SUCCEED Africa: SUpport, Comprehensive Care and EmpowErment for people with psychosocial Disabilities in sub-Saharan Africa Mental and substance use conditions are among the top five contributors to total global Disability Adjusted Life Years, and are the leading cause of Years Lived with Disability worldwide. People with psychosis and their families are among the most marginalised and vulnerable groups in society, and have a high risk of experiencing violence, poverty, homelessness, incarceration and unemployment. In many low- and middle-income countries (LMICs), and particularly in sub-Saharan Africa (SSA), people with psychosis also experience forced restraint, prolonged seclusion, sexual assault and other abuses in family homes, health facilities, social care institutions and traditional and spiritual healing centres.
The concept of “psychosocial disabilities”, as defined by the United Nations (UN) Convention on the Rights of Persons with Disabilities, requires a holistic response to the “interaction between the impairments” caused by a mental conditions and the “various barriers [that] may hinder their full and effective participation in society on an equal basis with others”. Yet the field of global mental health has been criticised for taking an overly biomedical perspective, focused primarily on the “treatment gap”, rather than the multidimensional concerns of people with mental conditions, their families and communities. Applying a disability rights perspective to global mental health means pursuing a multi-sectoral, multi-stakeholder approach that tackles social exclusion and inequalities in access to and quality of health and social services, in partnership with people affected, their families and communities.

Current evidence:
Over the past decade, the WHO has released normative guidance on treatment of priority mental health conditions by non-specialists (mental health Gap Action Programme, mhGAP); community-based rehabilitation (CBR) for people with psychosocial disabilities (an annex to the CBR Guidelines); empowerment of people with psychosocial disabilities to contribute to rights-based mental health system reform (using QualityRights); and recently, Guidelines for the Management of Physical Health Conditions in Adults with Severe Mental Disorders. However, faced with the “10-90 gap” in mental health research and a paucity of Disabled Person’s Organisations (DPOs) representing people with psychosocial disabilities in LMICs, WHO has often drawn on evidence and experience from high-income countries adapted through expert consultation (largely with mental health specialists) from LMICs. Although the WHO’s CBR Guidelines provide important insight into what these community-based interventions could include, there was virtually no evidence of effectiveness of CBR for psychosocial disabilities in LMICs at the time they were produced. It is critical to redress the gap by developing and testing an enhanced CBR package for psychosis that integrates existing normative guidance as well as recent and emerging evidence and experience on what works across the five CBR domains: health, education, livelihood, social and empowerment.
There is insufficient evidence from LMICs on how to involve people with psychosocial disabilities in research or decision-making. There is a need to fundamentally change how research on psychosocial disabilities is conducted in LMICs e.g. by modelling best practice in co-production and South-South partnership. We must start with the premise that people with psychosis, their families and communities, are the “experts by experience” who are best-positioned to define their needs and how to address them, with support from “experts by profession” such as researchers, practitioners and policy-makers.

Aims and Objectives:
SUCCEED aims to address these gaps, by
(1)	Developing a sustainable, effective, evidence-based package of multi-sectoral care and support  for people with psychosocial disabilities (focusing in the project on people with a diagnosis of a psychotic condition) in line with existing normative guidance that is feasible, acceptable and appropriate for low-resource, community-based settings
a.	Co-produce an enhanced CBR package for people with psychosis in community settings
b.	Co-produce new tools and outcome measures for improved research on psychosis to evaluate the implementation and effectiveness of the enhanced CBR package 
c.	Build capacity for co-production between researchers, providers, people with psychosis and families
(2)	Generating new knowledge on co-production for mental health research in LMICs, by modelling best practice in disability inclusion, addressing attitudinal barriers among key stakeholders, and building the capacity of “experts by experience” to engage meaningfully in mental health research and policy
a.	Synthesise evidence on What Works for psychosis and for psychosocial disabilities more broadly in LMICs
b.	Increase uptake of evidence-based guidelines, based on the research produced.

Partnership and Governance:
In order to improve the transferability and generalisability of our findings, we have partnered with sites in non-contiguous countries in West and Southeast Africa: University of Malawi /Kamuzu University of Health Sciences, University of Ibadan, University of Makeni (Sierra Leone), and University of Zimbabwe.
To ensure timely and high-quality delivery, we have divided SUCCEED’s programme of work into three work packages (Capacity-Building, Research and Uptake), each with their own measurable strategy, a dedicated manager at London School of Hygiene and Tropical Medicine (LSHTM), and a wider management team comprising senior leadership across the consortium. 

Research methodology:
Though our final research agenda will be co-produced, we intend to follow a Theory of Change (ToC)-driven approach aligned with the Medical Research Council Framework for Complex Interventions. 
Our research will be divided into three stages: (1)  Development, (2) Feasibility and Piloting, and (3) Evaluation.	
(1) We will conduct systematic reviews of the published and grey literature, to identify “What Works” for co-production and for psychosocial disabilities in LMICs. 
Carry out a situational analysis on psychosocial disabilities in each country including desk reviews, key stakeholder interviews, and equipping DPOs to apply the WHO QualityRights Toolkit to document CRPD compliance. 
Use the evidence to inform the theoretical basis for the development of a multi-sectoral package of care for psychosocial disabilities in consultation with key stakeholders, during a series of ToC workshops in each participating country. We will also select and adapt or develop outcome measures for piloting, in close consultation with DPOs. 

(2) We will carry out formative research to address knowledge gaps identified in the ToC workshops. 
Formative research may include conducting interviews and focus groups with key stakeholders, observation at the intervention sites, and auditing routinely collected data, results of which feed into a further iteration of the ToC. 
We will then initiate a six-month pilot to test the SUCCEED package, outcome measures and research procedures, and to calculate recruitment, retention and sample size for the subsequent evaluation at each site. 

(3) We will carry out or cluster-randomised trials of the package of care, plus multi-method process evaluations. 
Malawi, Nigeria, Sierra Leone and Zimbabwe will each host study sites, and differences in context, implementation and outcomes across study sites will be the subject of further implementation research using both qualitative and quantitative methods. 
Learning on co-production more broadly will be captured through interviews and focus group discussions with key informants, including the SUCCEED research teams and their peer researchers, LEAP members and local DPOs.

Participatory oversight: 
``SUCCEED aims to fundamentally change how research on psychosocial disabilities is conducted in LMICs, by modelling best practice in co-production. We start with the premise that people with psychosis, their families and communities, are the “experts by experience” who are best-positioned to define their needs and how to address them, with support from “experts by profession” such as researchers, practitioners and policy-makers. We will build the capacity of existing DPOs in SUCCEED countries to represent the interests of people with psyhosocial disabilities alongside local “experts by profession” on SUCCEED’s in-country Local Advisory Groups (LAGs), responsible for shaping the local research agenda through ToC workshops and ongoing consultation. DPO representatives elected from across the in-country LAGs will join representatives of the international disability movement on an international Lived Experience Advisory Panel (LEAP), which will elect members to an international Consortium Advisory Group (CAG) that will also include members of UN agencies, national ministries, and international funders. The CAG and LEAP will provide oversight in harmonising the international, cross-site ToC and research agenda for SUCCEED.
Further, this consortium draws on broad expert advice: international public policy consultants (World Health Organization), global leaders in disability inclusive development (CBM Global); DPOs representing people with psychosocial disabilities and their families in sub-Saharan Africa (e.g. Mentally Aware Nigeria, Mental Health Users and Carers of Malawi, Mental Health Coalition of Sierra Leone, Zimbabwe National Association for Mental Health); and experts in research uptake (Centre for Global Mental Health, International Centre for Evidence in Disability), including the largest knowledge management platform in the field of global mental health, Mental Health Innovation Network (MHIN), which is operated in partnership with the WHO.