'Opening up the mind': problem-solving therapy delivered by female lay health workers to improve access to evidence-based care for depression and other common mental disorders through the Friendship Bench Project in Zimbabwe.

Melanie Abas,Ethel Manda,Neha Lamech,Sara Cooper,Dixon Chibanda,Ruth Verhey,Debra Machando,Tarryn Bowers,Ricardo Araya

doi:10.1186/s13033-016-0071-9

Abstract

BackgroundThere are few accounts of evidence-based interventions for depression and other common mental disorders (CMDs) in primary care in low-income countries. The Friendship Bench Project is a collaborative care mental health intervention in primary care in Harare for CMDs which began as a pilot in 2006.Case presentationWe employed a mixture of quantitative and qualitative approaches to investigate the project’s acceptability and implementation, 4–8 years after the initial pilot study. We carried out basic descriptive analyses of routine data on attendance collected between 2010 and 2014. We also conducted five focus group discussions (FGDs) with LHWs in 2013 and 12 in-depth interviews, six with staff and six with patients, to explore experiences of the intervention, which we analysed using grounded theory. Results show that the intervention appears highly acceptable as evidenced by a consistent number of visits between 2010 and 2014 (mean 505 per year, SD 132); by the finding that the same team of female community LHWs employed as government health promoters continue to deliver assessment and problem-solving therapy, and the perceived positive benefits expressed by those interviewed. Clients described feeling ‘relieved and relaxed’ after therapy, and having their ‘mind opened’, and LHWs describing satisfaction from being agents of change. Characteristics of the LHWs (status in the community, maturity, trustworthiness), and of the intervention (use of locally validated symptom screen, perceived relevance of problem-solving therapy) and continuity of the LHW team appeared crucial. Challenges to implementation included the LHWs ongoing need for weekly supervision despite years of experience; the supervisors need for supervision for herself; training needs in managing suicidal and hostile clients; poor documentation; lack of follow-up of depressed clients; and poor access to antidepressants.ConclusionsThis case study shows that a collaborative care intervention for CMDs is positively received by patients, rewarding for LHWs to deliver, and can be sustained over time at low cost. Next steps include evaluation of the impact of the intervention through a randomised trial, and testing of a technological platform for supporting supervision and monitoring clients’ attendance.

Highlights

There are few accounts of evidence-based interventions for depression and other common mental disorders (CMDs) in primary care in low-income countries
This case study shows that a collaborative care intervention for CMDs is positively received by patients, rewarding for lay health workers (LHWs) to deliver, and can be sustained over time at low cost
Task-shifting is a way to increase coverage, but it is unknown if lay health workers (LHWs) working routinely in government systems in low-income countries can deliver evidence-based therapies for CMDs

Summary

Introduction

There are few accounts of evidence-based interventions for depression and other common mental disorders (CMDs) in primary care in low-income countries. There have been repeated calls to improve access to evidence-based interventions for depression and other common mental disorders (CMDs) through primary care in low-income countries [1]. Task-shifting is a way to increase coverage, but it is unknown if lay health workers (LHWs) working routinely in government systems in low-income countries can deliver evidence-based therapies for CMDs. The aim of this study is to report on a primary care mental health project called the ‘Friendship Bench’. The aim of this study is to report on a primary care mental health project called the ‘Friendship Bench’ This comprises a structured collaborative care intervention for CMDs, including screening and evidence-based psychological therapy provided by trained and supervised lay community health workers attached to primary care. The project, which uses materials from previous cross-cultural research in the country [4, 5], was started by a local psychiatrist (DC) in 2006 in response to a request from stakeholders in the local district community for a ‘no-cost’ community mental health intervention [6]

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