Title: Transforming Access to Care for Serious Mental Disorders in Slums - the TRANSFORM Project
Funder: Department of Health and Social Care

Abstract: We wish to address the problem of inadequate biomedical care for those with serious mental disorders (SMDs&ndash; psychotic disorders and severe mood disorders, often with co-occurring substance-abuse) living in urban slums in low- and-middle-income countries (LMICs). Slums have high rates of SMDs, poor access to biomedical care and conditions of chronic hardship and adversity. Faith-based and traditional healing can play an important part in delivering care in LMICs, especially for common mental disorders like anxiety and depression, but those with SMDs require additional biomedical treatment and follow-up. The TRANSFORM project aims to improve outcomes of persons with SMDs through better access to effective biomedical care by developing an innovative collaborative care model between traditional/faith healers, mental health professionals, primary care practitioners and community health workers (CHWs). We will develop and test community-delivered identification and referral pathways that recognise existing beliefs and pluralistic help-seeking of slum-dwellers in New Delhi, India and Ibadan, Nigeria (both ODA eligible countries). We will conduct rapid community-based ethnographic assessment using qualitative and participatory methods to explore community understandings of mental disorders and help-seeking. Using non-participatory observations, we will explore the role of traditional and faith healing for mental disorders, from the perspectives of the population, healers, CHWs and health professionals. Our findings will be used to co-design, with CHWs and traditional practitioners, training packages for screening, early detection and referral to biomedical care for individuals (18+) suffering from SMDs. We will evaluate the effectiveness of the training programmes in increasing referrals to and the provision of community mental health care of cases of SMDs and conduct a cost-effectiveness analysis of the intervention and its outcomes. We predict that as a result of our intervention, more individuals with SMDs will be identified and referred to appropriate biomedical care by both CHWs and traditional/faith healers. More SMD cases will therefore receive appropriate biomedical care following our intervention, as compared to those accessing help in the year preceding our intervention. The proposal was developed in detailed discussion with research teams in Delhi and Ibadan, slum community leaders, CHWs and local traditional/faith healers, and community organisations working with SMDs in LMICs. The project team involves academic/clinical partners from UK, India, Nigeria and Canada, all with expertise in global mental health, community organisations, and creative arts from partner sites. It builds on existing work by project partners in both improving psychosis outcomes and slum health in India and Nigeria. Besides disseminating findings through the usual channels of scientific publications and policy papers, we will develop street theatre and cinema based on our findings in order to increase the impact of the research and further engage the slum communities across LMICs, raise awareness, reduce stigma and provide information on plural health care for SMDs

Lay abstract: Slum populations in low- and-middle-income countries (LMICs) have high rates of serious and enduring mental disorders (SMDs &ndash; psychotic disorders and severe mood disorders, often with co-occurring substance abuse) and very poor access to mental health care. Sufferers and their families choose traditional and faith-based practices since these are more accessible, considered affordable, and are in tune with their cultural beliefs and traditions. Faith-based and traditional healing can play an important part in delivering care in LMICs, especially for common mental disorders like anxiety and depression, both in Africa and India ([1], [2]), but those with SMDs require additional biomedical treatment and follow-up. The TRANSFORM project aims to improve access to care and outcomes of SMDs in slums, by developing an innovative collaborative care model involving traditional/faith healers, mental health professionals, primary care practitioners and community health workers (CHWs). This multidisciplinary research programme will be conducted across two slum communities, one each in New Delhi, India and Ibadan, Nigeria (both ODA-eligible countries). We will conduct in-depth studies to understand local communities' awareness and understanding of SMDs and sit with traditional and faith healers to understand who seeks care, how care is given and how healers identify and could refer those with treatable SMDs to medical care. We will develop an understanding of the explanatory models of illness and care ([3]) in relation to SMDs from the perspectives of community members, healers and health professionals. Based on these findings, we will develop two training packages, one for healers and one for CHWs, focused on identification, referral to local psychiatric services and ongoing support for patients (18+) with SMDs. We will evaluate the effectiveness of the training programmes in increasing referrals to and the provision of community mental health care of cases of SMDs, and conduct a cost-effectiveness analysis of the intervention and its outcomes. The proposal has been developed in detailed discussion with research teams in New Delhi and Ibadan, slum community leaders, CHWs and local traditional/faith healers, who will be ongoing partners of the project. Besides disseminating findings through the usual channels of scientific publications and policy papers, we will develop street theatre and documentary films on our findings to increase the impact of our research and to further engage slum communities, raise awareness, reduce stigma and provide information on plural health care for SMDs.

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