UK–South Asia Collaboration on Mental Health: Nepal April 2018

Summary

The British Council and Bangor University hosted an event in Kathmandu, Nepal on 10th to 12th April 2018 that brought together policy makers, researchers, and clinicians in the South Asia region and researchers in the UK to develop an agenda and strategy for mental health research and practice. The event represented a step to building collaborations between South Asia and the UK, and served to promote science, innovation and partnership between South Asian countries (Afghanistan, Bangladesh, India, Iran, Nepal, Pakistan, Sri Lanka) and the UK.

The workshop focused on the following objectives which sit within the WHO's mental health action plan (to promote effective leadership and governance for mental health; to support the provision of comprehensive, integrated mental health and social care services in community-based settings; to implement strategies for promotion and prevention; and to strengthen information systems, evidence and research):

Provide a platform for scientists, researchers and policy-makers to discuss different aspects of mental health and share knowledge and expertise
Help fill the gap between mental health research and policy/ practice
Explore possibilities of promoting research and studies in the area of mental health
Develop a sustainable network of mental health research, policy and practice within South Asia and with the UK.

The themes focused work conducted during the event while ensuring flexibility to allow for other current needs to be identified and addressed by delegates. The emphasis of the event was on developing links and projects that will result in sustained and future collaborations beyond the event itself.

Themes

The following themes ('Theme content' column) were used to structure the sessions and facilitate discussion. Small, facilitated and interactive discussions enabled this type of participation. Each group was comprised delegates from a range of countries and group composition was changed in every session to ensure diversity of delegates and rich discussions.

Questions to be considered	Theme content
What are the known barriers that contribute to mental health challenges in your country? What contributes to good mental health? How is research evidence translated to clinical practice? Who is involved in mental health provision? What are the potential barriers to effective service provision (policy level, societal level, practical level)?	Identify the major mental health research and clinical practice challenges in South Asia and opportunities for international collaboration for overcoming these challenges
Where / when / how are effective mental health services provided in your region? What are the research strengths in your region? Who are the key researchers / organisations? How is success measured and demonstrated? Identify an area in which mental health provision has been improved through a systemic change? What were the factors that contributed to the improvement?	Identify needs and demands for capacity development at regional scale.
What sources of funding might be required? Who applies? What sort of infrastructure is required to facilitate collaborations (e.g., research centres, personnel)? Do we need to identify specific areas of work (e.g., a particular population, a particular approach) with which to start? If so, how do we prioritise areas? Is a country-specific / context-specific approach or method-based approach more appropriate?	Identify South Asia countries' areas of competence in mental health provision
Who needs to be involved? Consider 1) training and education, 2) clinical skill transfer, and 3) research	Highlight potential contributions of UK researchers and affiliated international entities

Theme 1: Major Mental Health Research And Clinical Practice Challenges In South Asia

Challenge	Issues / Concerns
Social and socio-economic work pressures	Migration can lead to poverty. Dependent family members can place stress on carers. Work-life balance can be challenging. Unemployment. Political instability. Caste, gender, and ethnicity. Sexual violence. Natural disasters.
No clear distinction between 'normal' mental health and challenges	Can be offensive to tell someone they have mental ill-health. People might be more comfortable talking to doctor than lay person
Negative reactions to research	Not desirable to conduct or fund research – bureaucrats need to be convinced. Research takes a long time to conduct and the results influence practice.
Most mental health help is medical or general advice	Lack of social-psychological services and professionals. Lack of guidelines and outcome measurement. Multi-disciplinary teams are expensive and difficult to assemble.
Mental health is not a priority	Very small proportions of budgets are reserved for mental health.
Research limits	Researchers may not know what to research (no bidirectional research linking need to science). Only a few institutions have the capacity to conduct high-quality research. Research is often for academic purposes only.
Lack of diverse services	Many services geared towards adults but many adults develop difficulties as young people. Expansive populations common in South Asian countries. Services sometimes designed for neurotypical populations.
Stigma, public perception, and understanding	Can be limited and hinder access to services.

Theme 2: Identify Needs And Demands For Capacity Development

Needs / Demand	Issues / Concerns	Objectives / Solutions
Sources of social support and importance of informal as well as formal supports	Formal supports might not be acknowledged or desirable. Informal or traditional supports (e.g., family) valued but might be disappearing.	Some examples of models to engage informal supports include peer support in the workplace, connecting older people with young people, festivals (e.g., for women in Nepal).
Teaching skills for promoting mental health	Funding can be a barrier. Quality assurance can be difficult and governments may be unwilling to pay for psychology (instead will pay for medication).	Building skills into school education (i.e., into skills for life classes). Seek methods to increase professional competence beyond medical models. Add to teacher training.
Psychological services are often delivered by psychiatrists or medical professionals	Lack of children's psychology services and professionals. Lack of social-psychological services.	Increasing training of paraprofessionals. Add counselling and psychology training to medical training. Ensure training is practical and not just didactic.
Lack of psychological research using mixed methods	Much research is regarding screening, prevalence. Little on intervention and very little on prevention.	Develop infrastructure and capacity to conduct qualitative research studies. Conduct meta-analyses and combine with epidemiological studies to generate database.

Theme 3: Identify South Asia Countries' Areas Of Competence In Mental Health Provision

Existing Infrastructure	Next Steps
Some countries have policies for improving mental health.	Action plans based on existing policies to promote and further provision.
Implementation of policies is often adequate but quality control is not always present.	Increase emphasis on quantity and impact. Education for policy-makers.
Progress can be market- and need-driven rather than policy-driven.	Learn from experiences of other countries and identify needs than can feed into policy.
Policies can be population-driven rather than addressing mental health for all.	Increase emphasis on promoting mental health and preventing ill-health.
Some international collaborations and research centres exist.	Increase capacity for psychological research with an emphasis on impact (de-emphasise psychological research in hospitals conducted for academic purposes).
Some current public education campaigns.	Widen public education and awareness efforts.

Theme 4: Highlight Potential Contributions Of Uk Researchers And Affiliated International Entities

Need / Example Collaborations	Potential Contributions
Pressuring governments from the bottom up occurs in other fields but not in health	Identify local leaders and make health a political issue. Include UK policy-makers.
PRIME model demonstrated an action plan for 15 days, trained practitioners, measured outcomes, and then used data to upscale	Good model for identifying behaviours for inclusion in policy
Translational research	Supporting culture-specific, cost-effective, doable research. Work collaboratively to ensure political sensitivities are addressed.
Iterative action plans	Develop action plans that have monitoring and measurement built in. Train policy-makers to learn and adapt to needs.
Outcomes are often measured in terms of number of patients seen rather than outcomes for an individual.	Develop training for people to conduct effective outcome monitoring.
Implementation science	Involve UK experts in implementation science. Emphasis on meaningful outcomes, operationalising objectives, and changing the behaviour of people implementing.

Delegate Feedback

Delegates were asked to provide their thoughts on the themes of the workshop and the challenges that were identified regarding mental health in South Asia. Delegates were also asked to identify any themes or challenges that were not addressed that they felt were important (second column). The following is a summary of the comments given by the delegates.

Themes And Challenges That Were Most Important	Themes And Challenges To Be Addressed In The Future	Desired Next Steps
Governance and infrastructure to support research and practice	Best ways to promote successful collaborations between South Asian countries	Effective follow-up and monitoring
Stigma of mental health and public awareness*	Methods of upskilling clinicians, education and training	Report and action plan derived from event
Linkages between research, practice, and policy	Geriatric mental health	Identifying ways to use indigenous resources
Assessment and screening	Quality of care measurement in mental health	Skill sharing*
Training of clinicians*	Screening processes and factors affecting mental health	Developing master trainers
Government support*		Identifying knowledge gaps in each country
Improving access to services		Collaborative network*
Promoting mental health research		Joint publications and proposals
Development of child and adolescent services*		National surveys to identify priority areas
Political and bureaucratic hindrances when streamlining research and practice efforts*		Behavioural design interventions project to target

Additionally, delegates indicated that they felt strongly that mental health was an appropriate priority for South Asia, and that the event raised the potential for future collaboration with others.

Some suggestions for specific pieces of work to be conducted by the group included a meta-analysis to identify gaps (e.g., a common project involving all participating countries using the same research tool that will highlight needs and can be used to convince the policy-makers of implementation steps. The research should target a specific group, and should be investigated with reference to scio- economic level and in rural and urban population).

NEXT STEPS:

It was identified that there were many possible outcomes and pathways that could be derived from the workshop focusing on mental health as a broad area. Based on the discussions during the workshop, delegate feedback, and an evaluation of achievable goals, three targets for focused next steps were identified. Additionally, communication was identified as an enabler for the three target areas; child mental health, public awareness, and skill sharing.

Proposed timeline: The three targets will be addressed through a number of events that will be held during 2018 and 2019.

COMMUNICATION.

1. Network created (hosted on Bangor University website, Yammer network)

2. Delegates have invited others to join the network.

3. Exploring Welsh Government funding and support

4. Continuing to explore funding for further projects and collaborations (e.g., Erasmus+, ESRC)

AWARENESS:

1.Planned event in April 2020 to connect policy-makers and key academics from the UK and South Asia (hosted in Nepal).

2.Materials to be delivered and distributed at the event to be delivered that will identify major research and practice challenges, needs for capacity development, and potential contribution of UK and South Asia researchers. Delegates to contribute.

SKILL SHARING:

1. Researcher Connect workshop conducted in March 2019 in Istanbul. The purpose of the workshop was to provide training for early career clinicians or researchers in South Asia.

2.Other training events to be planned (e.g., ABA training, DBT, mindfulness)

CHILD MENTAL HEALTH

1.Developing a project for which to apply for funding. The project will target a specific area (children’s mental health, including intellectual and developmental disabilities)

2. Bangor University and British Council to consider a workshop in 2019 or 2020 that falls under the Researcher Links scheme

Mental Health Initiative for South Asia (MhiSA)