The C-NEST

Cognitive impairment is a global public health concern, particularly after the rapid spread of COVID-19 (Fujii, 2022). Yet a disproportionate number of Caribbean individuals with cognitive impairment go undetected and untreated due to the lack of neuropsychological screening tools that are accessible, efficient, and culturally informed (Fujii, 2022). In Barbados, for example, there is one neuropsychologist per 200,000 citizens, and in other countries in the Eastern Caribbean, there are no practicing neuropsychologists at all. Consequently, screening and early intervention are generally only available to economically advantaged individuals. This is of grave concern because individuals with cognitive impairments have an increased likelihood of early-onset substance use, violence, rapid cognitive decline, and treatment failures (Walker, R. et al., 2007; Leon-Carrion & Chacartegui Ramos, 2003).

Moreover, there are significant implications across the lifespan when cognitive impairment goes unidentified or misdiagnosed. For example, children and young adults with undiagnosed neurocognitive challenges might be deemed as purposefully oppositional. Men and women in substance abuse treatment with undetected traumatic brain injury (TBI), Korsakoff’s Syndrome, or other neurocognitive impairments may self-discharge prematurely or have poor treatment outcomes. Older adults who access medical care at community clinics might have early-onset dementia, TBI, or COVID-19-related cognitive issues (Molera et al, 2007). Yet, timely referrals to appropriate interventions are not offered because of insufficient screening practices.  

Additionally, undetected moderate cognitive impairment can impede an individual’s ability to function independently, result in school failures, contribute to partner violence and crime, and increase healthcare costs (Turkstra et al., 2003; Leon-Carrion & Ramos, 2009). Yet, stakeholders in the Eastern Caribbean have not financed effective strategies to conduct surveillance of individuals at-risk of cognitive impairment. The challenge of conducting assessments in settings with limited resources is compounded by the complicated nature of neuropsychological screening and the expense of measurement tools. In the United States, only trained practitioners can purchase and administer neuropsychological batteries. Although this type of gatekeeping is necessary, it limits access for those who depend on free community-based services.

In addition to access and expense, the over-reliance on culture-bound, language-heavy Western tests can prevent the widespread use of neuropsychological assessment in the Caribbean (Fujii, 2022). Current neuropsychological screening batteries were normed on predominately European populations and evaluate verbal learning, verbal memory, and verbal fluency. These domains are often influenced by cultural experience and level of education.

The future outlook for countries without accessible neuropsychological screening is dismal, particularly as destabilizing events such as the COVID-19 pandemic continue to impact mental health and cognitive well-being.

Recognizing the importance of accessible, culturally responsive cognitive assessment, the Substance Abuse Foundation Inc.(SAF) proposes the C-NEST solution. C-NEST is an electronic neuropsychological screening used to identify neurocognitive disorders in English-speaking Caribbean men and women. The intervention component of the solution is a computerized eight-week cognitive rehabilitation workshop for individuals with severe substance use disorders.

The use of technology, in the form of a computerized neuropsychological screening battery designed with the Caribbean individual in mind, would enable practitioners in Barbados to provide quick, efficient, and culturally informed assessments. Practitioners could then make more accurate preliminary diagnoses and identify those needing referrals to neuropsychological services.

In addition to the development of an invaluable assessment tool, Caribbean-based stakeholders will have empirical data to inform programs and policies that address the needs of diverse communities across the Eastern Caribbean. If a holistic approach to health and well-being is to occur in countries such as Barbados, implementing strategies to maintain optimal cognitive health to the fullest extent possible is required. Chronic disease self-management programs must consider the needs and abilities of people with cognitive impairment. Schools and vocational training programs would also need to become conscientious of neurodiversity in children and young adults to provide effective programming. Additionally, addiction treatment must address brain health.

Programs such as SAF have seen first-hand the consequences of underdiagnosing and misdiagnosing individuals in treatment.  Men and women who enter substance abuse treatment often present with a history of traumatic brain injury, developmental delays, or substance-related cognitive impairment. Frequently, however, when the client enters treatment, the staff is unaware of any cognitive impairments. The client is then subjected to the same programming as everyone else. Ultimately, they leave without new tools to compensate for their cognitive deficits. If holistic treatment for substance use disorders is the true goal, then cognitive assessment and rehabilitation must be included in programming. Brain health cannot continue to be ignored in Caribbean treatment centers if we want significantly improved treatment outcomes.

In the substance abuse treatment arena, the C-NEST solution will:

• Accurately and quickly assess every new client.
• Provide appropriate interventions for clients with cognitive impairment.
• Assess whether cognitive impairment is significantly related to early discharge from treatment.
• Educate other treatment facilities in the region on best practices.

The development and piloting of a culturally informed neuropsychological screening tool and intervention workshop is the first step in mitigating the impact of cognitive impairment in Barbados and other countries throughout the Eastern Caribbean. 

The C-Nest solution will serve multiple target populations in Barbados. Once implemented in schools, healthcare clinics, and treatment centers, youth, adults, and older adults will benefit from affordable neurocognitive screening. The intervention component of the C-NEST solution will focus primarily on individuals with substance use disorders in a 90-day residential treatment program.

Specific ways that the solution will impact lives include:

• The C-NEST would enable school counselors to assess adolescents in the school environment and make appropriate recommendations for intervention.
• Including the C-NEST solution in substance abuse treatment facilities would enhance treatment planning.
• Young adults and those who are chronically unemployed would benefit from vocational training programs incorporating the C-NEST solution into their intake procedures. Early identification and stratification of individuals with cognitive impairment would (1) ensure that vocational trainees receive the additional support they may need to obtain and maintain employment and (2) ensure the appropriate allocation of resources within training programs such as the Barbados’ TVET program.
• Adults and older adults who access healthcare and mental health care at the community level are not assessed for cognitive impairment, increasing the risk of ineffective treatment interventions and noncompliance. Community-based practitioners can use the C-NEST in settings where resources are limited and time is short. They would be able to accurately screen for neurocognitive issues that may be associated with a patient’s medical conditions. Resources would be allocated more appropriately, and patients will be referred to needed interventions and social support services that can improve health outcomes. 
• The assessment component of the C-NEST solution could be used in the evaluation of persons with acquired immunodeficiency syndrome (AIDS). It would distinguish between organic-based cognitive deterioration and deterioration from secondary mental health disorders, such as depression. Accurate diagnosing enables practitioners to provide the appropriate treatment interventions and referrals.

  In summary, the C-NEST solution is a promising approach to improve psychosocial functioning among Caribbean individuals across the lifespan. Its two components address the lack of culturally informed neuropsychological screening tools by using technology to detect mild to severe cognitive impairment and provide researched-based cognitive rehabilitation. In the long term, by making neuropsychological screening and cognitive rehabilitation accessible, the C-NEST solution can reduce the societal ills associated with cognitive impairment (e.g., violent crime, school failure, unemployability, and high healthcare costs).

SAF is currently the only substance abuse residential treatment facility in Barbados. Established in 1996, it has focused on the melioration of the impact of substance misuse on individuals, families, and the wider community. More recently, SAF expanded its focus to include wellness for adults and teens. In 2015, the research arm of SAF began conducting empirical studies and providing training based on newly acquired knowledge about the needs of the Caribbean clientele. After identifying the high prevalence of clients with cognitive impairment at the treatment center, the SAF Clinical Team began the development of an in-house cognitive rehabilitation workshop. However, due to financial obstacles, further development of the workshop was interrupted.

The C-NEST Development Team is comprised of early-career scholars exceptionally knowledgeable about Caribbean culture. Five of them are Barbadian, one is St. Lucian, and one is Barbadian-American. The cultural makeup of the team creates a unique opportunity for conducting research through the lens of indigenous Caribbean people, thereby increasing the probability of “obtaining authentic and trustworthy data” (Wilson et al., 2019).

As the leader of the development team, Dr. Jerine Griffith brings her knowledge of research methods, clinical programming, and client-centered evaluation methods. Dr. Griffith will ensure that the highest standards are met during the preparation, execution, evaluation, and reporting stages of the solution. Her training as a clinical psychologist affords her the ability to guide the development of a brief yet comprehensive screening battery. Additionally, her work with SAF clients over the past eight years resulted in an expansion of mental health services for clients with co-occurring disorders.  Stephan Munroe, BSc, a graduate of the University of West Indies, will co-lead the design and implementation of the solution. His tenure at the island’s community-based mental health counseling center gives him insight into intake protocols and the needs of individuals and families who access community mental health. In addition, Lynriel Hunte, MSc, another member of the Research Team, brings her experience designing and executing research for the Ministry of Environment and the United Nations Development Programme (UNDP). Brittany Jordan has her Master’s in Neuroscience and completed her thesis investigating the effects of repetition and guided relaxation on memory in a non-brain injured population (analyzed against ABI patient data), conducted in collaboration with the Royal Hospital for Neuro-disability in London. The other team members, Nicole Arthur, MSc., Deon George, MSc., and Osude Bruce, BSc. have experience in data collection, analysis, and interpretation, which will be imperative in the final stages of the solution. The Team brings scientific expertise, but more importantly, an understanding of the Caribbean culture and experience and fluency in the many different dialects that make up the Eastern Caribbean.  

The concept of C-NEST began four years. When Dr. Griffith worked with the men and women at SAF in substance abuse recovery, she noticed several clients exhibited impaired cognitive functioning. There was, however, no formal assessment procedure or intervention strategy to address their needs. Instead, she worked one-on-one with clients and taught compensatory skills that would enable them to get the most out of treatment. More recently, in 2022, the clinical/research team began administering the Montreal Cognitive Assessment (MoCA) to provide formal assessment to all entering clients. The aim was to (1) assess the utility of using the MoCA with a Caribbean substance-using population and (2) collect data on the prevalence of cognitive impairment in Barbados. Subsequently, the development of the C-NEST prototype began. Culture-free assessment measures were identified, and a computerized battery was formalized. At this juncture, the C-NEST needs to be piloted for validity and reliability before it can be marketed to other treatment centers and used in other arenas in mental health and physical healthcare. Additionally, the workshop needs to be piloted and evaluated for its long-term effectiveness. Hence, we consider the C-NEST solution to be a prototype. 

We have not begun the implementation stage yet.

We are in the development stage of the C-NEST prototype and seeking funding to complete the process. Materials, such as hand-held tablets, are essential to our solution. However, as a non-profit organization that relies on charitable giving, SAF does not have the financial resources to fully support the solution’s development and implementation. Additionally, we aim to pilot the instrument and intervention with the clientele at SAF and track them over twelve months, thus, we would need incentives to secure a year’s commitment to the project from each participant. 

The C-NEST solution has the potential to significantly improve the healthcare sector in Barbados.

• Leveraging Technology
• Leveraging Data
• Combining best practices

Neuropsychological screening and intervention are in their infancy in the Caribbean (Fujii, 2022). Those with financial resources have access to neuropsychological services, but many others do not. The screening component of the C-NEST can be used in multiple arenas (e.g., schools, clinics, treatment centers, and hospitals). According to Bauer et al. (2012), “Computerized cognitive assessment measures have a number of potential advantages over examiner-administered neuropsychological tests, including automated and accurate scoring, precise reaction time measurements, and the ability to assess large numbers of individuals within a brief time frame.” Thus, leveraging technology to assess cognitive functioning is in line with industry standards.

In addition, the C-NEST cognitive rehabilitation component uses technology to improve treatment outcomes among substance-using individuals. Although a gold standard intervention has yet to be established in substance abuse treatment, computerized cognitive mediation therapies are highly regarded. For example, Verdejo-García (2016) states that interventions to improve cognitive functioning and teach compensatory skills have the potential to increase the likelihood of long-term recovery from addiction. More specifically, Marceau (2017) points out that computerized cognitive training has produced moderate to large effects on global cognition, attention, and working memory, as well as small to moderate effects on symptom severity and daily functioning in major depressive disorder populations. Thus, we can expect significant results when including cognitive rehabilitation in substance abuse treatment.

The C-NEST solution is client-centered and data-driven. We will collect and analyze data to make informed decisions that enhance the client experience and improve the effectiveness of the assessment measure and cognitive rehabilitation workshop. Moreover, data analysis of client feedback will ensure that C-NEST continues to meet the unique needs of the Eastern Caribbean population.

The assessment component of the C-NEST is a compilation of non-verbal, normed cognitive assessment measures. It has combined widely used tools that measure attention, impulsivity, cognitive flexibility, and executive functioning skills into one digital battery. The C-NEST, however, has removed the reliance on verbal reasoning, which is often influenced by culture. Thus, it will be able to provide non-bias test profiles. In addition, the reliability and validity of each assessment measure that comprises the C-NEST have been established, ensuring the credibility of each instrument.

4. Increasing accessibility of mental health services

C-NEST aims to solve a long-standing problem in the Caribbean mental healthcare sector- the inaccessibility of neurological services. By providing a computerized neurological screening tool, C-NEST increases the identification of cognitive issues in the population, decreases misdiagnoses, and promotes attention to brain health. Although other computerized screening tools exist in the United States, they do not consider the impact of culture on the assessment and interpretation of results.

  Thus, by leveraging technology and data, and expanding accessibility, the C-NEST solution could exponentially improve brain health in Barbados. 

For the first year, the C-NEST solution aims to impact the SAF clientele. Although it is a relatively small subset of the population in Barbados (about 110 adults), it will allow us to identify the project’s strengths and limitations. In addition, we will have continuous contact with the 2023-2024 cohort, affording us longitudinal data from which to launch the next phase of the project.

Over the next five years, we aim to accomplish the following:

• Train mental health and medical treatment providers in Barbados on how to administer the C-NEST and make use of the test results in their respective arenas.  
• Train medical and mental health providers in Grenada, Dominica, Guyana, and St. Lucia on how to administer the C-NEST and make use of the test results in their respective arenas.  
• Train school psychologists in the University of West Indies system on administering the C-NEST and using the test results with university-age young adults.
• Promote the use of the C-NEST Computerized Cognitive Rehabilitation Workshop in senior care homes in Barbados.

We estimate that by 2028, we will have impacted 80% of the population in Barbados and several hundred individuals in our sister countries of Grenada, Dominica, Guyana, and St Lucia. Future long-term goals are to expand our impact across the entire Eastern Caribbean.

To achieve these impact goals, we will (1) focus on strengthening the development team, (2) perfect the C-NEST assessment using data analytics from the initial cohort, (3) secure partnerships with medical and mental health providers outside of Barbados, and (4) identify affordable strategies to expand the use of the C-NEST tool and intervention program.  

We intend to measure progress using the following indicators:

• Number of in-house clients accurately identified with cognitive impairment issues at intake.
• Number of in-house clients who participated in the C-NEST intervention workshop and showed significant improvement in functioning after discharge from treatment.
•  Percentage increase in client satisfaction with the quality of the C-NEST intervention.
• Reduction in the incidence of early self-discharges of clients identified with co-occurring substance use disorders and cognitive impairment.
• Number of adult patients in the community who accessed neuropsychological screening at community clinics and the island’s hospitals through the C-NEST platform.
• Number of new treatment settings and senior care homes using the C-NEST solution (assessment or intervention component)
• Number of universities counseling centers using the C-NEST solution (assessment or intervention component)
• Increase in the number of treatment care providers in Barbados, Grenada, Dominica, Guyana, and St. Lucia who meet competence in administering neuropsychological screening.  

We believe that by improving access to affordable cognitive screening and interventions for underserved communities in the Caribbean, we can reduce societal ills, such as school failures, long-term unemployment, excessive healthcare costs, and the onset and continuation of substance abuse. Moreover, our theory of change is based on the premise that community-based treatment providers in the Caribbean should be skilled and trained in essential services to reduce the burden of care on the few professionals in the mental health care field. Lastly, we strongly believe in the impact and influence of culture in healthcare services and advocate for the consideration of culture in the development and execution of societal change solutions. 

The C-NEST solution has two components: assessment and intervention.

The assessment component of C-NEST uses digital technology to collect patient/client data. Often referred to as technology-based assessment, C-NEST will collect data, analyze, and report test results. The C-NEST tool is administered by a trained care provider using a tablet. The patient/client responds to the stimuli, and the results can be analyzed in real-time. The C-NEST does not rely on the tech-savviness or reading comprehension of patients and clients. The measures are all culture-free and use limited language. In addition, the tablet is user-friendly and straightforward.  

The core technology behind the intervention component of C-NEST is computer-based training (CBT). The C-NEST intervention workshop can be delivered via software installed on a single computer or through a corporate intranet. The C-NEST computer-based training will teach cognitive skills required in real-world situations. Currently, the C-NEST intervention component is designed for the substance-using population and has been used in the field with individuals with substance-use disorders (SUDs). 

DEI is a high priority for the C-NEST solution. We believe in the importance of our work being culturally informed. From inception to the execution of our products and services, we have DEI at the forefront. We interview a range of potential product users and employ ongoing evaluations as practical strategies to incorporate DEI.

Additionally, we will consult with local stakeholders who may work with different populations and hold different world views. We will incorporate these stakeholders in the evaluation process to ensure that the C-NEST remains inclusive.

Value Proposition: The C-NEST Solution addresses the lack of accessible brain healthcare in the Eastern Caribbean. Healthcare providers will be able to provide quick and reliable screenings for cognitive impairment for individuals who otherwise would go undiagnosed and untreated for potentially life-damaging cognitive issues.

Key Partners: Eastern Caribbean Substance Abuse Treatment Centers, Community-based Medical Clinics, Hospitals, Job-training Centers, School Mental Health Facilities, and Senior Care Homes.

Key Activities: Training and Consulting

Key Resources: Trained staff, Tablets, User Permissions, Workshop Space

Estimated Initial Costs:

 $480.00- 2 Samsung Tablets

Staff stipends -(4X 1500) $6000

Purchase of Assessment Measures: pending

Office Materials- $750

Customer Relationships: The assessment component of the C-NEST Solution will adopt a “train-the-trainer” format, where face-to-face training is offered to key personnel at each organization, who, in turn, train their staff. On-going in-person or virtual consultations will also be offered. The clinical team at SAF will provide the workshop component of the C-NEST Solution. Consumers of organizations in Barbados will be offered face-to-face workshops, while consumers in neighboring countries will have the option of face-to-face workshops or virtual workshops.

Customer Segments: Organizations that provide physical and mental healthcare to the community, focusing on the underserved.  

Channels: The C-NEST Solution will be marketed through various channels, including healthcare conferences and events, staff training, professional association meetings, and social media.

Revenue Streams: Subscription-based fees and fees for training and consulting services

To become financially sustainable, we will explore the following strategies:

• Offer subscription-based products and services.
• Offer on-site training of products and services.
• Offer consultation services once products are purchased. 
• Secure investments from socially responsible investors interested in supporting solutions that positively impact Caribbean society.

Thus far, we have not generated any revenue. We are actively pursuing grant funding with neuropsychological foundations.