank you for that. So, let’s turn to the results. So, what were the key findings?
[00:15:43.270] Priscilla Giri: So, overall, REESEED has a Teacher-led task-shifting youth mental health initiative involving in a 3D training, with minimal external support. So, Teachers found REESEED to be, overall, very acceptable and perceived positive behavioural and academic changes in students and changes in beliefs about the mental health in themselves. So, Teachers have expressed an improved understanding of child behaviour patterns and also, perceived possibly increased empathy for students. So, with continued need for the novel youth mental health approach, REESEED represents a potentially acceptable and feasible, minimal resource first step to improving mental health literacy in Teachers and also, beginning to address youth mental health needs in low-income countries.
[00:16:33.959] Mark Tebbs: Yeah, really important. Was there anything in your results that surprised you?
[00:16:39.589] Priscilla Giri: So, the programme was designed in a way where we thought REESEED could be the basic level of training, where Teachers might not be able to take in as much as possible because we believe the coaching process that takes place throughout the school year helps the Teacher invite the training and apply it in their own day-to-day practices. But without the external support, the Teachers were able to understand the concepts of the training, as well as use some of the tools that was explained in the training, in their day-to-day activities.
So, that was something which was very surprising, that how acceptable it was among the Teachers. One of main reason could be because the Teachers were never exposed to such trainings. This was the first time a Teacher was coming together to express or to have an understanding of the child and also, the whole perspective of the child’s mental health. So, this could be one of the reason to have the Teacher feel more acceptable of the whole concept.
[00:17:43.870] Mark Tebbs: That’s great. I’d like to turn to the implications of your work and maybe thinking, initially, about – from a policy perspective. So, what messages would you give to policymakers thinking about how best to support child mental health in resource-limited countries?
[00:17:59.480] Dr. Christina Cruz: That’s a great question. I think one of the big takeaways is that the solutions may already be there. Even in resource-limited settings, we’ve got people and we’ve got people who care, and we have people who are capable of learning. And so, I think it speaks to the importance of task-shifting, in that one has to be creative in places with fewer resources or fewer trained professionals, but it’s possible with creativity. You just need to think a little bit outside the box of how are we going to get this done? That’s one big piece.
The other big piece that we didn’t quite touch on, but that would be important for policymakers to consider, is that with things like task-shifting in resource-limited settings, people are proud of what they do, but in order to continue to do so, they’ll need to be renumerated on some level. They are filling a role that is unfilled and that requires quite a bit of skill, and so, to sustain that, it might not be much, but just enough to keep them engaged, and we’re seeing that play out today.
In The New York Times, for example, there is an article this week about community health workers feeling like they were not being renumerated for incredibly important services and starting to not want to engage in that way. And so, while it’s not necessarily free, I think it’s a relatively lower cost to get services into play. So, it’s a complicated picture of resources are there, but some should be spent in order for there to be sustainability, eventually.
[00:19:30.630] Mark Tebbs: Yeah, I think that’s really important. It’s low cost, but it’s not free and it needs to be, kind of, rewarded. So, I’m just thinking about the Teachers working in those settings. Is there any advice or implications from a practice or intervention perspective?
[00:19:47.429] Dr. Christina Cruz: I think in terms of practice or intervention, one of the big lessons we learned from REESEED, as Priscilla was saying, was that Teachers wanted this. From the ground up, they are already dealing in the classroom with the children with mental health concerns. So, whether it was REESEED, or we gave them just enough that they still wanted to use it, or fully Tealeaf, where we then support many more skills throughout the year, they were eager to have it. And I’ll share a quote from the paper to illustrate this. “This training taught us how to handle and help these types of children by being a bit loving and attentive towards them.” And another Teacher then said, “We are very blessed to have received training from you and we learned a great deal on how to handle children at school.”
And so, I think these two quotes, kind of, illustrate what was taught to them and then, how it was received and that REESEED, you know, we came up with the acronym, but it was really meant to say, like, we’re trying to change the landscape, we’re reseeding the ground, and in fact, what happened was a mental reframing. And so, they learned to think about children in a different way, with agency and with ones who have modems, that can be engaged, and then, they really liked it, in part to Priscilla’s point, because they had never had this kind of training before.
But we also know, worldwide, that mental health training is not a requirement for Teacher training and one in five children have a mental health condition and potentially, up to two in five after the pandemic. So, this is a really important skill for Teachers to have and it turns out effective in improving children’s mental health. And so, I think that’s the big lesson from Teachers, is that they’re willing, it needs to be structured well, they should be renumerated, but gosh, it can go a really long way.
[00:21:29.929] Mark Tebbs: And from a research perspective, are there any potential implication…?
[00:21:34.039] Dr. Christina Cruz: Absolutely. I think both Mike and I have talked to the birth of REESEED and that what was really interesting here is that research first, I think, elevated mental health, at least among some in the Darjeeling region, to be important. And then the context, by us being there, changed how we did the research, where we went from having Tealeaf and having a control trial with a standard of care, which is essentially no care, to then elevating standard of care to be this enhanced usual care, or REESEED.
And so, I think that was the lesson for us in terms of research, which was that it’s an iterative process when you’re doing community-based research, between the Researchers and Clinicians and then, the community you’re working with. And so, we’ve been really grateful to the community to be able to continue to work with them in this way, because they’re guiding us and then, we can guide them, and together, we’re creating this new kind of care.
[00:22:33.460] Mark Tebbs: I love that. So, have you got any follow-up research that you’re, sort of like, doing or planning?
[00:22:37.860] Dr. Michael Matergia: Yeah. So, as I alluded to previously, this began in 2019. We had a three to four-year trial planned and then, COVID came and wham, shut it down, but the questions still remain valid. Is Tealeaf, in a controlled setting, is it effective and can it be implemented at a larger scale? And so, I think those questions existed and then, the pandemic made them even more important, more pertinent. We’ve seen an explosion in interest in this work that wasn’t quite there pre-pandemic, because I think it’s hard to ignore youth mental health in 2023.
And so, we took what we shut down in RCT. We adapted that and then, in 2022, we began that process again. It’s a little bit different, based on what we’re talking about here and that REESEED, it’s viewed as the comparator, but it’s also that step, it’s that Stepped Care. It’s that first step before Tealeaf, and so, it’s more of an integral part of what we’re doing, rather than a research tool in and of itself.
So, Priscilla is living this every day. She is driving around that incredibly rough context of Darjeeling that she talked about, day in and day out, visiting schools right now, because we are, we’re in the midst of this. We’re in the second year of a four-year trial and they’re – so, we’re in our second step and there’s about 20 schools that are receiving Tealeaf during this academic year and 40 schools that are receiving the REESEED intervention. It’s really fun and really exciting and maybe we’ll back on your podcast in a few years to talk about the results of that full trial.
[00:24:19.179] Mark Tebbs: Definitely look forward to that. We’re coming to the end. What are the final take home messages?
[00:24:24.880] Dr. Michael Matergia: Yeah, so, the research we’re discussing today is the experience of a particular intervention, REESEED, in a specific context of the Darjeeling Himalayas. But if we zoom out and take a broader view of this, the – you know, there’s been a term that’s been thrown around recently, “youth mental health crisis,” and the enormity of that challenge can, kind of, become clear. Pre-COVID, ten to 20% of children had a diagnosable mental health condition and post-pandemic, that might be up to 40% in some regions of the world. Basically, I think mental health was important and the pandemic and post-pandemic experience really has only added fuel to an already raging fire.
And I imagine that most of the listeners on the podcast are like us, they’re Physicians, Psychiatrists, Social Workers, and I think there is immense value in our services, in our professional services. However, this idea that we’re going to be able to tackle this challenge ourselves, that we can support all these youth with professionalised one-on-one services, medications and counselling, is – would be almost a bit naïve.
There’s a desperate need for innovation. We’ve been, you know, we’ve been lucky enough that we, kind of, started this ten years ago in – ten/11 years ago in Darjeeling, and have worked, you know, really hard to develop a system, a novel – get our work to a point where we think a novel system of care is emerging. And I think ultimately, and the takeaway from our work, is that we believe that Teachers have immense promises – promise to meet youth where they are, in their school, in their everyday environment, and deliver mental healthcare.
[00:26:15.779] Mark Tebbs: Thank you so much. It’s really important work. I really appreciate your time. It’s been a really interesting podcast. For more details on Dr. Christina Cruz, Dr. Michael Matergia and Miss Priscilla Giri, please visit the ACAMH website, which is www.acamh.org, and Twitter @acamh. ACAMH is spelt A-C-A-M-H, and don’t forget to follow us on your preferred streaming platform, let us know how we did, with a rating or review, and do share with friends and colleagues.
