Title: NIHR Global Health Research Group on a package of care for the mental health of survivors of violence in South Asia at University College London Institute of Child Health
Funder: Department of Health and Social Care

Abstract: a) The UCL 2034 Global Strategy utilises the strength of cross-disciplinary, problem-focused research on social needs, ethical principles, and user engagement. UCL is “London’s Global University”, a world leader in research, a leading centre for innovation and interdisciplinarity, a beacon for public engagement, and a global leader in combined medical and health research. The four UCL Grand Challenges (Global Health, Sustainable Cities, Intercultural Interaction, and Human Wellbeing) concentrate expertise to address aspects of the world’s key problems. The strategic objectives of our research reflect those of UCL: create networking opportunities across disciplines and foster expert networks, provide spaces for debate bringing together different expertise, perspectives and methodologies to provoke new understanding, stimulate novel research through cross-disciplinary activity to generate wisdom and societal debate, and improve policy and practice through enhanced public service and policy, quality of life and social justice and equity. b) UCL had the highest research strength rating in the 2014 UK Research Excellence Framework. Global health and improving the lives of people in low- and middle-income countries are at the core of the UCL Grand Challenges programme. The hub of our group will be the new UCL Centre for the Health of Women, Children and Adolescents at the Institute for Global Health (IGH). IGH conducts multidisciplinary research with partners in over 40 countries, supported by funding from, among others, NIHR, Wellcome, MRC, DfID, BMGF, European Commission, and ESRC. It hosts the Global Alliance for Chronic Diseases and held a DfID Research Programme Consortium and a Wellcome strategic award across four LMICs, producing high-impact publications and policy impact on global maternal, child, and adolescent health. As Director of the UCL Centre for the Health of Women, Children and Adolescents, and with support from Prof Ibrahim Abubakar (IGH Director), Osrin will ensure office space, hardware and software, operational and administrative support for the group. IGH is committed to capacity development through a high-quality, extensive teaching programme that delivers an intercalated BSc, MScs, MPhils, PhDs and short courses. It has a track record of delivering strong community-based research in South Asia. Previous work with collaborators in DAC countries has cemented relationships and an emphasis on collaborative response to local and national issues. The Division of Psychiatry is a multidisciplinary centre that has a large research programme with over £40m of research income from NIHR, Research Councils, and medical charities. It has an excellent track record in developing the careers of young researchers. The Divisional strategy includes expanding work with LMICs, for which many of its research strengths in randomised controlled trials, epidemiology, and applied health research are priorities. c) The group will build on existing institutional partnerships between UCL and SNEHA (VAW), and LSHTM and Sangath (modern slavery and mental health). Substantial investments in research to prevent and address the consequences of VAW are already in place, with MRC, Wellcome, and large programme support from the UK Department for International Development (UKAid) for research on prevention of domestic violence in Asia. The LSHTM Gender, Violence and Health Centre (GVHC) has a current multi-country evaluation of prevention of modern slavery in South Asia, funded by UKAid, and a track record of quantitative and qualitative research on modern slavery in Asia, Africa, Latin America, and the UK. GVHC pioneered research on VAW, conducted the first systematic study on the global prevalence of gender-based violence, and, in partnership with the South Africa MRC, is conducting a global study on the effectiveness of interventions to prevent violence (in which DFID is investing £25 million over five years). LSHTM and KCL have a longstanding partnership through the Centre for Global Mental Health and through jointly held grants (PROTECT, NIHR PRP funded research on the NHS response to victims of human trafficking, led jointly by Howard and Zimmerman, with Oram and Abas as co-investigators). Howard, Abas and Oram have a strong track record of research on gender-based violence and mental health at the Section of Women’s Mental Health led by Howard,1 including NIHR funded research into partner violence, NIHR Research Professorship funded research into gendered violence including sexual violence, migrant health and domestic violence, and capacity building through MRC and NIHR funded clinical fellowships and PhD studentships at the Section of Women’s Mental Health led by Howard. Sangath has worked in collaboration with LSHTM for two decades to examine the burden of a range of mental and substance use disorders, and developed and evaluated treatment packages delivered by non-specialist health workers for autism, alcohol use disorders, depression, maternal depression, schizophrenia and dementia. Our group unites these partnerships, adds new ones, and prioritises sustainability through both common interests and the development of a cadre of early career researchers. d) Our research themes and intervention needs are derived directly from partners and user-group experiences. For example, Sangath is one of the world’s leading mental health research organisations that has been struggling to respond to violence in families dealing with mental health problems, including alcohol use. For SNEHA, the need for mental health interventions arises directly from work with survivors of VAW, for whom mental health conditions can be both cause and effect. The partnership with HAWCA in Afghanistan has arisen from the mental health support needs of women and children in shelters, and the Sri Lanka partner, University of Colombo, has identified the substantial mental health challenges facing survivors of conflict. As collaboration is fundamental to achieving user-driven, context appropriate responses, our interventions will be co-created from the start with user groups and in consultation with key decision-makers and other relevant stakeholders. We will respond to the Green and White Papers on Citizen Science, mandating that public engagement in research extends beyond data collection and consideration of findings to the framing of questions and design of interventions. Violence and mental health are both complex problems that require a grounded understanding of survivors' and their families’ responses to mental health concerns, and the realities of local resources and coalition-building to support functional referral. Work plans will address UCL engagement priorities (inform, consult, collaborate). Adapting and testing interventions grounded in community realities will require co-development with users whose needs they are designed to address. More broadly, our work will respond to user and stakeholder priorities articulated in UN Sustainable Development Goals 3.4 (reduce premature mortality from non-communicable disease, and promote mental health), 5.2 (eliminate violence against women, girls, and children), 8.7 (end human trafficking and child labour), 16.1 (reduce all forms of violence), and 16.2 (end abuse, exploitation, trafficking), the World Health Assembly 2014 resolution on strengthening the role of health systems in addressing violence, the goals of the Global Partnership to End Violence Against Children and the South Asia Institute to End Violence Against Children, and the UN Protocol to Prevent, Suppress and Punish Trafficking in Persons, especially Women and Children. It also addresses the 1980 Convention on the Elimination of All Forms of Discrimination Against Women, the 2006 UN declaration on response to violence against women and girls, the 2013 WHO Mental Health Action Plan, and the 2011 Grand Challenges in Global Mental Health.

Lay abstract: Our multidisciplinary group of established and early career researchers will develop a comprehensive, adaptable package of care to improve the mental health of survivors of violence against women (VAW), modern slavery, and civil conflict in resource-constrained settings in India, Sri Lanka, and Afghanistan. Important commonalities exist between the mental health needs of survivors of different forms of violence. VAW describes physical, sexual, emotional, or economic intimate partner, domestic, and non-partner violence. It affects 42% of women in South Asia. Modern slavery describes forced marriage, forced labour and commercial sexual exploitation. It affects 40 million people worldwide, with the greatest burden in Asia. Conflict in Afghanistan and Sri Lanka, amidst discriminatory gender norms, has exposed a majority of women to abuse, trauma and poor mental health. These forms of violence are gendered, culturally and generationally recapitulated, and strongly associated with mental illness, particularly depression, anxiety, post-traumatic stress disorder, and suicidal thinking. Reductions in prevalence and severity of these conditions will be our target outcomes in groups whose gender and age reflect local burden of violence. Alongside psychological therapies, the range of necessary non-clinical responses includes crisis counselling, shelter, legal and financial negotiation, social work, and community support networks. In developing a package of care adaptable to different forms of violence in resource-limited settings, we will identify and review promising models, refine them contextually through user engagement, pilot and collate them. Objectives Empirical: Identify candidate component interventions, understand survivors' mental health needs, codevelop with survivors and providers a care package that fills service gaps, determine how feasible components are to deliver, their acceptability to survivors and providers, and potential transferability. Developmental: Build an international multidisciplinary group committed to developing early career researchers by supporting them through a sequence of complex intervention development. Work package 1 Identify candidate interventions through systematic review and expert networks. Through household and institutional surveys, augment existing partner data with quantitative and qualitative information on mental health burden, needs, stigma, and care-seeking. Through interviews and workshops, work with survivors and providers to understand local perspectives, mental health and social support services, intervention opportunities, and potential resources. Work package 2 Collaborate with survivors and providers to pinpoint promising interventions and opportunities, barriers to uptake, and potential unintended outcomes. Through workshops and consultation, codevelop theories of change and delineate a provisional intervention package. Work package 3 Pilot interventions to understand feasibility (cultural appropriateness, delivery, uptake, barriers and enablers), acceptability (motivations and expectations, safety and unintended outcomes), and potential effectiveness. Outcome Within 3 years, our innovative international group will have designed and piloted a package of contextually-appropriate, multidisciplinary interventions for depression, anxiety, PTSD, and suicidal ideation in survivors of violence for government and non-government organisations to use according to the needs of users and providers.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: MENTAL HEALTH