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

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.

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.

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.