Investigating MUltimorbidity ThroUgh cApacity building (MUTUAL)

More than a third of adults around the world live with more than one chronic condition. This accumulation of diseases is otherwise known as multimorbidity. Existing studies of multimorbidity have identified that the number of people living with multimorbidity in communities is similar between High (HIC) and Low- and Middle-Income Countries (LMICs). However, very fewer studies have been carried out in LMICs. Not everyone who has multimorbidity share the same diseases, and several different possible patterns are thought to exist. These patterns are normally referred to as clusters, as they represent the clusters formed by different diseases. Most of the research on clusters has been carried out in HIC, with very few studies being conducted in LMICs. Some existing studies carried out in HIC have showed that when a person has both physical and mental disorders, their quality of life is lower, their risk of dying is increased, and their economic burden is higher, compared to a person who only has physical illnesses. This area of work has however been largely under-researched in LMICs, partly for the following reasons: a) analysing multimorbidity clusters is challenging and requires advanced training in data analysis; b) lack of suitable and up-to date data; c) neglect of LMICs mental health research more generally, and d) lack of interdisciplinary researchers trained with appropriate skills to address this complexity, especially in LMICs. With MUTUAL we will develop a platform for high-quality, LMIC-led research to investigate knowledge gaps in our understanding of multimorbidity associated with both mental and physical illnesses (MPM) in LMICs. This will be done by creating a capacity building programme taking place across three countries, in three continents, and with different levels of economic development: Brazil, Ethiopia and Malaysia. Training will be delivered by tutors and mentors in 3 areas of need: a) advanced statistical methods and epidemiology; b) health economics; and c) evidence synthesis. This will be further enhanced by training in transferable skills (e.g. research dissemination, public speaking, leadership, impact, data security). Training resources will be made available outside of the network so that other researchers interested in the training will be able to access it. Early career researchers across the three countries, with support of both UK and in-country tutors, will then work mutually to advance our understanding of multimorbidity using existing datasets of people living in the three countries, with detailed information of health status. This will be carried out using advanced statistical analysis. Health economics techniques will also be used to understand the economic impact associated with specific clusters, to assess which are the most burdensome. Our final objective is to create a network and platform for future training and for further research activities around the topic of multimorbidity. We hope that this project will have a direct impact on people's lives, both individuals living with multimorbidity, but also on early career researchers.

Multimorbidity is highly prevalent globally. In a recent systematic review, we showed that the prevalence of multimorbidity in the community is similar across High (HIC) and Low- and Middle-Income Countries (LMICs), even though the evidence base in LMICs is still fragmented. Little is known about patterns, clusters and overall economic burden of multimorbidity in LMIC, and even less is known about multimorbidity including both physical and mental disorders (MPM). Evidence from HIC has shown that MPM leads to worse outcomes, increased direct and indirect social costs, lower quality of life and excess mortality, compared to concordant multimorbidity. We believe that MPM has been under researched for many reasons, including the lack of interdisciplinary researchers with appropriate analytical skills, especially in LMICs. With MUTUAL we will address some of these challenges by developing a platform for high-quality, LMIC-led research to investigate knowledge gaps in our understanding of multimorbidity associated with both mental and physical illnesses (MPM) in LMICs. This will be done by creating a capacity building programme taking place across three countries with different levels of economic development: Brazil, Ethiopia and Malaysia. Training will be delivered by tutors and mentors in 3 areas of need: a) advanced statistical methods and epidemiology; b) health economics; and c) evidence synthesis. This will be further enhanced by training in transferable skills (e.g. research dissemination, public speaking, leadership, impact, data security). All resources will be made available outside of the network so that other researchers interested in the training will be able to access it. Early career researchers across the three countries, with support of both UK and in-country tutors, will then work mutually to synthesise and generate new evidence on key evidence gaps, around patterns and burden of multimorbidity using techniques such as cluster and network analysis

The initial network includes a mixture of academics, clinically active researchers, and educators, with extensive collaborations within and outside of academia. This will allow us to maximise the impact and activities of the MUTUAL. We envisage that this project will have academic, capacity building, economic and wider societal impact, and a number of activities throughout the project will be undertaken to maximise its potential impact.

Academic and research impact:
This project will generate evidence on patterns of multimorbidity in Low and Middle Income Countries (LMICs) and assess whether they are different to those identified in High Income Countries (HICs). This will go some way in addressing some of the gaps discussed in the Academy of Medical Sciences report on multimorbidity. The generation of new evidence and the creation of a new network working on multimorbidity in LMICs will also lead to further collaborations and grants aimed at reducing the burden of multimorbidity and improve our response to it in different settings. In order to make the most out the research impact we will: 1- publish in high impact journals; 2- present our findings at conferences; 3- organise a webinar at the end of the project; 4- use our connections to the global INDEPTH network to expand our network and disseminate our findings; 5- use social media to generate interest into the project.

Capacity building
This project will enhance LMICs early career researchers (ECRs) skills and develop highly trained and rounded individuals that can meet the demand for health researchers knowledgeable about the complexities of multimorbidity including both physical and mental disorders and trained in essential advanced research approaches to modelling, synthesis and economic techniques needed to understand these synergistic, multifactorial and dynamic associations. ECRs career opportunities will also be enhanced by the transferable skills and by the exposure to a strong group of tutors and mentors. We expect that this project will also a wider impact on ECRs based outside of the network, as all the training material will be recorded and be shared online on widely used and available platforms. Moreover, all the analytical codes for the analyses will be posted on the GitHub platform as learning material, and also to ensure reproducibility.

Economic and societal impact
We believe the project will have direct and indirect economic and societal impact. Initiatives that will maximise its impact will include: 1- engaging with national and international organisations and charities to disseminate findings with the wider public. 2- disseminate the results of the project with participants who took part in the studies using existing procedures. 3- the training component will increase the local workforce and also develop a new generation of researchers who will become champions of multimorbidity research and train future generations of early career researchers. 4- the general meeting will be used as a platform to showcase the project. Relevant stakeholders (including the Director General of Health Malaysia) will be invited to the meeting. We hope that this could ultimately influence policy making on multimorbidity in Malaysia. Similar discussions and exercises will take place across all countries. 5- An expansion of the network to more countries, including larger grant applications.