Optimising implementation strategies of the scale-up of a primary care psychological intervention: The Friendship Bench

Lead Research Organisation: King's College London
Department Name: Health Service and Population Research

Abstract

A randomised controlled trial showed unequivocally that the Friendship Bench (FB) is the first effective psychological treatment programme in primary care to be tested so far in Sub-Saharan Africa. The auspicious results persuaded the government to scale-up the FB to 72 clinics in and around Harare about one year ago. Additional scaling-up has been planned for later this year. Up until now, there has not been an evaluation of the results of this scaling-up initiative.

This study aims to evaluate the scaling-up so far but most importantly to identify the factors that have influenced the outcome of the implementation of the FB with a view to design an enhanced
facilitation intervention to improve the implementation in clinics that have not performed so well. We will use two well-known implementation science frameworks (RE-AIM and CFIR) to guide our work. Whilst RE-AIM will provide us with a framework for the outcomes, CIFR will guide us through the process of exploring the 'core' factors that determine the success or failure of the implementation of the FB. We will start with an evaluation of what has been achieved so far using all the data that has been routinely collected during the scale-up effort until now. This will be supplemented with additional data captured through a survey and other qualitative methods. The results will allow us to evaluate RE-AIM outcomes and classify clinics according to their implementation outcomes. Subsequently we will conduct a workshop with the main stakeholders to discuss and agree on the CFIR framework to use for the second phase of exploration. The main aim of the second phase is to identify key or core variables deemed to be key predictors of the successful implementation of the FB. In order to do this we will focus on comparing low and high performing clinics to identify those factors that might explain implementation outcomes. During the second phase, most research will be of a qualitative nature, through focus groups and semi-structured interviews, except for small surveys and the collection of additional economic data.

At the end of this phase, we will invite main stakeholders again to review our results and conclusions and to help us identify the components of an enhanced facilitation intervention that we will test in those clinics whose implementation achievements fall into the lowest quartile. We will conduct a hybrid type 3 study to ascertain if implementation outcomes improve four months after this
facilitation takes place in comparison with control clinics. The information generated in this study is vital to continue the successful expansion of the FB and to consolidate the implementation currently underway. Besides it will provide essential information for other neighbouring countries in terms of using implementation science methodology as well as learning about potential problems in the route to implementation as well as possible approaches to improve their implementation efforts.

Technical Summary

A RCT showed that the Friendship Bench (FB) is the first effective psychological treatment programme in primary care to be tested so far in Sub-Saharan Africa. The FB was scaled up to 72 clinics in and around Harare about one year ago. This study aims to evaluate the scaling-up so far and to identify the factors that have influenced the outcome of the implementation of the FB with a view to design an enhanced facilitation intervention to improve the implementation in clinics that have not performed so well. We will use well-known implementation science frameworks to guide our work. We will start with an evaluation of what has been achieved so far using all the data that has been routinely collected during the scale-up effort until now. This will be supplemented with additional data captured through a survey and other qualitative methods. The results will allow us to evaluate RE-AIM outcomes and classify clinics according to their implementation outcomes. Subsequently we will conduct a workshop with the main stakeholders to discuss and agree on the CFIR framework to use for the second phase of exploration. The main aim of the second phase is to identify key or core variables deemed to be key predictors of the successful implementation of the FB. In order to do this we will focus on comparing low and high performing clinics to identify those factors that might explain implementation outcomes. During the second phase, most research will be of a qualitative nature, except for small surveys and the collection of additional economic data. At the end of this phase, we will invite main stakeholders again to review our results and conclusions and to help us identify the components of an enhanced facilitation intervention that we will test in those clinics whose implementation achievements fall into the lowest quartile. We will conduct a hybrid type 3 study to ascertain if implementation outcomes improve four months after this facilitation takes place.

Planned Impact

This is a unique opportunity to learn from the first implementation in a large scale of a psychological treatment programme of proven effectiveness within primary care in Sub Saharan Africa. The aims and methods proposed seem to us robust enough to achieve our expected goals which are fully aligned with those of this call. The impact of this study can be substantial. Other than being the first such scale-up in an African country, it will provide services that should contribute greatly to decrease the mental health treatment gap in Zimbabwe. The model can be easily replicated in other African and similar settings where there are no specialists to deliver mental health care. This is the only psychological treatment on offer at present for poor people in Zimbabwe. This intervention is a 'game changer' in Zimbabwe and hopefully a model to imitate by other African countries. There are no other promising psychological interventions in SSA that has reached this level of implementation.

Having completed a successful RCT, to systematically analyse the performance of the FB intervention at the population and health-systems level, determine the main opportunities and barriers to implementing and scaling-up this intervention at a major scale, and test promising implementation strategies to maximize the public health effects of these scale-up efforts. As argued before, this research is vital for the successful implementation of this intervention in Zimbabwe, and represents a unique opportunity globally given the limited number of evidence-based interventions being scaled-up for treating CMDs across LMICs globally. This project aims to contribute to generalizable knowledge on optimal strategies to promote effective implementation and scale-up of task-shared treatments for CMDs across health system contexts and LMICs. Furthermore, this study has a strong economic component as described above. A health economic assessment will be undertaken to examine the resource impacts and cost-effectiveness of programme scale-up and spread (Aim 2). These data will be of interest to Ministries of Health and partners as they seek to consider efforts to close the mental health treatment gap in their countries.

There will be a series of communication activities including briefings and talks to present the results to stakeholders, policy-makers, and the public in general. We were very successful with the dissemination of the FB RCT results and we anticipate we will be with the results of this study. There is potential for major publications in high-impact journals. The group has shown capability to deliver in this respect. Likewise, we will present results in local, regional, and major international conferences. This study is unlikely to generate commercially exploitable results.
 
Description The implementation of the evidence-based Friendship Bench has experienced major difficulties from its beginning and this has been accentuated with the COVID pandemic and political problems. Contextual variables are key in resource-poor settings for the implementation of any successful programme. Nonetheless, we have been able to start testing other modes to deliver the service such as live phone calls, whatsapp, and community visits. It is early days to have a reasonable ideas of the outcome using these methods.
Exploitation Route Researchers evaluating the implementation of mental health programmes in resource-poor settings should benefit from the findings of this work. Nonetheless the pandemic has been a major problem that confounded all of our results.
Sectors Healthcare

 
Description The project contributed to attract funding from other Foundations to support its continuity. The pandemic forced to open up options to new ways of delivering the programme. The Zimbabwe team has been able to attract major funding for other projects through Wellcome Trust and NIH-R to continue its research endeavours and most importantly capacity building efforts. Several young Zimbabwean researchers have been able to publish research and complete research degrees.
First Year Of Impact 2021
Sector Education,Healthcare
Impact Types Economic,Policy & public services

 
Description AMARI: African Mental Health Research Initiative
Amount £3,108,527 (GBP)
Funding ID 107751/Z/15/Z 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 08/2015 
End 11/2017
 
Description NIHR Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa Kings College London
Amount £6,997,730 (GBP)
Funding ID 16/136/54 
Organisation National Institute for Health Research 
Sector Public
Country United Kingdom
Start 05/2017 
End 03/2022
 
Description Provision for Public Engagement.
Amount £100,750 (GBP)
Funding ID 108727/Z/15/A 
Organisation Wellcome Trust 
Sector Charity/Non Profit
Country United Kingdom
Start 08/2015 
End 03/2022
 
Title Implementation Evaluation methods 
Description We developed a model to evaluate the implementation of health programmes in primary care African settings 
Type Of Material Physiological assessment or outcome measure 
Year Produced 2021 
Provided To Others? Yes  
Impact There are two other papers currently under review and two in preparation that describe in more detail this method: Applying the Consolidated Framework for Implementation Research to optimize implementation strategies for the Friendship Bench psychological intervention in Zimbabwe - an observational qualitative study. Charmaine Chitiyo1,2, Ruth Verhey 1,2, Sandra Mboweni 1,2, Andy Healey5, Dixon Chibanda1,2,6, Ricardo Araya5, Bradley H. Wagenaar, MPH, PhD3,4 (Submitted to Implementation Science) Using the RE-AIM framework to evaluate the implementation of scaling-up the Friendship Bench in Zimbabwe. Ruth Verhey 1,2, Charmaine Chitiyo1,2, Sandra Mboweni1,2, Jean Turner1,2, Gift Murombo7, Andy Healey5, Dixon Chibanda1,2,6, Bradley H. Wagenaar3,4, Ricardo Araya5 (Submitted) Development of a Friendship Bench implementation blueprint Adapting the Friendship Bench to deliver services under the COVID pandemic: an ethnographic study The model allows to gather and analyse ongoing data to evaluate progress on the implementation of health programmes. 
 
Description GlobeLife initiative of Uppsala University and Karolinska Institute 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact The seminar was part of the GlobeLife initiative to promote research and education collaboration between UU and KI. This seminar focused on social innovations for health.
Year(s) Of Engagement Activity 2021
 
Description Keynote Alan Flischer Memorial Lecture University of Cape Town, South Africa 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact This is an annual lecture delivered by a highly selected international speaker
Year(s) Of Engagement Activity 2019
 
Description Learning Event focused on Models of Community-Centered Maternal Mental Health and Substance Use Disorder Programs, Community Health Accelerated Partnership chap.health 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Policymakers/politicians
Results and Impact Learning Event focused on Models of Community-Centered Maternal Mental Health and Substance Use Disorder Programs.
The purpose of the meeting is to showcase effective models of Community-Centered Maternal Mental Health and Substance Misuse programs.

We will invite discussion with experts and identify community-centered interventions that train community health workers, peers, and doulas on evidence-informed trauma attuned interventions that can be employed throughout the reproductive life course and improve maternal health outcomes while eliminating racial disparities.
Year(s) Of Engagement Activity 2022
 
Description McGill Global MH Research 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Postgraduate students
Results and Impact "Mental Health Research in Pandemics" held in the Global Mental Health Research seminar of the 27th Annual Summer Program in Social and Cultural Psychiatry
Year(s) Of Engagement Activity 2021
 
Description US Secretary's Office of Global Women's Issues spotlighting women-led innovations related to community health 
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 panelist representing The Friendship Bench for a virtual event entitled "The Innovation Station: Pacific Northwest" convened by the US Secretary's Office of Global Women's Issues spotlighting women-led innovations related to community health. Discussing innovations that may be used to address challenges faced by the Pacific Northwest community, as well as other communities around the world
Year(s) Of Engagement Activity 2021