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

Lead Research Organisation: University of Edinburgh
Department Name: Centre for Clinical Brain Sciences

Abstract

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.

Technical Summary

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.

Planned Impact

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.
 
Description We have engaged with healthcare providers in Karonga and Lilongwe and begun the processes leading up to the formative work and piloting of study questionnaires. We have involved local opinion leaders, decision makers and others. It will be possible to expand on the scope of this impact in future returns. Unfortunately, however, progress of our research and the flow of new findings has been severely hampered by Covid-19.
First Year Of Impact 2020
Sector Healthcare,Government, Democracy and Justice
Impact Types Societal

 
Description (CoMorMent) - Predicting comorbid cardiovascular disease in individuals with mental disorder by decoding disease mechanisms
Amount € 5,998,613 (EUR)
Funding ID 847776 
Organisation European Commission 
Sector Public
Country European Union (EU)
Start 01/2020 
End 12/2023
 
Description Centre for Biomedicine, Self and Society - Extension
Amount £844,510 (GBP)
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 01/2023 
End 04/2024
 
Description Exploiting genomic approaches to identify the environmental basis of depression
Amount £2,530,384 (GBP)
Funding ID 220857/Z/20/Z 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 06/2021 
End 05/2026
 
Description My depression, your depression - same name, different stories
Amount £65,600 (GBP)
Funding ID 217078/Z/19/Z. 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 03/2020 
End 12/2020
 
Description Non-invasive biomarkers of stress in mothers, fathers and infants in urban and rural Malawi: a feasibility study
Amount £95,989 (GBP)
Funding ID MR/T038683/1 
Organisation Medical Research Council (MRC) 
Sector Public
Country United Kingdom
Start 03/2020 
End 03/2021
 
Description One Health Models of Disease: Science, Ethics and Society
Amount £5,328,962 (GBP)
Funding ID 218471/Z/19/Z 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 10/2020 
End 09/2028
 
Description Transforming Primary Care in Scotland and China to meet the needs of an ageing population - are health inequalities being tackled?
Amount £832,923 (GBP)
Funding ID ES/T014164/1 
Organisation Economic and Social Research Council 
Sector Public
Country United Kingdom
Start 08/2020 
End 08/2023
 
Description Malawi Scotland Maternal Mental Health Partnership - a THET funded collaboration between Maternal Mental Health Scotland (MMHS); St John of God Hospitaller Services, Malawi; University of Edinburgh; and College of Medicine, Malawi 
Organisation Maternal Mental Health Scotland
Country United Kingdom 
Sector Charity/Non Profit 
PI Contribution University of Edinburgh (Angus Macbeth and Robert Stewart) support the project through expertise in training material development and monitoring and evaluation methods. Stewart is also closely involved in organisational activities on the ground in Malawi.
Collaborator Contribution Maternal Mental Health Scotland (MMHS) is a Scottish Charity, registered in 2014, whose members include health professionals and women with a lived experience of perinatal mental health problems. MMHS looks to improve the provision of perinatal mental health services; to educate the public and the medical profession; and to bring practitioners, patients, and families together. St John of God Hospitaller Services (SJOG) is a registered NGO that has been providing mental health services and education in Malawi since 1993. It established services in Mzuzu in the Northern Region, and has recently opened a 50-bedded mental health centre (with attached community services) in Lilongwe, Central Region. The SJOG College of Health Sciences trains psychiatric nurses and clinicians at degree level, as well as offering psychosocial counselling courses. Purpose of the partnership is to support the development of community based support activities led by women with lived experience in Malawi, as well as enhancing training of primary care health workers and staff in SJOG's facilities where women with severe mental disorders (e.g. postpartum psychosis) receive care.
Impact £10000 seed funding from Tropical Health Education Trust (THET) Visit to Malawi from 09/11/19 till 19/11/19 - 3 members of Maternal Mental Health Scotland (MMHS) visit to hosts St John of God (SJOG) where a programme had been organised - this included meeting the management and clinical teams, a presentation on the MH services provided by SJOG, and a question and answer session to enable the MMHS team develop an understanding of the mental health landscape in Malawi and consider the context, and in particular perinatal mental health (PNMH) provision, planning sessions on what the partnership can support, education/teaching session with clinical teams, and initial meeting with women who had accessed perinatal mental health care through SJOG to establish links with MMHS Change Agents and consider support and development of a pathway going forward. • Basic initial training to core staff teams at SJOG and Zomba • Malawi team engaged a group of capable, enthusiastic and empowered women with lived experience of maternal mental health problems to start the process of establishing peer support and how this would best meet the needs of women who are treated at SJOG. These women attended a workshop and were fully interactive and engaged in this process supported by the SJOG team. 45 pregnant women accessed 2 maternal mental health talks delivered by SJOG clinical staff who had attended the training delivered by UK team
Start Year 2019
 
Description Malawi Scotland Maternal Mental Health Partnership - a THET funded collaboration between Maternal Mental Health Scotland (MMHS); St John of God Hospitaller Services, Malawi; University of Edinburgh; and College of Medicine, Malawi 
Organisation St John of God Mzuzu, Malawi
Country Malawi 
Sector Hospitals 
PI Contribution University of Edinburgh (Angus Macbeth and Robert Stewart) support the project through expertise in training material development and monitoring and evaluation methods. Stewart is also closely involved in organisational activities on the ground in Malawi.
Collaborator Contribution Maternal Mental Health Scotland (MMHS) is a Scottish Charity, registered in 2014, whose members include health professionals and women with a lived experience of perinatal mental health problems. MMHS looks to improve the provision of perinatal mental health services; to educate the public and the medical profession; and to bring practitioners, patients, and families together. St John of God Hospitaller Services (SJOG) is a registered NGO that has been providing mental health services and education in Malawi since 1993. It established services in Mzuzu in the Northern Region, and has recently opened a 50-bedded mental health centre (with attached community services) in Lilongwe, Central Region. The SJOG College of Health Sciences trains psychiatric nurses and clinicians at degree level, as well as offering psychosocial counselling courses. Purpose of the partnership is to support the development of community based support activities led by women with lived experience in Malawi, as well as enhancing training of primary care health workers and staff in SJOG's facilities where women with severe mental disorders (e.g. postpartum psychosis) receive care.
Impact £10000 seed funding from Tropical Health Education Trust (THET) Visit to Malawi from 09/11/19 till 19/11/19 - 3 members of Maternal Mental Health Scotland (MMHS) visit to hosts St John of God (SJOG) where a programme had been organised - this included meeting the management and clinical teams, a presentation on the MH services provided by SJOG, and a question and answer session to enable the MMHS team develop an understanding of the mental health landscape in Malawi and consider the context, and in particular perinatal mental health (PNMH) provision, planning sessions on what the partnership can support, education/teaching session with clinical teams, and initial meeting with women who had accessed perinatal mental health care through SJOG to establish links with MMHS Change Agents and consider support and development of a pathway going forward. • Basic initial training to core staff teams at SJOG and Zomba • Malawi team engaged a group of capable, enthusiastic and empowered women with lived experience of maternal mental health problems to start the process of establishing peer support and how this would best meet the needs of women who are treated at SJOG. These women attended a workshop and were fully interactive and engaged in this process supported by the SJOG team. 45 pregnant women accessed 2 maternal mental health talks delivered by SJOG clinical staff who had attended the training delivered by UK team
Start Year 2019
 
Description Being Human Festival event 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Public/other audiences
Results and Impact 'Bedtime Stories for the Brain', Being Human Festival, Scottish Storytelling Centre, Edinburgh, 21st Nov 2019. (co-organiser and speaker).
Year(s) Of Engagement Activity 2019
 
Description Engagement with Scottish Parliament MSPs 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact The event showcased the work of the Medical Research Council (MRC) in Scotland. It brought together researchers from across the country into one place to talk with MSPs and other sector stakeholders about their work, the impact it is having in Scotland, the UK and beyond.

The event opened with speeches from Lewis Macdonald MSP (who hosted the event), Richard Lochhead MSP and Professor Fiona Watt, MRC Executive Chair.

During the event MSPs, key government officials and other sector stakeholders were able to explore the different exhibition stalls, speak to researchers and learn about the impact of their work. At our stand, we engaged directly with many MSPs including the Minister for Mental Health and the Minister for Sport. We held productive conversations and follow-on meetings were arranged.

The event provided an opportunity to increase understanding amongst MSPs of the MRC's strategic vision and the leading role it plays in improving human health, innovation and economic growth by seeing first-hand the research that is taking place and the researchers that make it happen.
Year(s) Of Engagement Activity 2019
URL https://www.parliament.scot/visitandlearn/104642.aspx
 
Description Instagram public engagement event 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Schools
Results and Impact 'Social and Ethical Aspects of Biobanks', Instagram public engagement event, U. Edinburgh 25th-26th Feb 2020 (co-organiser).
Year(s) Of Engagement Activity 2021
 
Description Schools engagement even on ELSI 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Schools
Results and Impact 'Reflections on Science, Ethics and Society', 'Meet the Researcher' sessions, Scotland Science Insights Online, 29th July 2020 (speaker).
Year(s) Of Engagement Activity 2020
 
Description Visit by Jeane Freeman, Cabinet Secretary for Health in Scotland 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Hosted by Professor Andrew McIntosh, the Cabinet Secretary met MRC researchers working on the MRC Mental Health Data Pathfinder award and the Generation Malawi project, both based at the University of Edinburgh.

The Cabinet Secretary, was welcomed by Vice Principal, Professor Jonathan Seckl, and heard from researchers about how the Scottish Government can support researchers in the vital work they are doing, for example by improving access to data.

Ms Freeman said: "These two projects being funded by the MRC are important. Improving mental health is a priority for the Scottish Government and research looking at the causes and consequences of mental health conditions, both in Scotland and abroad, is crucial."

In genuine two-way dialogue, the cabinet secretary not only heard about the two projects but was also able to offer her advice and input to the researchers. She recommended several people that the researchers should contact, and these suggestions are being followed up.
Year(s) Of Engagement Activity 2019
URL https://mhdss.ac.uk/news/19/08/9/visit-jeane-freeman-cabinet-secretary-health-scotland
 
Description Visit from Dr Catherine Calderwood, Chief Medical Officer for Scotland 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Dr Catherine Calderwood, Chief Medical Officer for Scotland, visited Mental Health researchers at the University of Edinburgh in January to hear about the projects the team is working on in Scotland and Malawi.

She was welcomed and accompanied on the visit by The Principal of the University of Edinburgh, Professor Peter Mathieson.
The researchers were keen to impress upon Dr Calderwood the importance of Big Data Science to the future of mental health research.

Dr Calderwood replied: "The time is now to talk about this. Everyone has Mental Health."

High on the agenda at the meeting was the pending public consultation around the use of Guthrie Cards [newborn blood spots] for research. The researchers asked Dr Calderwood to lend her support towards further action which would allow this wealth of blood and DNA data to be used to improve healthcare for all.
Dr Calderwood indicated a change in her view and a desire to expedite this consultation.

Dr Calderwood also mentioned her upcoming visit to Malawi and a desire to visit our researchers who are based there. We will continue to liaise with her team to arrange this.
Year(s) Of Engagement Activity 2019
URL https://mhdss.ac.uk/news/20/02/27/chief-medical-officer-scotland-visits-researchers