Indigo (International study of discrimination and stigma outcomes)

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.

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

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.