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

常见精神障碍，即焦虑和抑郁，在全球青少年中非常普遍，是造成这一年龄组残疾调整生命年的主要原因。在资源匮乏的环境中，CMD未得到诊断，并且存在很大的治疗差距。在成人中，由非专业卫生工作者提供的CMD治疗是有效的。我们最近完成了一项由非专业卫生工作者（LHW）提供的干预（友谊长凳干预（FBI））的试验；www.friendshipbenchzimbabwe.org)。它在治疗成人CMD方面非常有效。联邦调查局包括一个基于问题解决疗法的6期心理干预，由训练有素的LHW提供。反应不佳的参与者将被转介给护士进行更专门的治疗。2016年，加拿大大挑战组织（GCC）和荷兰无国界医生组织（MSF-Holland）正在资助津巴布韦3个城市的60家初级保健诊所扩大成人联邦调查局的规模。这种规模的扩大为年轻患者（16-19岁）引入和评估FBI提供了理想的框架。最初试验的数据表明，FBI对年轻人（18-22岁）和老年人同样有效，但一个关键的障碍是，去诊所的年轻人相对较少。我们计划开发一套青年友好的联邦调查局方案，由受过培训和支持的青年卫生工作者提供；Ii)在包括学校和诊所在内的社区环境中提供；（三）包括以弱势青年（包括怀孕少女和少犯）为目标；（四）在社区活动的支持下，减少围绕不良心理健康的污名，提高对青少年心理健康的认识，特别是对青年友好的联邦调查局的认识。我们将确定这两项策略的接受程度、有效性和成本效益，以可持续的方式向16-19岁患有CMD的青少年提供FBI服务；(a)目前正在扩大为成人提供的以诊所为基础的常规护理服务，以及(b)对青少年友好的联邦调查局一揽子服务。我们的假设是，实施青少年友好一揽子计划将i)与常规护理FBI相比，增加16-19岁青少年对干预的接受度和接受度；ii)成为治疗16-19岁青少年CMD的有效和可持续模式。我们将随机选择30个诊所接受常规护理FBI和30个诊所接受青年友好FBI包。参与者将是年龄在16-19岁的个体，他们使用当地验证的Shona症状问卷-14 （SSQ-14）筛查CMD呈阳性。在6个月的时间内，随机抽取500名符合条件的诊所参与者，并要求他们同意在接受FB干预6个月后参加结果评估。6个月后的访谈将亲自或通过电话进行，并将包括社会人口统计数据和全面的心理健康评估，包括SSQ-14、患者健康问卷-9 （PHQ-9）、广泛性焦虑症-7 （GAD-7）和世卫组织残疾评估表（WHO- das）。将收集有关如何提供干预措施的详细数据，例如，接受治疗的年轻人人数，他们参加了多少次会议，包括与实施机构、年轻人和诊所工作人员的深入访谈，以评估提供干预措施的可接受性和可持续性。这项研究的结果将用于改进现有的“友谊长椅”方案，使之包括一个可持续和有效的青少年一揽子方案，以补充现有的成人方案。这项工作将与已经参与扩大成人干预的市卫生部门和卫生部共同完成。我们预计，随着友谊长凳在津巴布韦和该地区更广泛地扩大规模，这些结果将超越当前的研究环境进行推广。

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.