Title: NIHR Global Health Research Group on sustainable care for anxiety and depression in Indonesia.
Funder: Department of Health and Social Care

Abstract: Background: The total proportion of people living with common mental health disorders is rising. These disorders impact significantly on patient and population health and challenge sustainable development in low-to-middle-income countries (LMICs). _x000D_ _x000D_ Fourteen million people live with depression and anxiety in Indonesia, placing it in the top two countries for prevalence in the WHO’s South-East Asia region. Effective psychological interventions are available for depression and anxiety but robust evidence to maximise their scalability and sustainability is lacking. _x000D_ _x000D_ Aim: Our group aims to improve health and productivity in Indonesia by increasing the availability and accessibility of evidence-based treatments for adults living with anxiety and depression. _x000D_ _x000D_ Methods: Our 4-year programme comprises 5 work-packages (WPs) and 2 cross-cutting themes (CCTs). _x000D_ _x000D_ WP1 (Month 0-28) will pilot a new household survey to understand the distribution, determinants and socio-economic consequences of depression and anxiety in Indonesia and area-level influences on service supply. _x000D_ _x000D_ WP2 (Months 4-15) will qualitatively explore the different contexts into which psychological interventions may be introduced in Indonesia and culturally-adapt, with Community Engagement and Involvement (CEI) representatives, a low intensity psychological intervention for Indonesian use. _x000D_ _x000D_ WP3 (Month 16-22) will work in partnership with professional and community stakeholders to co-develop local implementation strategies to increase access to depression and anxiety treatments in Indonesia, and deliver and evaluate sustainable training to increase workforce capacity. _x000D_ _x000D_ WP4 (Month 23-46) will use implementation science methodologies to evaluate the delivery, reach and impacts of a culturally-adapted, low-intensity psychological intervention for depression and anxiety in Indonesia and identify any outstanding barriers to its uptake, access and use. _x000D_ _x000D_ WP5 (Month 34-46) will take a health economic perspective to identify priority regions for treatment roll-out and deliver a sustainability toolkit to support national scale-up. _x000D_ _x000D_ Two cross cutting themes, community engagement and partnership working (CCT1) and leadership and capacity building (CCT2) span our programme, establishing intersectoral networks and upskilling clinical, academic and public collaborators to undertake high quality service development and mental health research. _x000D_ _x000D_ Anticipated impact & dissemination: Our proposal builds on strong partnerships between the Universities of Manchester and Indonesia developed over 3 years. It directly addresses two research priorities identified through collaboration with local Indonesian community groups. It is supported by the Indonesia Workforce Council at the Ministry of Health, and the Directors of Mental Health and Primary Care in Indonesia. _x000D_ _x000D_ We will adopt an inclusive, proactive approach to dissemination with high stakeholder participation. At programme end, we will deliver manualised protocols to support high quality service delivery, sustainable workforce capacity building and treatment resources. We will have quantified costs and completed a budget impact analysis to optimise scalability and sustainability. We will have strengthened mental health advocacy in Indonesia, established a vanguard health services research training hub, developed culturally-acceptable CEI guidelines and produced a new evidence-based framework to optimise knowledge mobilisation.

Lay abstract: Depression and anxiety are common mental health problems, affecting large numbers of people around the world. Depression and anxiety affect 14 million people in Indonesia, and this country has one of the highest rates of depression in the South East Asia region. Depression and anxiety can affect how people feel and how communities function; these disorders can worsen physical health conditions and significantly increase healthcare costs. This challenges sustainable development in low-middle income countries. Depression and anxiety are treatable but there is a shortage of trained professionals. Many people in Indonesia, and across the world, are not getting the help they need._x000D_ _x000D_ Talking treatments can help people with depression and anxiety to recover. These treatments can be delivered by people without a mental health qualification and are recommended by the World Health Organisation's for areas where mental health services are limited. Training lay workers to deliver talking treatments is cheaper and more feasible than training a smaller number of highly skilled professionals. It can reduce the stigma of mental health treatment and make treatment more accessible. Similar approaches have been tested in other countries, but the best way to organise and support these services is unknown. This means that we do not know how best to deliver these interventions in Indonesia, how acceptable they will be or what benefits they will have. _x000D_ _x000D_ We will use information from existing national surveys in Indonesia to identify where rates of depression and anxiety are highest and where talking treatments are needed the most. We will find out which groups of people have the greatest difficulties accessing talking treatments and explore what effects this has. We will work directly with patients and professionals to understand their experiences of, and preferences for, receiving and delivering treatments and the types of challenges they face._x000D_ _x000D_ Once we understand the problem, we will work with patients, lay workers, professionals and policy makers to culturally adapt talking treatments, produce locally relevant delivery plans and provide workforce training. We will explore the impact of our intervention on individuals, communities and health service use. We will talk to patients and professionals about their experiences of our intervention and identify any other needs. We will measure the cost of delivering our intervention and identify the geographical areas and patient groups that should be prioritised for treatment roll out. We will compare and contrast findings from different regions within Indonesia to help us understand how best to support treatment availability and uptake in the longer term, and deliver new learning to help us enhance the delivery of talking treatments in other global settings. _x000D_ _x000D_ Our research team represents an international partnership between mental health professionals and health researchers in the UK and Indonesia. Our research topic and our study design have been selected and shaped by Indonesian public and community volunteers. We will hold collaborative, face-to-face engagement events to engage individuals, families and communities in our programme and deliver training programs to Indoesian health researchers and public representatives to enable further high quality work. We will work with the Ministry of Health and patient and public representatives to tell patients, professionals and policy makers what we find.

Research activity codes: 6.6 PSYCHOLOGICAL AND BEHAVIOURAL;8.1 ORGANISATION AND DELIVERY OF SERVICES;8.2 HEALTH AND WELFARE ECONOMICS
Health categories: MENTAL HEALTH