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.

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

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.

Publications

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

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

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

 
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