A ‘Grantathon’ model to mentor new investigators in mental health research

Mental health and substance use disorders comprise 7.4% of global disability-adjusted life years and 22.7% of global years lived with disability [1]. Much of the disability occurs in low- and middle-income countries (LMICs) such as India, where individuals face the dual challenges of limited healthcare provision and the stigma and heavy economic burden of mental illness. This combined burden often traps individuals in a downward spiral and, in turn, increases the mental health treatment gap [2]. To address these deficiencies, WHO, in its Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020, proposed a challenging agenda for change, mapping a plan to strengthen mental health leadership and policymaking, provide comprehensive and integrated community-based care, implement prevention strategies and strengthen information systems to support data-driven decision-making [3].

Building capacity for health research in developing countries is integral to the goals of building effective interventions and strengthening existing infrastructure. Bolstering mental health services research capacity will enable LMICs to pinpoint interventions that are effective in their cultural and geographic settings, to apply and replicate results, and ultimately to strengthen mental health service systems. Unfortunately, in many LMICs, including India, mental health research has lagged [4]. In addition, there is a relatively low proportion of Indian research publications in international journals, which demonstrates lost opportunities to disseminate knowledge regarding effective approaches [5]. In India, structural inequalities persist, creating funding and methodological challenges that differ by region, making national research collaborations and capacity-building efforts difficult to implement and sustain.

One way to address these gaps is to increase research capacity in medical colleges in India [6]. Indian medical education has historically been divorced from research, in part due to significant shortages in funding and in faculty members who can provide research training. The Medical Council of India mandates that medical students complete a thesis based on practical research. However, these studies are rarely published, suggesting missed opportunities to disseminate findings, create research collaboratives and apply research findings at the regional or national levels. Bridging this gap and ensuring sustainable research are serious challenges, since research training is traditionally intensive, time consuming and expensive. Because there is a paucity of human resources even for delivering clinical care, formal research training is viewed as an unaffordable luxury in LMICs.

India accounts for 15% of the disease burden of global psychiatric, neurological and substance use disorders, which is greater than that in all LMICs combined. Depressive and anxiety disorders are the most common mental illnesses in India [7]. According to the Summary document of the National Mental Health Survey 2016 [7], 10.6% of the population suffers from any mental health or substance use disorder. Alcohol and tobacco use disorders were the most common, followed by neurotic and stress-related disorders. The burden of these disorders in India is projected to increase by 23% between 2013 and 2025 [7]. Unfortunately, only approximately 10% of those living with psychiatric disorders in India are thought to receive evidence-based care [8]. More than 60% of people with mental disorders receive care in district hospitals, but up to 40% of patients must travel 10 km or more to access services [9].

To address its unmet mental health needs, India initiated a National Mental Health Programme (NMHP) in 1982, followed by the launch of the District Mental Health Programme (DMHP) in 1996. The goal of the DMHP is to provide community-oriented services to reduce the burden and impact of mental health disorders. As of April 2015, the DMHP covered 36% of all districts in the country [10]. However, a significant mental health treatment gap persists due to restricted funding and shortages of human resources. Even in many districts where the DMHP operates, services are limited to mental health outreach clinics in a few primary healthcare centres. In addition, systematic evaluation of the efficacy of the DMHP is an ongoing challenge.

In recognition of these issues, in May 2016, the Indian Council of Medical Research (ICMR) organised a meeting of experts entitled Brainstorming on Prioritization of Mental Health Research in India (http://​www.​icmr.​nic.​in/​final/​Report_​Brainstorming.​pdf). The goal of the meeting was to identify priority areas for Indian research on mental health and substance use and misuse for the next 5 years. One of the priorities that evolved from the meeting was to initiate training to build research capacity among medical and paramedical staff throughout India to address the mental health services gap. The experts acknowledged that, in view of resource limitations, formal research training for even a small number of individuals could be challenging. An advisory committee was created, which held a series of in-depth discussions regarding directions for research capacity-building. The advisory committee suggested a workshop model to identify, motivate and mentor promising individuals in conducting mental health research. In addition to skills development, the workshop would provide the opportunity for participants to develop research funding proposals, which would be submitted directly to ICMR at the conclusion of the workshop. ICMR agreed to review these proposals and consider funding those deemed worthy of support. Thus, the workshop was innovative in its plan to not only build participants’ skills, but also to provide a direct interface between two critical groups, namely clinicians providing and evaluating mental health services and ICMR leadership, who had the authority to prioritise the country’s mental health needs and make funding decisions to address those needs. Through the workshop, it was hoped that individualised mentorship would not only enable trainees to acquire research planning skills but also to establish links between the trainees, their mentors and ICMR leadership. In this way, workshop participants would contribute to evaluation research for the ICMR-sponsored mental health services research in an efficient and productive manner.

This paper describes the development and implementation of a ‘grantathon’ workshop model to address the mental health services research gap by building capacity among junior and mid-level faculty members providing mental health services in clinic- or community-based settings throughout India. We describe the background and development of the capacity-building workshop loosely based on a ‘hackathon’ model, which is a form of crowd sourcing intended to spur innovation among groups with diverse backgrounds that learn from each other and work collaboratively toward a common goal. We also describe our methods of evaluation and data collection, workshop outcomes and planned next steps.

Workshop participants represented different parts of India and had prior training in psychiatry, psychiatric social work, clinical psychology, social work, pharmacology or community medicine. Though it was not required, two participants had previous funding (from state governments to their institution) and two had received training and research support through NIH-funded training grants to two of the authors (SND and VLN). All trainees had completed research theses or dissertations as a requirement for their post-graduate training. When examining mean differences in pre-test versus post-test self-assessment scores, pairing scores for each participant, we found significant improvements indicating overall gains in each participant’s perceived skills and confidence (t(22) = 5.844, P < 0.0001). All but one participant reported improved self-assessment scores at the conclusion of the workshop. Statistically significant improvements for each self-assessment item were noted (Tables 3 and 4), with the exception of responses to the question, “I can develop collaborative relationships with other participants from within my own institute that I plan to continue”. There was a numeric improvement that was not statistically significant for this item. All but one participant noted improvements in perceived skills across all domains in the self-assessment. We also fit a multivariate generalised linear model in SPSS to the data to produce a Hotelling’s trace statistic in order to examine all of the pre- and post-assessment questions as joint outcomes, which was also significant (Hotelling’s T2 = 62.65, f = 5.6, P = 0.000072) and further indicates improvements in participants’ self-assessed learning (Fig. 1).

All participants were able to draft full research proposals during the workshop. Participants remained in touch with each other and with their mentors via email and the ‘WhatsApp’ messaging group after the workshop. Within 30 days of workshop completion, all 24 participants successfully submitted a total of 12 individual or multi-centre research proposals to ICMR for funding consideration. Multi-centre proposals were submitted by 17 participants and single centre proposals by the rest (Table 2). Each proposal was critically reviewed by ICMR programme staff and experts, in addition to review by the mentors. Based on these reviews, ICMR decided to fund all the proposals beginning in 2017.

The hackathon model is a form of crowd sourcing intended to spur innovation among groups with diverse backgrounds that learn from each other and work collaboratively toward a common goal. Other features of the hackathon model include focusing on a specific problem, developing a solution using design thinking techniques, pitching the solution to participants, gathering rapid feedback and quickly altering the prototype design. Prior hackathons have focused on stroke innovation, rehabilitation medicine, human cognition and brain mapping, reaching underserved populations in LMICs, and using data for clinical problem-solving.

Our ‘grantathon’ workshop was designed to engage and support new investigators in mental health services research by incorporating elements of the ‘hackathon’ model that has been used to stimulate innovation in health and public health. To our knowledge, this type of process or its evaluation has not been conducted in India or, for that matter, elsewhere in the world. The grantathon model extended the hackathon model by expecting trainees to prepare for the workshop by developing a priori research ideas that they wished to explore and expand into full research proposals. Our workshop design also included didactic sessions and attendees were assigned to several parallel working groups to foster collaboration and team learning. Further, trainees were paired with mentors who led the groups. Like the hackathon model, our approach emphasised sprint-style capacity-building and problem-solving and brought together professionals from several health-related disciplines who could bring their own perspectives to a common problem. The training faculty will continue to provide advice and consultations to the trainees for their funded work pro bono, as required by ICMR regulations, and to facilitate transition of the trainees to independent investigator status.

Participants represented a wide range of mental health-related specialties and were drawn from a mix of primary care facilities, including medical schools and research institutions. The Indian culture is broadly heterogeneous and inclusive of many different languages and religions, and workshop participants represented a wide range of Indian districts from across the country. Participants focused heavily on adaptation and translation of scales and other data collection methods for use in their home regions, and this level of transcultural adaptation improves the likelihood that the programmes designed during the workshop will have high degrees of relevance in the districts in which they will be implemented. The fact that 62.5% of the attendees engaged in collaborative projects, despite representing numerous cultures and geographic regions, demonstrates that the workshop was successful in creating the collegial atmosphere characteristic of the hackathon approach and emphasised by the workshop faculty.

Important communication channels were established between young medical faculty and researchers of international repute, many of them on a one-to-one basis. Participants also created foundations for ongoing collaboration by establishing discussion groups among themselves. Since the emphasis was on cooperation and collaboration, a research model that is less well-developed in India, it is important to note that the majority of workshop participants collaborated with peers and mentors to submit multi-site projects. The key ingredients for the workshop’s success included motivated and focused trainees, dedicated faculty members with complementary skillsets and continued direct involvement by ICMR, the funding agency. We acknowledge that other projects seeking to replicate our model might not have a similar commitment, which could limit their success. We therefore call out to other funding agencies wishing to improve health services in LMICs to consider sponsoring future research learning opportunities that incorporate the funding commitment demonstrated by ICMR in our model.

To spur learning from our capacity-building model, it is important to identify and share, not only the model’s strengths and successes, but also its limitations and opportunities for improvement. One of the challenges in our capacity-building approach was that participants were initially resistant to the idea of submitting collaborative proposals, even though it was one of ICMR’s stated interests. Further, the wide range of research aims presented by the trainees occasionally made it difficult to compose synergistic groups. Strategies used to address these challenges included group discussion among mentors to identify projects and participants that would be well-suited for collaborative work, targeted counselling to specific trainees who had difficulties understanding the concepts, and focused collaborative work between mentors and trainees on the development of succinct research aims. The ICMR was also flexible in accommodating some proposals that were not a primary focus in NMHP, for example, neurodevelopmental disorders and virtual learning.

Only 4 months were available for organising the workshop, posing another hurdle that was addressed by frequent discussions and consensus-based decisions among the training faculty. Because the turnaround time between participants’ application to and acceptance in the workshop was only 1 month, there was also relatively little time available for trainees to complete pre-workshop readings. We recommend that planners begin the workshop development process 12 months in advance of the training opportunity. To enable greater productivity, we also recommend that clear goals be set and key expectations (such as those related to collaboration) be stated explicitly. Further, we recommend a 2-month period prior to the workshop to enable trainees to complete designated reading assignments and to engage with mentors prior to the workshop.

There are several other ways to improve our model. We recommend that attendees be asked to provide detailed information, including background, study design, methods and availability of data about the research question to be addressed during the workshop. We found that many applicants described the problem to be addressed in great detail but had far less to say about study design or methods. By providing more guidance in advance, we could begin ‘pre-mentoring’ before the workshop and offer an application format that would enable workshop planners to evaluate applications equitably. A pre-workshop survey would help planners to identify participants’ learning needs. For example, our attendees’ need for qualitative research methods was not anticipated, possibly because mentors were more accustomed to the need for quantitative research methods training. In the same vein, pairing mentors with participants and establishing communications between participants prior to the workshop could accelerate the rapport-building and learning processes necessary to facilitate research collaborations. In the international arena, country-specific guidelines for peer review would enable participants to tailor their narratives to their most relevant reviewers and funders. As part of the post-grantathon evaluation, it would be important to track mentors’ involvement with their trainees throughout the research projects. This is being planned for the ongoing training in India.

Our workshop enabled 24 junior investigators to develop and submit research proposals to ICMR for funding, thus attaining its primary goal. Moreover, ICMR ultimately funded all of these proposals. Given this funding commitment and our capacity-building emphasis on evaluation and data collection, these projects may yield important information about the implementation and impact of community-based mental health services throughout India. The grantathon model described here can be modified to build research capacity in other contexts. For example, medical schools could incorporate ‘thesithons’ for planning thesis topics on a common medical problem addressed in different ways by diverse departments. In addition, our capacity-building model could be tested in other LMICs to address the global burden of mental illness. Given that this workshop was not only conceptualised and delivered but also returned results in less than 1 year, the model has the potential to quickly build research capacity and ultimately reduce the mental health treatment gap in resource-limited settings.