Title: NIHR Global Health Research Group: Improving Outcomes in Mental and Physical Multimorbidity and Developing Research Capacity (IMPACT) in South Asia at the University of York
Funder: Department of Health and Social Care

Abstract: STRATEGIC ALIGNMENT: Our proposal aligns closely with the vision of the University of York (UoY) Research Strategy (2015-20) - to deliver world-leading excellent research with life-changing impact, taking a global perspective and interdisciplinary approach. ‘Health and Wellbeing’ and ‘Justice and Equality’ are prioritised UoY research themes which resonate with our proposal. In recent years, York has prioritised mental health and international development, with significant investment (posts, research office support, funding), including on-going work to establish a Centre of Excellence for Mental Health Research (https://www.york.ac.uk/research/themes/health-and-wellbeing/mentalhealth/) and approval of a new Centre for Global Sustainable Development. York also has an ambitious and ethical engagement with the Global Challenges Research Fund, aiming to leave a legacy for our partners in the global South, for UK research and for the University. ENVIRONMENT: York is recognised for having created “an environment that is conducive to producing research of world-leading quality, in terms of its vitality and sustainability”. In the 2014 Research Excellence Framework, York was rated joint top in the UK for research environment in Unit of Assessment 2. York’s Research Office provides specialist operational support, recognising the complexities of research in LMICs, including guidance on codes of good practice on ethics, study design and data management and provides excellent infrastructure for research study management in LMICs. York’s International Development Network (IDN) (york.ac.uk/idn) provides a vehicle to access extended networks of expertise in the delivery of research programmes in partnership with ODA recipient countries. There is also a rapidly expanding hub of global health expertise e.g. public health (Kamran Siddiqi), health economics (Marc Suhrcke) and econometrics (Rowena Jacobs), social policy (Martin Webber); history of medicine (Sanjoy Bhattacharya), infectious diseases (Paul Kaye) and inequalities (Kate Pickett). Mental health research is the largest clinical-thematic grouping at York with a strong track record for attracting research funding (current portfolio £25 million), leading collaborations and delivering nationally and internationally important research, with high impact (e.g., leading the mental health comorbidities theme for the Yorkshire and Humber NIHR CLAHRC and programmes on self management of long-term conditions in severe mental illness (DIAMONDS); pharmacy-based interventions for alcohol problems; smoking cessation in SMI (SCIMITAR) and integrated care for depression in older people (CASPER), funded by NIHR Programme, HS&DR & HTA grants and research charity funding. Mental health research at York is co-located with other internationally excellent research groups, with expertise covering the full range of disciplines needed to support the proposed IMPACT programme, including i) Mental Health and Global Health Economics teams in the Centre for Health Economics (CHE), which produces policy relevant research; ii) the Centre for Reviews and Dissemination (CRD) and the Cochrane Common Mental Disorders Group, a partner of Cochrane Global Mental Health, with expertise in evidence synthesis and knowledge mobilisation (http://globalmentalhealth.cochrane.org); iii) The UKCRC registered York Trials Unit (YTU), with an international reputation for large high quality trials in mental health and in LMICs (https://www.york.ac.uk/healthsciences/research/trials/) and in using innovative methods, including ‘trials within cohorts’ (TwiCs). YTU is part of an international TwiC consortium, has the largest number of TwiCs nationally and advises/supports other groups on this approach. York also hosts world-class research programmes addressing health risk behaviours and interventions delivered by lay-health workers in the UK and in LMICs.[1-7] The IMPACT Group’s ambition to apply and expand this world-leading research expertise into global health research fully fits the remit of the NIHR Group call. SUPPORT FOR THE IMPACT GROUP: Our ambition is supported by significant new institutional investment in global health. The UoY and Hull York Medical School (HYMS) have committed substantial additional resources, reflecting strong commitment to this Programme. Specifically: • Allocation of competitive internal research priming funding (e.g., Partnership and Priming awards (refs:204829; 50102204 & 097829/Z/11/A)) • Appointment of a Chair/Reader in Global Public Health and Senior Lecturer in Mental Health at HYMS • Costs for HYMS and Health Sciences senior staff salaries have not been claimed • Health Sciences have reduced estates/indirect cost recovery from 100% to 90% • A senior post-doctoral research fellow (3 years) The total value is equivalent to £0.46 million. LINK TO INSTITUTIONAL PARTNERSHIPS AND STRATEGIES: York has a strong track record of partnership with UK and international organisations that will support this Programme, e.g. YH CLAHRC, making an impact on smoking,[8] and the management of diabetes for people with SMI;[9] and research, teaching and capacity-building partnerships with governments, NGOs and universities in S. Asia (e.g. EU-H2020 Consortium on TB and Tobacco). In choosing partners for this Group, we have built on these previous links and have also established new partnerships (e.g. with National Institutes of Mental Health, NGOs and WHO offices) to form a collaboration including the key constituencies necessary for successful delivery of the Programme. The Group comprises organisations that have previously worked together within and across the 3 LMICs, providing a strong basis for success. We have already demonstrated effective collaborative working; in the short time since coming together in January 2017, the Group secured pump-prime funding through a UoY/Wellcome Trust Institutional Strategic Partnership award, held a successful international meeting, agreed a programme of research, submitted a joint research grant application, and set up a survey study sharing common protocols. WORKING WITH COLLABORATORS: The Group will ensure that all partners are actively involved in setting research priorities and making strategic decisions, following best practice guidance,[10, 11] privileging views of LMIC partners, who have first-hand knowledge and experience of the challenges faced by their populations, health systems and researchers. We will establish inclusive decision making processes, robust management arrangements and clear and regular communication. We have demonstrated this approach in agreeing priorities and developing this application. PATIENT AND PUBLIC INVOLVEMENT (PPI): This will be secured through Community Advisory Panels (CAP), including patients with experience of long-term conditions, their families and other interested community stakeholders, recruited through links with health providers and NGOs in each country. CAPs will meet regularly to advise on proposed research and support dissemination and take-up of findings. Two CAP representatives will also be members of each Study Management Teams (SMT), and one representative will join the Advisory Board from each country. Their involvement will ensure the patient and family voice is included, and that the Programme remains grounded in, and addresses the needs of users of the research. Meaningful engagement is challenging, and we will support these representatives through a ‘buddying system’ whereby a researcher will be available to discuss the Programme in a timely, open, informal and uncritical manner. How best to secure PPI in research in LMICs is unclear. Although we benefit from learning from our extensive experience of PPI (and that of partner NHS Trusts) in the UK, this cannot be applied uncritically. We are, therefore, also currently conducting a synthesis of the literature to develop a framework for PPI in research in LMICs, as part of an Academic Clinical Fellowship.

Lay abstract: People with severe mental illness (SMI) (e.g. schizophrenia and bipolar disorder) die ~ 20 years earlier than the general population, mainly because of remediable chronic physical disorders associated with a higher prevalence of health risk behaviours such as smoking, physical inactivity, diet and alcohol. Around 30% of those with a chronic physical disorder (e.g. diabetes) also have depression or anxiety, which often goes undetected and untreated, and worsens outcomes for physical illness. The coexistence of mental and physical illness is a major and growing problem, particularly in S. Asia, affecting some of the poorest and most vulnerable people. Although prioritised in global health agendas, it remains under-researched. The aims of our IMPACT Group, agreed with partners from Bangladesh, India and Pakistan, are to: • Improve health and reduce deaths associated with diabetes, heart and lung diseases in people with SMI by addressing the most common health risk behaviours. • Reduce depression and anxiety in people with chronic physical health conditions. In this 3-year Programme we will: A. IN PEOPLE WITH SMI i) conduct a physical health survey and assemble a cohort of people who can be approached for future research, ii) design interventions aimed at changing health risk behaviours (tobacco, physical activity, alcohol and diet) based on a brief talking therapy. B. FOR PEOPLE WITH CHRONIC PHYSICAL DISORDERS (e.g. diabetes, heart disease, hypertension), integrate the detection and treatment of depression/anxiety into an intervention package for chronic diseases delivered in primary care. C. BUILD RESEARCH TEAMS AND CAPACITY to secure competitive funding and deliver worldclass applied health research informing policy and practice in these areas. We will design interventions to fit with healthcare policy and systems and cultural contexts, and build on learning from previous chronic disease research programmes in S. Asia. We will carry out preliminary testing of these interventions, and prepare for full-scale testing of their effectiveness, costs and implementation. We will also identify and address gaps in ability and capacity to conduct such research through mentoring, supervision, training, qualifications and experiential learning for researchers. Our team combines expertise in a) designing and culturally adapting brief talking and behavioural interventions delivered by non-specialists, b) testing effectiveness and value using trials, epidemiology, statistics and analyses of healthcare costs (c) summarising evidence for decisionmakers in LMICs, and (d) scaling up interventions through health policy and systems analysis, and strengthening capacity. LMIC partners bring in-depth understanding of country health systems, workforce and infrastructure, and stakeholder engagement. The central involvement of WHO ensures links to policymakers and governments are maximised in each country, as well as globally. We will develop an agile programme to generate and mobilise knowledge not only about ‘what is effective and value for money’ but also ‘what works for spread and sustainability’. Our Programme has the potential to improve health and quality of life, save lives, and help break down stigma and discrimination for people with mental illness. It will also provide health and economic benefits for wider society, helping efforts to reduce health and economic inequalities, achieve Sustainable Development Goals 1, 3, 8 and 10, and realise universal health coverage.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS;7.4 RESOURCES AND INFRASTRUCTURE (DISEASE MANAGEMENT)
Health categories: GENERIC HEALTH RELEVANCE;MENTAL HEALTH