Indigo (International study of discrimination and stigma outcomes)
Lead Research Organisation:
King's College London
Department Name: Health Service and Population Research
Abstract
Summary for lay readers
The overall aim of the Indigo Partnership is to improve understanding of stigmatisation against people with mental illness, and then to develop and test new methods to reduce such stigma in economically developing countries.
The reason why this is important is that all over the world stigma and discrimination have negative effects, which exclude people with mental illness from the mainstream of society. For example, employment rates for people with mental illness are much lower than for the general population in most countries, and the prospects of marriage can be severely harmed.
The participating centres in this Partnership are in 4 low and middle countries, who will work in close collaboration with staff from 4 high income countries: China (Peking University Health Science Centre, and Guangzhou Medical University); Ethiopia (Addis Ababa University); Germany (University of Ulm); India (George Institute, New Delhi and NIMHANS, Bengaluru), Switzerland (WHO, Geneva); Tunisia (Hôpital Razi, Tunis); UK (KCL); and USA (George Washington University).
The plan is to conduct 4 research activities to understand better how stigma has a negative impact. These will be focussed upon: (i) unconscious bias (for example health care staff who treat people less well without intending to do so); (ii) how people can manage to cope with stigma without it having a negative impact; (iii) how to improve the effect of 'inter-personal contact' between people with and without experience of mental illness to reduce stigma; and (iv) how to adapt stigma reduction interventions to the local context and culture in low and middle income countries. These studies are based upon the findings of research in high income countries that such inter-personal contact is the most effective way to reduce stigma.
We shall also culturally adapt 7 scales which measure different aspects of stigma and translate them into Amharic, Arabic, English, Hindi, Kannada, and Mandarin and Telugu, and make these openly available as an 'evaluation toolkit'.
We shall go on to carry out 3 pilot projects to test specific methods intended to reduce mental health related stigma in: (i) local communities using a public awareness and social marketing programme to increase referrals for people with mental illness to attend local health care services; (ii) in primary health care staff; and (iii) with specialist mental health care staff.
The instructions for these interventions will be adapted, learning from these studies, and made openly available as 'intervention manuals'. If the results of these projects are positive in achieving stigma reduction, we shall apply for research funds in future to test their effectiveness more thoroughly within international, multi-site intervention trials.
In the course of this work the, staff in the whole partnership will support staff in China, Ethiopia, India, and Tunisia to develop their research skills and their careers, so that they can establish centres of excellent in stigma research in each of these countries in future.
Our longer term objectives are to identify effective way to reduce stigma and discrimination against people with mental illness in low- and middle-income countries, and to make a contribution towards more people with such conditions gaining access to effective mental health care in future (namely to decreases the so-called 'treatment gap'), and better outcomes, and achieving greater social inclusion.
The overall aim of the Indigo Partnership is to improve understanding of stigmatisation against people with mental illness, and then to develop and test new methods to reduce such stigma in economically developing countries.
The reason why this is important is that all over the world stigma and discrimination have negative effects, which exclude people with mental illness from the mainstream of society. For example, employment rates for people with mental illness are much lower than for the general population in most countries, and the prospects of marriage can be severely harmed.
The participating centres in this Partnership are in 4 low and middle countries, who will work in close collaboration with staff from 4 high income countries: China (Peking University Health Science Centre, and Guangzhou Medical University); Ethiopia (Addis Ababa University); Germany (University of Ulm); India (George Institute, New Delhi and NIMHANS, Bengaluru), Switzerland (WHO, Geneva); Tunisia (Hôpital Razi, Tunis); UK (KCL); and USA (George Washington University).
The plan is to conduct 4 research activities to understand better how stigma has a negative impact. These will be focussed upon: (i) unconscious bias (for example health care staff who treat people less well without intending to do so); (ii) how people can manage to cope with stigma without it having a negative impact; (iii) how to improve the effect of 'inter-personal contact' between people with and without experience of mental illness to reduce stigma; and (iv) how to adapt stigma reduction interventions to the local context and culture in low and middle income countries. These studies are based upon the findings of research in high income countries that such inter-personal contact is the most effective way to reduce stigma.
We shall also culturally adapt 7 scales which measure different aspects of stigma and translate them into Amharic, Arabic, English, Hindi, Kannada, and Mandarin and Telugu, and make these openly available as an 'evaluation toolkit'.
We shall go on to carry out 3 pilot projects to test specific methods intended to reduce mental health related stigma in: (i) local communities using a public awareness and social marketing programme to increase referrals for people with mental illness to attend local health care services; (ii) in primary health care staff; and (iii) with specialist mental health care staff.
The instructions for these interventions will be adapted, learning from these studies, and made openly available as 'intervention manuals'. If the results of these projects are positive in achieving stigma reduction, we shall apply for research funds in future to test their effectiveness more thoroughly within international, multi-site intervention trials.
In the course of this work the, staff in the whole partnership will support staff in China, Ethiopia, India, and Tunisia to develop their research skills and their careers, so that they can establish centres of excellent in stigma research in each of these countries in future.
Our longer term objectives are to identify effective way to reduce stigma and discrimination against people with mental illness in low- and middle-income countries, and to make a contribution towards more people with such conditions gaining access to effective mental health care in future (namely to decreases the so-called 'treatment gap'), and better outcomes, and achieving greater social inclusion.
Technical Summary
Aim
The overall aims of the Indigo Partnership are to establish a strong research collaboration to provide the infrastructure for harmonised metrics and to develop stigma reduction interventions, and to carry out platform activities to strengthen the scientific understanding of mechanisms of action of stigma processes against people with mental illness. The longer term aim is to reduce the mental health treatment gap.
Partners
Participating centres are: China (Peking University Health Science Centre, and Guangzhou Medical University); Ethiopia (Addis Ababa University); Germany (University of Ulm); India (George Institute, New Delhi and NIMHANS, Bengaluru), Switzerland (WHO, Geneva); Tunisia (Hôpital Razi, Tunis); UK (KCL); and USA (George Washington University).
Methods
1. Improve theoretical understanding of stigma processes by conducting the following types of platform activities to support better understanding of the underlying mechanisms of action of stigma related to: (i) unconscious bias; (ii) optimising inter-personal contact; (iii) cultural adaptation of interventions; and (iv) psychometric assessment of 7 stigma related measures in Amharic, Arabic, Hindi, Kannada, Mandarin and Telugu.
2. Incorporating these results into 3 proof-of-principle activities in the 6 LMIC sites to assess feasibility, relevance, acceptability and costs of the intervention related to primary care staff, mental health staff, and local area awareness-raising to reduce stigma.
Outputs
1. A sustainable platform of collaboration across 8 countries, with established centres of research excellence.
2. Career progression for the early- and intermediate-career researchers in the low and middle income sites.
3. Publication of the results of the studies in strong peer-reviewed journals.
4. Openly available: (i) evaluation toolkit of the 7 scales for future international research use, and (ii) intervention guides for the 3 stigma-reduction interventions.
5. Pilot data that wil
The overall aims of the Indigo Partnership are to establish a strong research collaboration to provide the infrastructure for harmonised metrics and to develop stigma reduction interventions, and to carry out platform activities to strengthen the scientific understanding of mechanisms of action of stigma processes against people with mental illness. The longer term aim is to reduce the mental health treatment gap.
Partners
Participating centres are: China (Peking University Health Science Centre, and Guangzhou Medical University); Ethiopia (Addis Ababa University); Germany (University of Ulm); India (George Institute, New Delhi and NIMHANS, Bengaluru), Switzerland (WHO, Geneva); Tunisia (Hôpital Razi, Tunis); UK (KCL); and USA (George Washington University).
Methods
1. Improve theoretical understanding of stigma processes by conducting the following types of platform activities to support better understanding of the underlying mechanisms of action of stigma related to: (i) unconscious bias; (ii) optimising inter-personal contact; (iii) cultural adaptation of interventions; and (iv) psychometric assessment of 7 stigma related measures in Amharic, Arabic, Hindi, Kannada, Mandarin and Telugu.
2. Incorporating these results into 3 proof-of-principle activities in the 6 LMIC sites to assess feasibility, relevance, acceptability and costs of the intervention related to primary care staff, mental health staff, and local area awareness-raising to reduce stigma.
Outputs
1. A sustainable platform of collaboration across 8 countries, with established centres of research excellence.
2. Career progression for the early- and intermediate-career researchers in the low and middle income sites.
3. Publication of the results of the studies in strong peer-reviewed journals.
4. Openly available: (i) evaluation toolkit of the 7 scales for future international research use, and (ii) intervention guides for the 3 stigma-reduction interventions.
5. Pilot data that wil
Planned Impact
Impact summary
The Indigo Partnership is designed to deliver the following types of positive impact:
1. A sustainable platform of collaboration across 8 countries, with established centres of research excellence. We shall create individualised career development plans for all early- and intermediate-career researchers in the low and middle income sites to support their career progression, and to assist them to establish centres of excellence in stigma research in each field site
2. Peer-reviewed publication of the results of the theoretical and proof-of-principle studies in strong international journals.
3. Generation of pilot data suitable to support future multi-site international RCTs of manualised stigma-reduction interventions, consequent upon the Indigo Partnership studies related to stigma among: (i) primary care staff; (ii) mental health staff; and (iii) local populations.
4. Providing actionable beneficial knowledge to:
Research staff who are engaged in studies to improve understanding of the basic mechanisms of action under-pinning stigmatisation processes
Academic staff who need access to valid and reliable scales to use in stigma-related interventions studies (the 7 scales of the Evaluation Toolkit)
Researchers who wish to test the cost-effectiveness of manualised and theory-based interventions intended to reduce stigma among: (i) primary care staff; (ii) mental health staff; (iii) local populations
Higher education institutions and professional organisations: concerned with clinical health care staff training.
Consumer and family groups, eg associations of people with mental illness and their family members, and advocacy organisations, to adapt and use the Indigo Partnership materials
Mental health care provider organisations, including managers and administrators of health services, including addressing how far primary and secondary health care providers can scale up service supply if service demand increases.
Government agencies concerned with primary and mental health care policy making and planning.
Global mental health communities, including the Movement for Global Mental Health and the World Federation for Mental Health, and Mental Health Innovation Network to dissemination the Indigo Partnership results.
Users of web-based and social media resources. The internet repository will allow open access to Indigo Partnership materials including: intervention manuals, evaluation toolkit, technical documents, policy briefs, and all other materials, in all the Indigo Partnership languages.
WHO (Geneva) will both be a beneficiary and a knowledge transfer agent. The intervention Manuals and Evaluation Toolkit will be used to produce an evidence-based module on how to reduce health care staff stigma as a component of the WHO mhGAP Intervention Guide (v2). The first edition of this guide is now in use in over 90 countries worldwide. In relation to knowledge transfer WHO is uniquely well placed to do this with an active global network in regular contact with all 193 members states of the United Nations, via their network of WHO Regional Offices, and by disseminating Indigo material and results to WHO Collaborating Centres worldwide.
The Indigo Partnership is designed to deliver the following types of positive impact:
1. A sustainable platform of collaboration across 8 countries, with established centres of research excellence. We shall create individualised career development plans for all early- and intermediate-career researchers in the low and middle income sites to support their career progression, and to assist them to establish centres of excellence in stigma research in each field site
2. Peer-reviewed publication of the results of the theoretical and proof-of-principle studies in strong international journals.
3. Generation of pilot data suitable to support future multi-site international RCTs of manualised stigma-reduction interventions, consequent upon the Indigo Partnership studies related to stigma among: (i) primary care staff; (ii) mental health staff; and (iii) local populations.
4. Providing actionable beneficial knowledge to:
Research staff who are engaged in studies to improve understanding of the basic mechanisms of action under-pinning stigmatisation processes
Academic staff who need access to valid and reliable scales to use in stigma-related interventions studies (the 7 scales of the Evaluation Toolkit)
Researchers who wish to test the cost-effectiveness of manualised and theory-based interventions intended to reduce stigma among: (i) primary care staff; (ii) mental health staff; (iii) local populations
Higher education institutions and professional organisations: concerned with clinical health care staff training.
Consumer and family groups, eg associations of people with mental illness and their family members, and advocacy organisations, to adapt and use the Indigo Partnership materials
Mental health care provider organisations, including managers and administrators of health services, including addressing how far primary and secondary health care providers can scale up service supply if service demand increases.
Government agencies concerned with primary and mental health care policy making and planning.
Global mental health communities, including the Movement for Global Mental Health and the World Federation for Mental Health, and Mental Health Innovation Network to dissemination the Indigo Partnership results.
Users of web-based and social media resources. The internet repository will allow open access to Indigo Partnership materials including: intervention manuals, evaluation toolkit, technical documents, policy briefs, and all other materials, in all the Indigo Partnership languages.
WHO (Geneva) will both be a beneficiary and a knowledge transfer agent. The intervention Manuals and Evaluation Toolkit will be used to produce an evidence-based module on how to reduce health care staff stigma as a component of the WHO mhGAP Intervention Guide (v2). The first edition of this guide is now in use in over 90 countries worldwide. In relation to knowledge transfer WHO is uniquely well placed to do this with an active global network in regular contact with all 193 members states of the United Nations, via their network of WHO Regional Offices, and by disseminating Indigo material and results to WHO Collaborating Centres worldwide.
Organisations
- King's College London, United Kingdom (Lead Research Organisation)
- Ulm University Medical Center (Collaboration)
- University of Sussex, United Kingdom (Collaboration)
- University of Ibadan, Nigeria (Collaboration)
- George Washington University, United States (Collaboration)
- Peking University Sixth Hospital (Collaboration)
- Transcultural Psychosocial Organization (Collaboration)
- London School of Economics & Pol Sci, United Kingdom (Collaboration)
- World Health Organization (WHO) (Collaboration)
- National Institute of Mental Health and Neurosciences (Collaboration)
- George Institute for Global Health (Collaboration)
Publications

Alenezi A
(2021)
Translation and validation of the Arabic version of the barrier to access to care evaluation (BACE) scale
in Mental Health and Social Inclusion

Asian J Psychiatr
(2021)
Systematic review of interventions to reduce mental health stigma in India.
in Asian J Psychiatr

Bakolis I
(2019)
Development and validation of the DISCUS scale: A reliable short measure for assessing experienced discrimination in people with mental health problems on a global level.
in Schizophrenia research

Barber S
(2019)
Microaggressions towards people affected by mental health problems: a scoping review.
in Epidemiology and psychiatric sciences

Barbui C
(2020)
Efficacy of psychosocial interventions for mental health outcomes in low-income and middle-income countries: an umbrella review
in The Lancet Psychiatry

Breuer E
(2019)
Partnerships in a Global Mental Health Research Programme-the Example of PRIME.
in Global social welfare : research, policy & practice

Clay J
(2020)
Core components of mental health stigma reduction interventions in low- and middle-income countries: a systematic review.
in Epidemiology and psychiatric sciences

Codjoe L
(2019)
Tackling inequalities: a partnership between mental health services and black faith communities.
in Journal of mental health (Abingdon, England)


Das-Munshi J
(2020)
Gaps and challenges: WHO treatment recommendations for tobacco cessation and management of substance use disorders in people with severe mental illness.
in BMC psychiatry
Description | E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project) |
Organisation | Transcultural Psychosocial Organization |
Country | Nepal |
Sector | Charity/Non Profit |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2018 |
Description | E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project) |
Organisation | University of Ibadan |
Country | Nigeria |
Sector | Academic/University |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2018 |
Description | E-MhGAP Intervention guide in Low and middle income countries: proof-of-concept for Impact and Acceptability (Emilia project) |
Organisation | World Health Organization (WHO) |
Country | Global |
Sector | Public |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2018 |
Description | Indigo Partnership |
Organisation | George Institute for Global Health |
Department | George Institute for Global Health (India) |
Country | India |
Sector | Charity/Non Profit |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | George Washington University |
Country | United States |
Sector | Academic/University |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | London School of Economics and Political Science (University of London) |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | National Institute of Mental Health and Neurosciences |
Country | India |
Sector | Hospitals |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | Peking University Sixth Hospital |
Country | China |
Sector | Hospitals |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | Transcultural Psychosocial Organization |
Country | Nepal |
Sector | Charity/Non Profit |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | Ulm University Medical Center |
Country | Germany |
Sector | Hospitals |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | University of Sussex |
Department | Brighton and Sussex Medical School |
Country | United Kingdom |
Sector | Academic/University |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Description | Indigo Partnership |
Organisation | World Health Organization (WHO) |
Country | Global |
Sector | Public |
PI Contribution | Coordination of research programme |
Collaborator Contribution | Individual research site coordination and site lead |
Impact | Current publications are listed in the publication section. Further papers are currently in submission. |
Start Year | 2019 |
Title | Implicit Association Test (IAT) app |
Description | Mobile phone application for administering the Implicit Association Test (IAT); adapted for use in all study settings (India, China, Nepal, Tunisia, Ethiopia) considering language and other contextual differences. |
Type Of Technology | Webtool/Application |
Year Produced | 2021 |
Impact | Ability to carry out IAT on mobile devices |
Description | INDIGO coordination meeting in Pokhara |
Form Of Engagement Activity | Participation in an activity, workshop or similar |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Other audiences |
Results and Impact | INDIGO coordination meeting before the initiation of the project was conducted in Pokhara metropolitan city with mayors, health coordinators, and other stakeholders (n=16) to inform them about the project objectives, research design, and get their approval for implementation of the project. The coordination meeting was conducted on February 24, 2021 |
Year(s) Of Engagement Activity | 2021 |
Description | Indigo Partnership newsletter |
Form Of Engagement Activity | A magazine, newsletter or online publication |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Study participants or study members |
Results and Impact | Newsletter developed and disseminated in collaboration with WHO to share updates about Indigo Partnership project progress and upcoming work. |
Year(s) Of Engagement Activity | 2022 |
Description | The European Region WHO Collaborating Centre annual meeting |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Policymakers/politicians |
Results and Impact | Shared details of the Indigo project at the European Region WHO Collaborating Centre annual meeting in November 2021. |
Year(s) Of Engagement Activity | 2021 |
Description | WHO EMRO region meeting |
Form Of Engagement Activity | A talk or presentation |
Part Of Official Scheme? | No |
Geographic Reach | Regional |
Primary Audience | Policymakers/politicians |
Results and Impact | Meeting with the Regional Advisor for WHO Regional Office for the Eastern Mediterranean (EMRO) to discuss plans for a regional meeting with participation of selected member states with the objectives of : (1) Orienting the national mental health focal points about the work being done in countries around the region and beyond to tackle the issue of stigma related to mental health (2) Sharing the available tools and resources to set up anti stigma programmes -- what (interventions which are evidence based), what (content), where (settings), How (implementation issues including measuring change) (3) Identify the support needed by countries to develop and set up ant stigma programmes |
Year(s) Of Engagement Activity | 2021 |
Description | WHO MSD lunchtime seminar |
Form Of Engagement Activity | A formal working group, expert panel or dialogue |
Part Of Official Scheme? | No |
Geographic Reach | International |
Primary Audience | Policymakers/politicians |
Results and Impact | Webinar on "Evidence for reducing mental health related stigma: The Indigo collaboration". Held for the WHO Department of Mental Health and Substance Abuse, and regional office staff. Aim to orient WHO colleagues in HQ and the Regions to the INDIGO Partnership work and identify path for future collaborative work to build on this. |
Year(s) Of Engagement Activity | 2021 |