Generation Malawi: A study of family, maternal and childhood mental health

A lack of research training, resources, infrastructure and data in Low- and Middle-Income Countries (LMIC) greatly limits their ability to conduct studies of common mental health conditions. Nowhere is this more true than in Africa generally and in Malawi specifically, where sparse mental health care alone limits not only clinical research capacity, but also the ability to attract inward investment. In a partnership between UK and Malawian institutions, we propose to directly address this challenge by building clinical research capacity through the coordinated appointment of new researchers and research assistants, a programme of education and dissemination, and the development of a population mental health dataset focussed on an area of great unmet need - the mental heath of mothers and their children.

After a period of piloting our research assessments and obtaining the necessary approvals, we will recruit 5000 mothers prior to delivery of their child from antenatal clinics in Lilongwe and Karonga districts, selected to represent urban and rural populations respectively. We will assess the mental health of mothers before and after birth, and the mental health of their spouses and other family members with a view to identifying the major risk factors for mental health disorders and mitigating variables that promote resilience. We will then examine the impact of maternal and, where possible, paternal mental health on the neurodevelopment of their offspring.

In addition to creating new and highly valuable data, we will also create the bioresources needed for future genetics and 'omics based research. We believe this is essential to prevent the current imbalance in genetic research favouring rich countries of predominantly European ancestries leading to greater entrenchment of global health inequalities.

As part of the proposed work, we will develop internationally competitive research capacity and datasets in Malawi, augment standard of care treatment, develop research training and the availability of affordable and effective interventions for depression and other common mental disorders, such as the "Friendship Bench" intervention. Our research will be multidisciplinary, involving experts from psychiatry, clinical psychology, nursing, reproductive and child health, and social sciences in both UK and Malawi. Throughout the project, we will carefully monitor our progress and impact on the participants and their communities.

The project, if funded, will lead to a step change in mental health research capacity in Malawi, paving the way for new inward investment and the development of evidence based interventions and policies.

A lack of research training, clinical capacity, resources, infrastructure and data in Malawi, greatly limits its ability to attract inward investment and conduct mental health research and healthcare improvements. We propose to directly address this challenge by building clinical research capacity through the coordinated appointment of new researchers and research assistants, a programme of education and dissemination and the development of a population mental health dataset focussed on an area of great unmet need - the mental heath of mothers and their children. We will recruit 5000 mothers prior to delivery of their child from antenatal clinics in Lilongwe and Karonga districts, selected to represent urban and rural populations respectively. We will assess the mental health of mothers before and after birth, and the mental health of their spouses and other family members with a view to identifying the major risk factors for mental health disorders and mitigating variables that promote resilience. We will then examine the impact of maternal and, where possible, paternal mental health on the neurodevelopment of their offspring. We will create a new and highly valuable dataset and bioresource for future genetics and 'omics based research.

Generation Malawi will deliver HEALTH, ECONOMIC and SOCIAL IMPACTS by engaging country stakeholders - women, families, academic groups, healthcare providers, policy makers and governments. We will build data resources, research and healthcare capacity and sustainability through our links to charitable organisations and research funders, philanthropy, private investment and national governments.

HEALTH IMPACT
Healthcare providers, policy makers and governments will benefit from new knowledge on the scale and correlates of poor maternal and family mental health and how this influences the developing infant. We will engage with healthcare providers and researchers through local communications with clinician networks including the African Alliance on Maternal Mental Health (AAMMH), the African Mental Health Research Initiative (AMARI) and through existing training links between the Universities of Edinburgh, Cape Town and Malawi, and through the Malawi-Scotland partnership (https://www.scotland-malawipartnership.org). We will engage with existing national media and radio, local knowledge brokers and our existing network of community contacts including churches, school festivals, and art/drama for health activities. Government and policy maker engagement will be achieved through targeted meetings and workshops and inclusion of policy leaders in our Advisory group. Health academic impacts will be disseminated through open access publications, video clips on university websites, and through our many education routes. We have world class expertise in Edinburgh in data collection, analysis, archiving and data sharing, complying with regulations in privacy and data protection.

ECONOMIC IMPACT
The availability of an internationally competitive training environment in Malawi, incoming investment for mental heath research capacity building, new dataset and bioresources of DNA and relevant samples will ensure that the research is sustainable and attracts further inward investment. The resources created will be valuable for UKRI, Wellcome Trust and other charitable and philanthropic funders in both mental, neonatal and physical health. Philanthropic funders, such as the Bill and Melinda Gates foundation, are also keenly interested in maternal mental health as a risk factor for infant mortality and morbidity but without the investment proposed in our application, it is uncertain that mental health research in Malawi would be sufficiently competitive to attract the investments required to sustain its future stability and development.

SOCIAL IMPACT
We anticipate that our proposal, healthcare and public involvement will further disseminate the value of scientific research in mental health and reduce stigma. The information obtained from our planned research programme will enable the correlates and causes of risk and resilience of mental disorders to be identified in a local context. This will have wide ranging positive effects on healthcare and social policy as governments in Malawi and elsewhere in the region access the new knowledge provided.