People with mental illness in low- and middle-income countries face routine exclusion from jobs and marriage because of stigma. The Indigo Partnership brings together research centres in China, Ethiopia, India, and Tunisia with collaborators in high-income countries to measure how stigma operates and test ways to reduce it. The problem is that stigma is not just hurtful—it blocks people from work, healthcare, and social life. In many countries, employment rates for people with mental illness are far lower than for the general population, and marriage prospects can be severely harmed. Current anti-stigma methods developed in wealthy nations may not transfer well to different cultures and health systems. The partnership will first study four aspects of stigma: unconscious bias among healthcare staff, how people cope with stigma, how personal contact between those with and without mental illness can reduce prejudice, and how to adapt interventions to local contexts. Researchers will translate and openly share seven stigma measurement scales into six languages. They will then run three pilot projects testing stigma-reduction methods in communities, primary care, and specialist mental health settings. If results are positive, the team will seek funding for larger international trials. The project also aims to build lasting research capacity in the participating low- and middle-income countries.
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Summary for lay readers The overall aim of the Indigo Partnership is to improve understanding of stigmatisation against people with mental illness, and then to develop and test new methods to reduce such stigma in economically developing countries. The reason why this is important is that all over the world stigma and discrimination have negative effects, which exclude people with mental illness from the mainstream of society. For example, employment rates for people with mental illness are much lower than for the general population in most countries, and the prospects of marriage can be severely harmed. The participating centres in this Partnership are in 4 low and middle countries, who will work in close collaboration with staff from 4 high income countries: China (Peking University Health Science Centre, and Guangzhou Medical University); Ethiopia (Addis Ababa University); Germany (University of Ulm); India (George Institute, New Delhi and NIMHANS, Bengaluru), Switzerland (WHO, Geneva); Tunisia (Hôpital Razi, Tunis); UK (KCL); and USA (George Washington University). The plan is to conduct 4 research activities to understand better how stigma has a negative impact. These will be focussed upon: (i) unconscious bias (for example health care staff who treat people less well without intending to do so); (ii) how people can manage to cope with stigma without it having a negative impact; (iii) how to improve the effect of 'inter-personal contact' between people with and without experience of mental illness to reduce stigma; and (iv) how to adapt stigma reduction interventions to the local context and culture in low and middle income countries. These studies are based upon the findings of research in high income countries that such inter-personal contact is the most effective way to reduce stigma. We shall also culturally adapt 7 scales which measure different aspects of stigma and translate them into Amharic, Arabic, English, Hindi, Kannada, and Mandarin and Telugu, and make these openly available as an 'evaluation toolkit'. We shall go on to carry out 3 pilot projects to test specific methods intended to reduce mental health related stigma in: (i) local communities using a public awareness and social marketing programme to increase referrals for people with mental illness to attend local health care services; (ii) in primary health care staff; and (iii) with specialist mental health care staff. The instructions for these interventions will be adapted, learning from these studies, and made openly available as 'intervention manuals'. If the results of these projects are positive in achieving stigma reduction, we shall apply for research funds in future to test their effectiveness more thoroughly within international, multi-site intervention trials. In the course of this work the, staff in the whole partnership will support staff in China, Ethiopia, India, and Tunisia to develop their research skills and their careers, so that they can establish centres of excellent in stigma research in each of these countries in future. Our longer term objectives are to identify effective way to reduce stigma and discrimination against people with mental illness in low- and middle-income countries, and to make a contribution towards more people with such conditions gaining access to effective mental health care in future (namely to decreases the so-called 'treatment gap'), and better outcomes, and achieving greater social inclusion.
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