The Friendship Bench for adolescents: evaluating strategies for scaling interventions to treat common mental disorders among adolescents in Zimbabwe

Lead Research Organisation: Liverpool School of Tropical Medicine
Department Name: International Public Health

Abstract

Common mental disorders, (CMD) namely anxiety and depression, are highly prevalent among adolescents globally and are the main cause of disability-adjusted life years in this age group. In low resource settings CMD are under diagnosed and there is a large treatment gap. In adults, treatment for CMD delivered by non-specialist health workers is effective. We recently completed a trial of a lay health worker (LHW) delivered intervention (the Friendship Bench Intervention (FBI); www.friendshipbenchzimbabwe.org) in Zimbabwe. It was highly effective at treating CMD in adults. The FBI comprises a 6-session psychological intervention based on problem-solving therapy, delivered by a trained LHW. Participants who do not respond well are referred to a nurse for more specialised treatment. Grand Challenges Canada (GCC) and MSF-Holland are funding scale-up of the FBI for adults to 60 primary care clinics in 3 cities in Zimbabwe in 2016. This scale up provides the ideal framework to introduce and evaluate the FBI for younger patients (16-19 years old).

Data from the original trial indicate that the FBI was equally effective in young people (aged 18-22 years) as in older adults, but a key barrier is that relatively few young people attend clinics. We plan to develop a youth friendly FBI package which is i) delivered by trained and supported youth LHWs; ii) delivered within community settings including schools and clinics; iii) includes targeting of vulnerable young people (including pregnant teenagers and young offenders) iv) supported by community activities to reduce stigma surrounding poor mental health and raise awareness of adolescent mental health specifically and the youth-friendly FBI in particular.

We will determine the uptake, effectiveness and cost-effectiveness of the two strategies to deliver the FBI to 16-19 year olds with CMD in a sustainable way; (a) the usual care clinic-based delivery currently being scaled-up for adults, and (b) the youth-friendly FBI package. Our hypothesis is that implementation of the youth friendly package will i) increase the acceptability and uptake of the intervention to 16-19 year olds compared with usual care FBI; and ii) be an effective and sustainable model to treat CMD among 16-19 year olds.

We will randomly select 30 clinics to receive the usual care FBI and 30 clinics to receive the youth friendly FBI package. Participants will be individuals aged 16-19 years who screen positive for CMD using the locally validated Shona Symptom Questionnaire -14 (SSQ-14). A random sample of 500 eligible participants attending the clinics will be selected over a 6 month period and asked consent to participate in the outcome evaluation 6 months after they receive the FB intervention. The interview after 6 months will be conducted either in person or by telephone and will include socio-demographic data and a comprehensive mental health assessment including the SSQ-14, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and WHO Disability Assessment Schedule (WHO-DAS). Detailed data on how the intervention is delivered, for example, number of young people seen, how many sessions they attended, will be collected, including in-depth interviews with implementing agents, young people and clinic staff to assess acceptability and sustainability of delivering the intervention.

The results of the study will be used to refine the existing Friendship Bench programme to include a sustainable and effective adolescent package to complement the existing programme for adults. This will be done collectively with the City Health Departments and the Ministry of Health who are already involved in the scaling-up of the intervention in adults. We anticipate that these results will be generalizable beyond the immediate research setting, as the Friendship Bench is scaled-up across Zimbabwe and the region more widely.

Technical Summary

We recently completed a cluster randomised trial of a lay health worker (LHW) delivered intervention for common mental disorders (CMD) in Zimbabwe called the Friendship Bench Intervention (FBI); (www.friendshipbenchzimbabwe.org). It was very effective among primary healthcare clinic (PHC) attenders aged 18 or older. The FBI comprises 6-sessions of problem-solving therapy, delivered by a trained LHW, stepped-up to treatment by a nurse for those who do not recover. Scale up of the FBI is funded from April 2016 to 60 clinics in 3 cities in Zimbabwe. Trial data indicate that the FBI was equally effective in those aged 18-22 as in older adults but few young people attend PHCs.

We hypothesise that implementation of the FBI as part of a youth friendly package will i) increase the demand for and uptake of the FBI among 16-19 year olds compared to usual care FB delivery; and ii) be an effective, cost-effective, and sustainable model to treat CMD among 16-19 year olds. We will evaluate the uptake, effectiveness and cost-effectiveness of two strategies among 16-19 year olds with CMD. The two strategies are 1) the usual care FBI with delivery extended to include 16-17 year olds; 2) a youth-friendly FBI package. We will randomize 30 clinics to receive the usual care FBI and 30 to the youth friendly FBI package. Individuals aged 16-19 years who screen positive for CMD using the locally validated Shona Symptom Questionnaire (SSQ-14) will be enrolled. A random sample of 500 eligible participants will be recruited to take part in the outcome evaluation after 6 months. This will include a comprehensive mental health assessment using the SSQ-14, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7) and WHO Disability Assessment Schedule (WHO-DAS). A detailed process evaluation and cost effectiveness study will be conducted.

Our aim is that this study will result in a sustainable, effective adolescent component to complement the existing FBI for adults.

Planned Impact

The impact of the FBI in adults is currently being seen by the enthusiastic support for scale-up of the intervention to 60 clinics, funded by GCC/MSF-Holland and supported by the Zimbabwe Ministry of Health and City Health Departments. After scale-up FB will be the largest integrated mental health programme in Africa, with over 50,000 people receiving services each month through the local clinics. If successful, the youth-friendly FBI will provide a sustainable, cost-effective strategy to treat adolescents living with CMD as well as adults. To our knowledge, there are no other proven strategies which are scalable and effective in treating CMDs among adolescents in Africa.

Strategies such as the FBI which improve mental health in adolescence in a cost-effective and sustainable way can have a substantial impact on morbidity globally for several reasons: i) most common mental disorders begin in adolescence, although they are often first detected later in life; ii) building emotional resilience in adolescence can delay the onset of mental illness and mitigate future symptoms; ii) when left untreated, CMD can impair role functioning, self-care and adherence to treatments, and lead to reduced productivity and an increase in healthcare costs; and iv) in addition CMD in adolescence effects educational attainment, sexual and reproductive health and risk of violence, as well as smoking, alcohol and substance misuse. Depressive disorders are the primary cause of disability-adjusted life years (DALYs) in adolescents, responsible for an estimated 12.2 million DALYs globally among 10-19 year olds. Further, in the 2012 WHO global community consultation with adolescents, mental health was the most important problem reported by the adolescents. Effective treatment of CMD has the potential to alter the present and future life course of adolescents.

A strength of our intervention is its sustainable nature through the use of trained lay health workers. This is essential for future impact, not only in adolescents but also in adults, as in many parts of the world, including in sub-Saharan Africa, there are few psychiatrists and other trained mental health specialists. In Zimbabwe, there are only 10 psychiatrists in the country and only four psychologists working in government practice. This intervention has the potential to dramatically increase the accessibility of mental health care for this age group.

In addition to the lack of specialist personnel, there is currently little availability of mental health diagnosis and treatment close to where young people live; our community based approach will directly address this. Further, it is known that primary health care attendance is poor among adolescents regardless of their health need. We anticipate that our integrated youth friendly package of community-based services will encourage young people to access care at places convenient to them.

Lastly in Zimbabwe, as in many parts of the world, mental health stigma is pervasive, myths and misconception relating to mental illness abound and inhumane treatments are common. By working in communities to raise awareness and create demand for the Friendship Bench intervention we anticipate that we will have a positive influence on mental health knowledge and stigma within communities (although we will not measure this directly within this study).

Publications

10 25 50
 
Guideline Title Zimbabwe - National Strategic Plan for Mental Health Services 2019-2023
Description Friendship Bench included in Zimbabwe Ministry of Health and Child Care's National Mental Health Strategic Plan
Geographic Reach Africa 
Policy Influence Type Citation in clinical guidelines
 
Description Theory of Change
Geographic Reach Africa 
Policy Influence Type Participation in a national consultation
 
Description Comic Relief
Amount £299,154 (GBP)
Funding ID 2757238 
Organisation Comic Relief 
Sector Charity/Non Profit
Country United Kingdom
Start 01/2018 
End 12/2020
 
Description Friendship Bench Scale up
Amount $1,200,000 (USD)
Organisation African Academy of Sciences 
Sector Charity/Non Profit
Country Kenya
Start 05/2020 
End 03/2023
 
Description NIHR Global Health Research Units
Amount £6,977,300 (GBP)
Funding ID 16/136/54 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 04/2017 
End 03/2020
 
Description Operations Research to measure a peer led mental intervention on viral load suppression and mental health outcomes among HIV positive adolescents
Amount $653,244 (USD)
Organisation Children's Investment Fund Foundation 
Sector Charity/Non Profit
Country United Kingdom
Start 02/2018 
End 07/2020
 
Description SUCCEED - DfID funded Research Partner Consortium
Amount £6,900,000 (GBP)
Organisation UK Department for International Development 
Sector Public
Country United Kingdom
Start 04/2020 
End 03/2026
 
Title Inuka - digital platform for managing Friendship Bench 
Description An application to guide problem solving therapy via 'chat'. 
Type Of Technology Webtool/Application 
Year Produced 2018 
Open Source License? Yes  
Impact Started using it in 2019 for Friendship Bench delivery in Zimbabwe. Available on Google Play 
URL https://en-gb.facebook.com/Inuka.Io/
 
Description Appearance at World Economic Forum 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Part of a panel discussion at Davos Economic Forum on raising awareness of mental health with Prime Minister of Sweden and Prince William.
Year(s) Of Engagement Activity 2019
URL http://unitedgmh.org/index.php/2019/01/28/mental-health-at-davos-signs-of-
 
Description LA Times 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Professor Dixon Chibanda interviewed by the LA Times about the Friendship Bench
Year(s) Of Engagement Activity 2017
URL http://www.latimes.com/world/.../la-fg-global-dixon-chibanda-oped-20170516-story.html
 
Description Radio interview National Public Radio (US) 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Professor Chibanda was interviewed by National Public Radio (US) about the Friendship Bench
Year(s) Of Engagement Activity 2017
 
Description Radio interview of Zimbabwe public radio 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Multiple radio interviews on Zimbabwe public radio.
Year(s) Of Engagement Activity 2018,2019
 
Description TED talk 
Form Of Engagement Activity Engagement focused website, blog or social media channel
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact TED Talk by Professor Dixon Chibanda on the Friendship Bench - over 750,000 views
Year(s) Of Engagement Activity 2017
URL https://www.ted.com/talks/dixon_chibanda_why_i_train_grandmothers_to_treat_depression
 
Description The Conversation 
Form Of Engagement Activity A magazine, newsletter or online publication
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Professor Chibanda was interviewed by The Conversation about the Friendship Bench and its activities
Year(s) Of Engagement Activity 2017
URL http://theconversation.com/how-a-community-based-approach-to-mental-health-is-making-strides-in-zimb...
 
Description The Guardian 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact In depth article in the Guardian about Professor Chibanda's work with the Friendship Bench
Year(s) Of Engagement Activity 2018
URL https://www.theguardian.com/.../horrors-mugabe-zimbabwe-haunt-our-people-mental-sc
 
Description Washington Post interview about Davos 
Form Of Engagement Activity A broadcast e.g. TV/radio/film/podcast (other than news/press)
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Public/other audiences
Results and Impact Professor Chibanda appeared at the Davos World Economic Forum to discuss Mental Health and the Friendship Bench. He was interviewed by hte Washington Post after his appearance.
Year(s) Of Engagement Activity 2019
URL http://www.youtube.com/watch?v=OS-znIS-8ho