The e-Friendship Bench, digital mental health therapy

Mental health is a growing area of concern in Zimbabwe and the global south countries. The prevalence of depression and anxiety globally is estimated to be 7.2% which is around 548 million. In Zimbabwe, the prevalence is over 20% of the adult population. The Government of Zimbabwe recognizes mental health as a serious public health and development concern. Mental health was recognised as a priority in the most recent National Health Strategy for Zimbabwe (2019-2023), and the current Ministry of Health and Child Care (MOHCC). Mental Health Strategic Plan key areas include to improve awareness of mental health and improve community engagement. Access to quality primary mental health continues to be a challenge within Zimbabwe, according to WHO,  the country has a severe shortage of human resources for mental health, with an estimated 18 psychiatrists (17 of them in Harare) or approximately 0.1 per 100,000 population. There are 917 psychiatric nurses (6.5 per 100,000) and 6 psychologists (0.04 per 100,000). Economic instability has led to a substantial brain drain, with trained specialists leaving the country or practicing in other areas of medicine. Though there is a relatively large number of psychiatric nurses in Zimbabwe, many have diverted to HIV-related care given increased funding, primarily from international donors, for these areas of health services, according to the WHO Zimbabwe ranks with one of the highest seroprevalence at 13.8%. The WHO also estimates that 70% of the Zimbabwean population lives below the poverty datum line which makes access to quality mental health beyond the access of many sufferers of Mental illness. The Friendship Bench through an evidence-based intervention is currently attempting to bridge the gap of mental health service provision through the use Lay Health workers. To date 965 LHWs have been trained to provide lay counselling services through talk therapy. The major shortfalls with the primary mental health care performance of the intervention centre around:

• Timely data submission for real time decision making
• Marginalised clientele with lack of access to counselling services due to limited personal and resources
• Lack of a proper tracking system to monitor and evaluate the various cases that are engaged with at the Friendship benches across the country. 

The Solution: The solution builds on existing platforms,

The proposed improved solution/ platform will be a digital platform that can perform the following mental health care services

• Psychoeducation/awareness raising through the provision of digital mental health tips on demand and self-care materials. These will be disseminated through WhatsApp for those with smart phones and a dedicated USSD code, where prompts can grant access the mental health tips and self-care material. According to the Postal Telecommunications and Regulatory Authority of Zimbabwe, 93.5% of Zimbabweans have access to a mobile device, either smart or feature phone. (Abridged-Sector-Performance-Report-Q3-2021-HMed.pdf (techzim.co.zw)) . Accordingto the most recent report from GSMA, an association of mobile network operators worldwide, there are 747 million SIM connections in sub-Saharan Africa, representing 75% of the population  The solution will leverage on the mobile penetration to utilise mobile phone networks to destigmatize and raise access and awareness to psychoeducation
• Mental Health Screening through digitising the SSQ14 screening tool and using Artificial Intelligence (AI) clientele will receive screening through a mobile application and based on their scores are referred to further counselling or self-care material. The automated screening will take out the human element guaranteeing unlimited mental health screening at any time, confidentiality, and enhanced referral pathways to mental health service providers

 The proposed solution limits the role of the physical human interaction for raising awareness or providing psychoeducation to targeted clients , providing  digital a hybrid solution supporting offline capability that incorporates a mobile application and a web portal to cater for the demand and supply of mental health services and products, to bridge the information gap, and counselling services across the supply chain of mental health services.

• At source/provider end, the Friendship Bench, the platform will be used to track and draw insights from the big data generated from real time data submissions by the Lay health workers as they interact with clientele. This will pick on trends:
  • In line with FBs vision of “A friendship bench within a walking distance for all” the proposed solution the Application will augment the physical benches spread across the country, and will be an e-friendship bench, being a one stop electronic solution for mental health services offering 1. self-care material 2. Online counselling – this will cater for those in the Urban setting as well as those in rural low connectivity settings, this will be achieved through a USSD code functional on feature phones and through prompts one can receive mental health screening and if deemed at risk referred to the nearest LHW/counsellor.  3. Mental health awareness through sending automated SMSs with mental health tips. Raising awareness has been found to be integral in improving mental health and de-stigmatising issues pertaining to mental health.
•  A Web portal that will serve as the administration point for sending material, generating messaging and IEC materials.
• Fb application that will run on android and IOS mobile devices to provide automated screening services and analytics to inform program designs and redesigns.
• A dedicated USSD code run on local network providers to ensure functionality on the feature phone or in low bandwidth settings
• Artificial Intelligence to enable chat bots to run on the web page and WhatsApp platform for dissemination of self-care material and mental health tips on demand
• Automated systems that will assist in booking for sessions and generation of reports and analysis. 

 This solution is simple to use across all the age groups of clients and Lay Health workers as most of these Grandmothers/Community Health Workers are above 60 years of age. They require a design that is straight forward and allows for easy accessibility of reading materials.

 A hybrid solution supporting offline capability allows for use in rural areas of Zimbabwe where internet connectivity is a challenge. Clients and Community Health Workers (Grandmothers) can have readily available materials for counselling. This is a much-needed solution in Zimbabwe as most of the population cannot afford data bundles due to high data bundle pricing. USSD functionality can also cater for the population that does not have smartphones.

Primary health care data is collected by Community Health Workers (Grandmothers) using an android mobile app, a web-based counselling platform (Inuka) and also the paper-based data collection forms. The current systems have not been well adapted in rural areas since they require internet connectivity thus the use of paper forms in the rural areas.

Technology used will include

•  A Web portal that will serve as the administration point for sending material, generating messaging and IEC materials.
• Fb application that will run on android and IOS mobile devices to provide automated screening services and analytics to inform program designs and redesigns.
• A dedicated USSD code run on local network providers to ensure functionality on the feature phone or in low bandwidth settings
• Artificial Intelligence to enable chat bots to run on the web page and WhatsApp platform for dissemination of self-care material and mental health tips on demand
• Automated systems that will assist in booking for sessions and generation of reports and analysis.  

The solution will serve an approximate 20% of the adult population in Zimbabwe said to be susceptible to depression and anxiety (Abas & Broadhead, 1997; Chibanda, Cowan, et al., 2016; Chibanda, Verhey, et al., 2016) as well as in rural youth ((Kohn et al., 2004)) .The estimated treatment gap for major depression in Zimbabwe is 67% (Kohn et al., 2004). The solution will scale up the mental health services/counselling from primarily physical face to face at the clinics and community, where 85% of the current FB clients are reached , to enhance the online platform , where at present 15% of the total clients  reached by the Friendship bench are from the Online platform. The solution will impact the communities we work in through:

• Enhanced performance tracking and measurement of the client cases as they are seen on the bench by the Community Health Workers (CHWs). The platform will allow for real time tracking of data to inform adaptive management and programming design and redesign.
• Ease of access to counselling services by the clientele in the communities that FB serves, through awareness raising and provision of counselling and products-IEC materials and mental health self-care products
• It will enable case care tracking by the lay health care workers for better and informed counselling.

The target population of the solution will be the those currently staying in Zimbabwe , according to the 2022 preliminary census report (2022 Population & Housing Census - Preliminary - Zimbabwe Data Portal (opendataforafrica.org)) , the country currently has a population of 15,178,979 individuals of which 52% are female , 61.4% reside in the rural areas and an approximate 60% are youth. The female population in Zimbabwe is disproportionately affected by socio-economic factors (https://borgenproject.org/tag/gender-inequality-in-zimbabwe/), poverty on the continent has a female face, and by default this means they lack in resources to demand and access primary health care, including mental health. Zimbabwe also has a fairly young population and according the evidence, https://orcid.org/0000-0002-37... ,  there exists a treatment gap in the provision of mental health treatment amongst the youth. The female and youth population with limited economic opportunities and the various burden of care at the household level face varying societal pressures and this impacts negatively on mental health and with limited resources and awareness have no access to quality mental health services. The proposed solution will offer a low-cost mental health service provision solution to the marginalised in the communities that Friendship Bench serves.  This is done through leveraging on existing technological advancement associated with the mobile devices and SIM card penetration. 

The Friendship bench team utilises a community volunteer model that embeds the citizens it serves in its implementation model. With a network of 900 Grandmothers/community health workers spread across the provinces of Zimbabwe with a target of community lay health workers by the end of FY2022, the Friendship Bench represents the community needs across the country. With several years of implementing the evidence-based intervention, through several iterations guided by lessons learnt and challenges encountered the Friendship Bench model mimics a solution that was formulated by and for the communities. The name Friendship Bench was coined by the grandmothers to infer a solution that came about because of a consultative process of solution building. The Friendship Bench innovation is a brief, evidence-based intervention shown, in Zimbabwe, to significantly reduce symptoms of depression and anxiety[1]. Research has shown the model to also be effective in adults and young PLHIV[2]. Through several participatory evidence generation studies the Friendship Bench has gathered the lived experiences of the communities it serves to come up with a solution that best serves them.

[1] Verhey R, Chibanda D, Vera A, Manda E, Brakarsh J, Seedat S. Perceptions of HIV-related trauma in people living with HIV in Zimbabwe’s Friendship Bench Program: A qualitative analysis of counselors’ and clients’ experiences. Transcultural Psychiatry. 2020;57(1):161-172. doi:10.1177/1363461519850337

[2] .;  Verhey R, Chibanda D, Vera A, Manda E, Brakarsh J, Seedat S. Perceptions of HIV-related trauma in people living with HIV in Zimbabwe’s Friendship Bench Program: A qualitative analysis of counselors’ and clients’ experiences. Transcultural Psychiatry. 2020;57(1):161-172. doi:10.1177/1363461519850337.

Through resources that can be availed through this challenge the Friendship Bench can be able to get the required technical and financial support to upgrade current technological systems that are in place to provide digital mental health service awareness, counselling, and self-care material/health tips

• Technological upgrade to facilitate a platform that can handle online mental health awareness, counselling and the dissemination of Information Communication and Education material for mental health. The platform will avail real time access to primary mental health care as well as monitor and track cases/clients receiving lay counselling and lay counsellor activity  for informed programming and program designs and redesigns.
• The financial resources availed will assist to carry the cost of data and communication – the solution will offer:
  • a low-cost access to mental health through a USDD code- which is granted at cost from the Mobile network operators (MNOs) in country. 

The proposed solution is innovative in that it aims to improve primary mental health provision through bridging the supply gap of mental health services through low-cost scalable technology. In an environment characterized by social and economic drivers of inequality in the communities we serve coupled by suppressed supply of mental health services the proposed solution will significantly scale mental health services provision to the most marginalised communities. The e-Friendship Bench is going to be available to those who need it most in Zimbabwe and globally. The solution because it primarily functions on the basic mobile devices is adaptable across geographic spaces and markets. The solution avails mental health services at scale -with limited head count involved. According to WHO special initiative country report for Zimbabwe, the Government of Zimbabwe has demonstrated modest support for mental health services, of the total health budget, 0.42% is allocated to mental health. Public spending on mental health is estimated at 0.13 USD per capita each year. The solution through leveraging on low cost technology will impact the sector quite significantly at a broader scale by availing the primary mental health services, through online and mobile device linked  platform.  

We have also been able to partner with the Ministry of Health and Child Care through an 5 year MOU.  The partnership provides Friendship Bench with an opportunity to leverage on the existing infrastructure (primary health care clinics) throughout Zimbabwe.  The solution will enable us to continue providing technical and capacity building in problem solving therapy with the Ministry of Health and Child care community health workers, primary care counsellors and nurses at the primary health care facilities and clinics.  We will also through this solution provide mentorship to the Ministry's field staff which will ensure that they have the current skills and knowledge in Common Mental Disorder intervention.  We will also use the technology to conduct community campaigns to raise and increase awareness around mental health issues.  The objective is to initiate early detection and primary prevention of common mental, neurological and substance abuse disorders. 

The Friendship Bench Goal: Reduced Common Mental Health disorders for at risk individuals and communities in Zimbabwe. The model aims to reduce depression and anxiety to an estimated 20% of at risk persons. This goal is achieved through the attainment of the following objectives/outcomes:

• Objective 1: Enhanced access to mental healthcare counselling for at risk individuals
• Objective 2: Improved Livelihoods, Food & Nutrition security for CKT support group participants
• Objective 3: Improved collaboration learning and sharing of best practices

The Friendship Bench will attain its goal and objectives through the following activities as an organisation:

• Mobilisation/sensitisation and providing psychoeducation to stakeholders and the communities that the organisation works in. This will include providing physical and virtual awareness raising and health tips to at risk individuals
• Capacity building of delivering agents to provide both face to face and online lay counselling services
• Creation of support groups for those that would have gone through therapy sessions with the various delivering agents spread across the country and beyond.
• The Friendship Bench also uses data and evidence to inform program designs iteratively, this is a participatory process where feedback loops from clients and delivering agents informs what and how the model is implemented.  

The Friendship Bench utilises key performance indicators to measure progress of its efforts. The following area a few indicators that are used:

• Proportion Improvement in Mean SSQ14 score of clients that received problem solving therapy
• Number of delivering agents capacitated in Problem Solving Therapy & Skills (new and refresher)
• Number of clients served by the Friendship Bench
• Number of therapy sessions conducted (online & physical)
• Number of CKT (peer led support) groups created
• Number of implementing partners. 

The Friendship Bench theory of change consists of two models the action model and the change model:

• The action model is centred around capacitating a critical mass of lay health workers to provide problem solving therapy/talk therapy to clients that present themselves at the bench or online platforms for counselling. The modalities involved are benches in communities across 6 provinces in Zimbabwe, and an online platform that still exists primarily to book clients for sessions through the WhatsApp platform. The model is also implemented through vetted partners in Zimbabwe and beyond. The biggest partner for the organisation being the Government of Zimbabwe Ministry of Health and child welfare, where the community health workers affiliated to the ministry are trained in how to provide lay counselling. To cater for the youth and those that prefer online counselling there exists an online platform where bookings are made and sessions happen over WhatsApp. Thus Friendship Bench has successfully managed to create safe spaces for mental health services by tapping into existing structures as well as exploring new avenues for lay counselling services that include online platforms and digital services like WhatsApp.
• The change Model – The Friendship Bench has operational buckets of implementation that include:
  • Mobilisation/Psychoeducation, where awareness campaigns are conducted in the community by FB staff, volunteers and partners. This is demand generation for mental health services
  • Sensitisation/Stakeholder engagement – where key community gate keepers are engaged for mental health so as to gain buy in and acceptance in the communities that the friendship bench operates
  • Training- the Friendship Bench embarks on capacity building of lay delivering agents across the country and beyond in order to up skill for therapy/counselling
  • To ensure sustainability centred around certain quality of life indicators the FB creates peer led support groups call Circle Kubatana Tose groups that enable like minded peers and community members to come together and address common issues affecting them that’s in a way avoids relapse and provides a sense of community and belonging.
  • Presentation of data – integral to what Friendship Bench does is measurement, and through periodic reflections and evaluation of data, programming is evidence informed. This allows for programming to take in the dynamic context that the model is implemented.

Thus through  capacity building of community delivering agents and through support of key enablers and tools  for counselling  the Friendship Bench makes impact and change in the communities it works in.

The Friendship Bench will leverage on a web and mobile application to allow for the administration and roll out of mental health services- this will allow for:

• The broadcast of SMSes for mental health services – self care material,  and mental health tips
• Enable the functioning of the ussd code so that marginalised communities can have access to mental health services. Through mobile short code prompts a client can access material/self care tips and make a booking to the nearest counselling services
• Online counselling services
• Case management from the backend by the Friendship Bench (for data analytics, trends and insights for program designs) and also the front end by the lay health worker for- this will allow for and enable better tracking and reporting. Artificial intelligence will also be embedded into the platform – in the form of a chat bot to enable automated bookings and access to self-care materials. 

At present a network of 1,000 lay delivering agents are collecting data.  By the end of 2022 a total of 1,340 will have been capacitated to carry out therapy sessions. Integral to the model is volunteerism, the majority of the FB delivering agents are grandmothers domiciled in the various localities that Friendship Bench works in.  These are passion driven individuals that work in the health delivery system, some of them for many decades and it’s the passion that drives them to continue to offer community counselling services. The platform will be manned by the FB staff and online counselling services offered by a network of youth buddies/trained delivering agents.

Friendship Bench a diverse, inclusive, and equitable workplace, is one where all employees and volunteers, whatever their gender, race, ethnicity, national origin, age, sexual orientation or identity, education or disability, feels valued and respected. We are committed to a non-discriminatory approach and provide equal opportunity for employment and advancement in all of our departments, programs and communities we work in.  It is important in the work that we do, we create safe spaces and a sense of belonging in communities to enhance quality of life.  

As the Friendship Bench, we set ourselves apart as an organisation that brings together individuals with a diverse range of skills who have a passion and are dedicated to the cause of ensuring the mental well-being of community members. Friendship Bench seeks to inspire its staff and create a world-class working environment that will improve their quality of life. We recognise that it is people who drive our success and that we cannot achieve our ambitions without talented, passionate and motivated staff. Our approach is to create an environment where the employees, regardless of background, can focus on their strengths, can focus on their strengths, can thrive and make a difference. 
The Leadership team comprises of individuals whose skills range from clinical psychiatry, governance, organisational development and entrepreneurship, financial management, psychology and public health. This has been a deliberate strategy to allow for a more holistic and inclusive approach towards decision-making, leveraging on different experiences, talents, tools and techniques. Leadership meets weekly to discuss elements of the organisation's strategic priorities, including program, finances and operations. Any decisions that require Board approval are forwarded to the Chair and Board members through a resolution via email.

We encourage our team members to participate in the growth of the organisation.  We host weekly team meetings where staff have an opportunity to learn more about work being conducted by Leadership. This platform brings together a diversity of voices to the table, young and mature individuals, experiences in work and new to the job, etc. Through this, Friendship Bench has been able to create an environment that promotes inclusivity, encourages input allowing for everyone to share and voice their opinions through feedback. Team members also serve as volunteer committee members which allows them the opportunity to make decisions and provide their diverse viewpoints. An example of this is our procurement and wellness committees. 
 
Our core team consists of men and women from diverse professional backgrounds that consists of a clinical psychologist, social workers, community psychologists, sociologists, development practitioners, a psychiatrist, a physiotherapists, administration, business and finance. We value all of our combined personal experiences and how those have influenced our life paths in the work we are committed to do at Friendship Bench. The Friendship Bench team supports attachment students from various Zimbabwean universities who are introduced to delivering evidence-based mental health care. The inclusion of the youth voices (buddies), both male and female who are represented through the Youth FB initiative enables us to reach to the younger population and provide them with problem solving therapy. Our intention is to attract and include highly qualified diverse employees who understand and can relate to the diverse backgrounds of our clients and communities. 

The traditional pillars of our program are the seasoned community grandmothers and grandfathers from within various communities who helped shape the Friendship Bench program and are reaching the people in need. This diversity of education, experience and interest assists the Friendship Bench team to grow and keep building a strong service in the area of mental health. Our training focuses on the inclusion of marginalised groups in Zimbabwe with emphasis on equitable distribution of our resources such as training, placement and access to Friendship Bench services and inclusion in the work- place.

As the Friendship Bench, important to us is that: 

•  We believe in an inclusive work environment where Friendship Bench employees are welcomed, valued, respected, and heard
•  We believe that Friendship Bench employees will be provided a safe work environment

•  We believe that diversity brings strength and enables success of the organisation
•  We believe in equality of opportunity free from discrimination
•  We believe in hiring and promoting the most qualified candidate and
•  We believe in employee development at all levels of the organization.

We also have an  Engagement Policy Incorporating Equal Opportunity Diversity Equity And Inclusion policy. 

FB trains and supports community members (affectionately referred to as “grandmothers”) to deliver evidence-based mental health therapy in their communities, literally on a park bench.  

With over 50 peer-reviewed publications and over 10 years of research, our intervention model and theory of change are rooted in research – developed, validated and showing clinically significant improvements in mental health outcomes in Zimbabwe.

Friendship Bench’s innovative model focuses on training community health workers to provide basic Cognitive Behavioral Therapy (CBT) with an emphasis on Problem Solving Therapy (PST), combined with subsequent peer-led group support. This task shifting approach means the Friendship Bench can deliver an effective, affordable and sustainable solution to bridge the mental health treatment gap at a primary healthcare and community care level. Friendship Bench makes the “bench” the first port of call for anyone in need, using an army of empathic, socially connected therapists. Clients are screened for common mental health disorders using locally validated psychometric tools (the Shona Symptom Questionnaire). During training, a referral pathway is established for cases which are considered ‘red flags’ such as suicidality or psychosis, where a higher level of care is needed. Post therapy, clients are invited to join community support groups for sustained long-term impact, resulting in sustainable recovery.

The talk therapy intervention is delivered to people with common mental health disorders, such as anxiety and depression, known locally as ‘kufungisisa’- thinking too much. Trained community health workers sit with their clients outdoors, on wooden park benches in discreet safe spaces in the community. Clients are screened for common mental health disorders using two locally validated psychometric tools, the Shona Symptom Questionnaire (SSQ) or SSQ14, and the Patient Health Questionnaire or PHQ-9. Both have shown to have good psychometric properties (J Affect Discord 2016 Jul 1;198:50-5). The SSQ is administered to all clients accessing Cognitive Behavioral Therapy by ‘sitting’ on the Friendship Bench at 6 weeks, 3 and 12 months to determine clinical improvement. Data is collected on the number of clients that have accessed individual therapy, have joined a support group and how many have become gainfully employed. During training, a referral pathway is established for cases which are considered ‘red flags’ where a higher level of care is needed. Post therapy, clients are invited to join community support groups for sustained long term impact. We support our community health workers with quarterly refresher workers, including monitoring and supervision visits. We place significant importance on creating access to depression care in under-served communities and for those that earn less than $2/day as there simply exists no alternative access to mental health services. There is no charge to patients for these services. Our intervention leverages the existing infrastructure of the national healthcare system to deliver mental health services that are anchored in research and proven to be effective at reducing depression and anxiety. Through this, we have been able to take advantage of the existing health workforce, the psychiatric nurses who are potential and additional resources for delivering mental health services across the country. Our costs are essentially tied to the training and support of community health workers or “grandmothers” and other community health workers who typically see and serve 4 clients or patients a week and lead community circles that welcome clients who have completed their on the bench therapy sessions. Given our train-the-trainer approach and our ability to leverage existing partner infrastructure and workforce, the deployment of our community health worker model is exceptionally cost effective and scalable. Our calculations show that a current client therapy session on the bench costs just under $15 to deliver. This includes our total organizational costs, including our research programs. We believe that Friendship Bench can decrease this cost per patient served to close to $2 over the course of the next couple of years, given our work with implementing partners and the increased use of digital technology. As Friendship Bench transitions to scale, we will leverage our implementation blueprint to continue to develop and refine our intervention model to improve efficiencies and optimize impact. 

The successful implementation of Friendship Bench activities is reliant on a diverse range of funding sources and streams of funding to sustain its operations, these include grants from INGOs, Foundations, Philanthropists. Friendship Bench has identified the following financial sustainability opportunities:

• Fee for service or Implementing partner fees - To support our scaling strategy, Friendship Bench partners with organisations that have an interest to integrate mental health into their existing programming.  Fees are charged to the implementing partner to support training and quarterly technical assistance provided by the Friendship Bench team. 
• Earned income - We have recently launched the mental health in the workplace initiative where we partner with the public and private sector to provide training to their wellness champions, conduct sensitisation and mental health workshops, provide counselling to their employees. We also generate revenue through speaker engagement workshops.

The majority of our funds are from grants raised and these include funding received from:

MacKenzie Scott - USD$2,000,000; Draper Richards Kaplan Foundation - USD$300,000 over 3 years; Mulago Foundation - USD$500,000 (2021 and 2022); Schooner Foundation - USD$300,000 over 3 years; Evolve Foundation - USD$200,000; Tides Foundation - USD$500,000; Elevate Prize Foundation - USD$250,000; Bohringer Ingelheim - USD$402,000; Goldman Sachs - USD$100,000; Dovetail Foundation - USD$125,000; African Visionary Fund - USD$180,000; Risk Pool Foundation -USD$51,000; CRI - USD$73,300; Grand Challenges Africa - USD$92,532; Peery Foundation - USD$25,000; Segal Family Foundation - USD$25,000

We have also been able to generated earned revenue from implementing partners in the amount of USD$40,000.00