Three out of four people with chronic psychosis in India and Pakistan cannot access appropriate care. This project adapts and tests DIALOG+, a low-cost intervention that improves quality of life and reduces costs in high-income countries, for use in routine community care by local staff—including lay health workers—without requiring specialist referrals. The problem is stark: chronic psychosis affects over 2% of the global population, but low- and middle-income countries lack the financial and human resources for comprehensive community care. DIALOG+ works within existing appointments, making it a practical solution for resource-poor settings. If successful, the adapted intervention could shift community-based care for millions of affected individuals, their families, and communities across both countries. The programme also builds local research capacity and uses participatory arts—such as Theatre of the Oppressed—to engage communities and give voice to people with psychosis. A Lived Experience Advisory Panel in each country ensures the research is shaped by those it aims to help. The ultimate impact is sustainable, efficient care that reaches people who currently have none.
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BACKGROUND AND RATIONALE Chronic psychosis affects >2% of the world s population causing significant distress to individuals, families and wider communities and high societal costs. Low- and middle-income countries lack the financial and human resources to provide comprehensive community care as in high-income countries. This results in a large treatment gap, with three out of four people unable to access appropriate care. Low-cost, effective interventions are therefore an urgent priority. One potential solution is DIALOG+, a patient-centred and solution-focused intervention, which has been shown to improve patients quality of life and reduce care costs in high-income countries. It does not require specific professionals or additional referrals, but is instead implemented within routine appointments by a range of staff, including lay health workers. AIMS AND OBJECTIVES The overall aim is to improve the quality of life for people with chronic psychosis. This will be achieved by adapting and testing DIALOG+. The programme also aims to foster knowledge exchange, increase local research and service capacity and upscale the intervention through participatory arts methodologies and community engagement. METHODS Five interlinked work packages (WPs) will utilise a range of participatory methods. WP1 will iteratively adapt DIALOG+ to ensure it is culturally appropriate. An initial situation analysis and 5 interactive workshops with local stakeholders per country will be followed by piloting the adapted intervention over a 3-month period with 4 clinicians and 20 patients per country. The effectiveness and cost-effectiveness of the adapted DIALOG+ intervention will be tested in a cluster randomised controlled trial with 28 clinicians and 210 patients per country. Health and social outcomes, including quality of life, will be assessed at baseline, 6 and 12 months post-randomisation (WP2). A qualitative process evaluation (WP3) will identify barriers and facilitators to implementation. This will be used alongside participatory workshops with stakeholders employing different engagement methods (SALT and QI) to develop the implementation toolkit. Service and research-capacity will be enhanced through a programme focused on developing a critical mass of skilled individuals to sustain research activities (WP4). WP5 will utilise different arts-based methods including Theatre of the Oppressed to interact with local communities, give voice to people with psychosis and promote new understandings for researchers and services. To support the research, a Lived Experience Advisory Panel (LEAP) will be set up in each country. The LEAPs will develop research materials, interpret results and ensure appropriate dissemination methods. This will provide a model for future user-engagement, an area highlighted as a need in both countries. IMPACT AND DISSEMINATION Through participatory methods we will raise awareness of the research and promote local ownership. We will facilitate sustainable change by increasing service capacity through higher efficiency, promoting local research expertise and widely disseminating the intervention and implementation toolkit. The main impact will be the improvement of community-based care and quality of life for people with chronic psychosis. Ultimately, the programme has the potential to have a positive impact on the quality of life of millions of affected individuals, their families and communities in both India and Pakistan.
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