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

常见的精神障碍，即焦虑和抑郁，在全球青少年中非常普遍，是该年龄组残疾调整生命年的主要原因。在低资源环境下，CMD的诊断不足，治疗差距很大。在成人中，由非专业卫生工作者提供的CMD治疗是有效的。我们最近在津巴布韦完成了一项由非专业卫生工作者（LHW）提供干预的试验（友谊长凳干预（FBI）; www.friendshipbenchzimbabwe.org）。它对治疗成人CMD非常有效。联邦调查局包括一个基于解决问题疗法的6次心理干预，由受过训练的LHW提供。反应不佳的参与者将被转介给护士进行更专业的治疗。2016年，加拿大大挑战（GCC）和荷兰无国界医生组织（MSF）正在资助将联邦调查局的成人初级保健诊所扩大到津巴布韦3个城市的60个初级保健诊所。这种规模扩大为年轻患者（16-19岁）引入和评估FBI提供了理想的框架。原始试验的数据表明，FBI在年轻人（18-22岁）和老年人中同样有效，但一个关键的障碍是相对较少的年轻人去诊所。我们计划制定一个方便青年的联邦调查局一揽子计划，这是i）由受过培训和支持的青年LHW提供; ii）在社区环境中提供，包括学校和诊所;（三）以弱势青年为目标（包括怀孕少女和青少年罪犯）iv）由社群活动支持，以减少对精神健康不良的污名化，并提高对青少年精神健康的认识，特别是青年人-尤其是友好的联调局我们将确定以可持续的方式向16-19岁的CMD患者提供联邦调查局的两种战略的吸收、有效性和成本效益;（a）目前正在扩大的以成人为对象的常规护理诊所提供，以及（B）对青年友好的联邦调查局一揽子计划。我们的假设是，实施青年友好包将i）与常规护理相比，增加16-19岁奥尔兹对干预的接受和吸收; ii）成为治疗16-19奥尔兹儿童CMD的有效和可持续模式。我们将随机选择30家诊所接受联邦调查局的常规护理，30家诊所接受联邦调查局的青年友好套餐。参与者将是使用当地验证的Shona症状问卷-14（SSQ-14）筛选CMD阳性的16-19岁个体。将在6个月内随机选择500名参加诊所的合格参与者，并在他们接受FB干预后6个月要求他们同意参加结局评价。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学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WHO残疾评估表（WHO-DAS）。将收集关于如何实施干预措施的详细数据，例如，所见青年人数、他们参加了多少次会议，包括与执行机构的深入访谈，研究结果将用于完善现有的友谊长凳方案，以纳入可持续和有效的青少年一揽子计划，补充现有的成人方案。这项工作将与市卫生局和卫生部共同完成，它们已经参与了扩大成人干预措施的工作。我们预计，随着友谊法庭在津巴布韦和该区域更广泛地扩大规模，这些结果将普遍适用于当前的研究环境之外。

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.