“Seeing a Brighter Future” – Experiences of Adolescents with Common Mental Disorders Receiving the Problem-Solving Therapy “Youth Friendship Bench” in Zimbabwe

Abstract

In Zimbabwe common mental disorders are prevalent among adolescents and the treatment gap is large. The recently introduced Youth Friendship Bench intervention (YouFB) addresses this gap by task-shifting youth lay health workers to offer a culturally contextualised, manual-based, six-session problem-solving therapy to adolescents, 16-19 years of age. The aim of this study was to explore participants´ experiences of YouFB to attain a first insight into this novel intervention. Interviews with nine adolescents were analysed using qualitative content analysis on a latent level. The experience of YouFB was positive, perceived to offer hope and relief from feelings of isolation and uncertainty, increase manageability of problems, and contribute to feelings of autonomy, resulting in a feeling of optimism about the future. The notion among participants that this brief intervention had such a positive influence on their lives, sparks interest because of its applicability in low-resource settings.

Background

Globally, more than 320 million people suffer from depressive disorders and over 260 million from anxiety disorders, collectively referred to as common mental disorders (CMD) (World Health Organization, 2017a). Mental disorders are a major cause of mortality, accountable for 14% of deaths, or 8 million deaths yearly (Walker et al., 2015) and depression is the single leading cause of disability globally (World Health Organization, 2017a). The burden of CMD has more than doubled in the past 30 years in Sub-Saharan Africa and is especially high among adolescents and young adults (Gouda et al., 2019).

Adolescence involves the rapid developmental transformation from childhood to adulthood; these biological and psychosocial changes involve risk-taking and experimental behaviour, as well as new ways of relating to one’s own future and health (World Health Organization, 2014). CMD most often manifest in adolescence (Kessler et al., 2005), and suicide and accidental death from self-harm are collectively the third leading cause of adolescent mortality (World Health Organization, 2017b). In the WHO developed Global School Based-Health Survey of students aged 13-17, the African region in general, and Zimbabwe in particular, stood out by having some of the highest prevalences of suicidal ideation among the 32 included low- and middle-income countries (LMIC) (McKinnon et al., 2016). The prevalence was 22% in Harare, the capital of Zimbabwe (Rudatsikira et al., 2007). In rural Zimbabwe, more than 50% of adolescents and young adults screened positive for CMD (Langhaug et al., 2010). Poverty and food shortages are widespread in Zimbabwe, and indirectly, but strongly associated with CMD (Lund et al., 2010). Stigma surrounds mental illness in Zimbabwe (Pitorak et al., 2012) and HIV-related problems are prevalent in primary care (Chibanda et al., 2011; Chibanda et al., 2016). Widely speaking, in Sub-Saharan Africa, depression is perceived to be rooted in social adversity. Self-help and community resources are considered first line treatments for CMD and spiritual, rather than biomedical, explanatory models tend to be more widely adopted among those with no engagement in formal health systems (Mayston et al., 2020).

In Zimbabwe, where Shona is the predominant ethnic group and language, local models for explaining distress are widespread. “Thinking too much” or kufungisisa, is a Shona idiom associated with mental disorders, used both as a causal factor and a descriptive term for distress (Verhey et al., 2020; Willis et al., 2018). This emphasises the need for culturally contextualised and validated mental health care, including diagnosing, prevention and treatment.

In many LMIC, three out of four of persons with CMD are estimated to be untreated (Dua et al., 2011). In Zimbabwe, lack of human resources and proper funding is chiefly responsible according to a system analysis of mental health care (Liang et al., 2016). In Zimbabwe, with a population of nearly 15 million, merely a dozen psychiatrists are in clinical practice (Chibanda et al., 2016; Liang et al., 2016), and many mental health workers, i.e. clinical psychologists, mental health nurses and occupational therapists have left the public sector (Liang et al., 2016). The large discrepancy between the burden of CMD and the lack of health professionals (Liang et al., 2016) raises the question of task-shifting (Joshi et al., 2014; Pitorak et al., 2012)—the practice of having a person with less formal, less comprehensive or lower level of health education, so called lay health workers (LHW), to perform limited tasks conventionally undertaken by specialised health workers.

Task-shifting approaches have evidence for CMD treatment effect in adults and are demonstrated to be cost-effective in LMIC (Abas et al., 2016; Joshi et al., 2014; Petersen et al., 2012; van Ginneken et al., 2013) although further research is needed. Similarly, a qualitative study indicated that persons with CMD who had been treated by LHW in a low-resource setting experienced positive effects on depressive symptoms, social function and care satisfaction (Shinde et al., 2013).

Problem-solving therapy (PST) is a cognitive-behavioural approach aiming to increase well-being and to mitigate and prevent psychiatric illness (Bell & D’Zurilla, 2009). PST emphasises problem-solving skills and adaptive attitudes to cope with stressful major events and everyday problems. Specifically, it intends to help persons to define their problems, to adopt a positive problem-orientation, for example seeing problems as challenges solvable with one’s own abilities, and to acquire and implement a rational problem-solving strategy to tackle them (Bell & D’Zurilla, 2009). PST is an evidence-based method for treating depression and anxiety (Bell & D’Zurilla, 2009; Cuijpers et al., 2018; Zhang et al., 2018). It has consistently significant, although heterogeneous treatment effect sizes in meta-analyses, comparable to those of other psychotherapies (Bell & D’Zurilla, 2009; Cuijpers et al., 2018; Zhang et al., 2018), with stronger effect on depression than anxiety (Zhang et al., 2018). PST is well-established (Zhang et al., 2018) and has been used effectively in Zimbabwe (Chibanda et al., 2016).

The Friendship Bench intervention (FB), developed in Zimbabwe, aims to reduce the treatment gap for CMD by task-shifting using trained LHW to deliver a brief, six-session, face-to-face PST treatment to persons with CMD along with peer support (Chibanda et al., 2016). The LHW in FB are elderly women called “grandmothers” with a 2-week training in the manual based PST used in FB. CMD is identified by the Shona Symptom Questionnaire (SSQ-14), a validated questionnaire developed to recognise CMD in the Zimbabwean context using a mix of sociocultural concepts, including kufungisisa, and etic criteria of distress (Patel et al., 1997). The FB is part of a stepped-care model where those not improving, or those showing signs of suicidal ideation or psychosis, are referred to mental health professionals (Chibanda et al., 2018). During six sessions of 30-60 minutes, and the following additional group support therapy sessions called Kubatana Tose circles (CKT), participants go through four phases (Chibanda et al., 2017; Verhey et al., 2014). In short, the first phase focuses on acknowledging problems, the second on finding solutions, the third on realising those solutions and in the fourth phase, CKT, the participant is invited to share experiences and listen to others who have had similar challenges in a safe environment (Chibanda et al., 2018). Thus FB includes all major problem-solving skills, associated with the most effective PST interventions (Bell & D’Zurilla, 2009), plus group support. The traditional PST concepts have been customised to the Zimbabwean setting for example by the use of local nomenclature and by focussing on relatable problems like HIV-related issues and stigma. These adaptions have simplified the implementation of the PST, being delivered by minimally educated LHW (Chibanda et al., 2017). The FB is, aside from being low-cost, overall encouragingly received and delivered, and seems therefore to be sustainable in the Zimbabwean setting (Abas et al., 2016; Chibanda et al., 2011). A randomised controlled trial demonstrated the effectiveness of FB compared to standard-care (nurse-led evaluation, psychoeducation, information, brief support counselling, optional pharmacological treatment and referral to psychiatric clinic if required) (Chibanda et al., 2016). The FB group showed significant improvement of anxiety, disability and quality of life compared to controls (Chibanda et al., 2016). All participants were over 18 years old, but only few were 18-22 years old. The effectiveness in lowering SSQ-14 scores seemed proportional to the number of sessions attended (Chibanda et al., 2011). CMD treatment effect was also evident among those with suicidal ideation at study enrollment (Munetsi et al., 2018). FB has been integrated into primary care, scaled up to over 60 primary care clinics in Zimbabwe, and is now the largest integrated programme for mental health in Africa.

The recently introduced Youth Friendship Bench intervention (YouFB), was piloted in Harare mid-2018 to early 2020. YouFB is adapted from FB to address adolescents aged 16-19, and the issues typical of that age like relationships, sexuality, young parenthood and bullying (Verhey & Turner, 2018). In contrast to the “grandmothers” in FB, YouFB has younger LHW comprised mainly of psychology and sociology students doing a 1-year internship at the YouFB before their final year of education (Wallén et al., 2021). YouFB delivers PST not only at clinic sites, but also in public parks and other community settings, targeting vulnerable populations like pregnant teenagers and offenders. YouFB arrange public awareness events where clients can be recruited. The therapy of 4-6 weeks is followed by 6 weeks of CKT where participants share their experiences in a safe forum. A recent study exploring the experiences of YouFB counsellors found that counselling was perceived as meaningful and a source of personal and professional growth, but also that connecting with the client could be stressful and yield feelings of inadequacy (Wallén et al., 2021). One still unpublished mixed-method pilot study (Chibanda et al., 2018) has been conducted on YouFB, focussing on uptake, acceptability, adherence, effectiveness and cost-effectiveness of the intervention.

To our knowledge, there is no other effective, evidence-based and low-cost treatment strategy for adolescents with CMD in Africa. A recent article illuminated the counsellors’ experiences of YouFB (Wallén et al., 2021), but no study has yet focussed on the experiences of youth attending the project. The aim of this study was to illuminate adolescents´ experiences of the YouFB.

Methods

Study design

A qualitative inductive interview study was conducted to illuminate experiences within the YouFB attender group. Content analysis on a latent level was performed (Lindgren et al., 2020).

Setting and participants

This study was nested in a mixed methods YouFB pilot study (Chibanda et al., 2018) where youths, 16 − 19 years old, with CMD were invited to take part of six PST sessions either at an health clinic or in a park or other community setting, with a young LHW, followed by 6 weeks of CKT. The study was set at the FB headquarters in Harare, Zimbabwe, and conducted by researchers from FB and from Lund University, Sweden. Participants from YouFB counselling sites in clinics as well as community settings in Harare were purposefully selected by a FB study coordinator and approached and informed of the study by telephone or in person by a counsellor. Interviews were conducted in March and April 2020, making recruitment retrospective as no new patients had been enrolled to the YouFB since the termination of pilot study recruitment (Chibanda et al., 2018) earlier in 2020. Recruitment ended when there was national lockdown in Zimbabwe due to the Coronavirus pandemic.

Inclusion criteria were having participated in a minimum of three counselling sessions and having scored ≥9 on SSQ-14 screening, thereby fulfilling criteria for CMD. To capture a variety of experiences, participants were purposefully selected for invitation to be of different ages and gender and to have had different number of completed sessions. At least 15 persons were invited of which 11 accepted invitation. Nine interviews were conducted (two persons did not show up). Participants had a median age of 19 years and had participated in 3 – 6 PST sessions (median 5). Participants had completed their final session the same day as the interview to 5 months prior (median 3 months). Five participants had not participated in CKT in addition to their individual sessions. Interviews lasted 21-48 minutes (mean 34 minutes). Few participants were fluent in English, but all were fluent in Shona. Participant characteristics and site for sessions are presented in Table 1.

Table 1. Characteristics of study participants and their choice of counselling site.

Characteristic	Participants (n = 9)
Gender
Male	3
Female	6
Age
16	1
17	2
18	1
19	5
Counselling site
Clinic	4
Community	5

Data collection

A semi-structured interview guide with mostly open-ended questions, focussing on the personal experiences of YouFB, was composed by the first author (SB) and modified with input from co-authors and from members of the FB research team in Harare. Feasibility of the questions were assessed by SB during a roleplay with a YouFB counsellor. The interview guide was translated into Shona by a member of the FB research team, fluent in English and Shona. The interviews started with the question “How did you experience going to the YouFB?” followed by questions like “Did you talk with your parents, friends or partner about your problems before you started PST?” and “Can you talk with your counsellor about everything?”

In-depth, face-to-face, individual interviews were conducted. Eight participants chose to be interviewed in Shona, one in English. The interviewer from the FB research team in Harare, experienced in qualitative research, had no relationship to any participants. SB, who did not speak Shona, attended interviews and kept a reflexive field journal, facilitating awareness of biases and preconceptions (Krefting, 1991). Participants were encouraged to speak freely. Interviews were audio-recorded and transcribed verbatim before being translated into English.

Data analysis

The translated interviews were analysed using qualitative content analysis on a latent level (Lindgren et al., 2020). The translated transcripts were read through multiple times to get a sense of the whole. SB then divided the text into meaning units and condensed the meaning units, whereupon the condensed meaning units were interpreted of their underlying, latent, meaning (Lindgren et al., 2020). As interviewing progressed, and data became richer, patterns started to emerge. Thereafter sub-themes and themes were formed during a continuous critical reflection and discussion between SB and KL (Lindgren et al., 2020). The interviews were read by the co-authors who gave input and suggested minor changes in sub-themes and themes.

Ethical considerations

Participants of this study, young people with CMD, belong to a vulnerable group and the main ethical issues are related to the risk of anxiety and distress from feeling pressured to share sensitive information, and the risk of that information being misinterpreted. This was accounted for by carefully formulated interview questions, and a studious and (to the extent reasonably possible) unbiased data analysis to reduce the risk of misinterpretation (Richards & Schwartz, 2002). The inescapable power imbalance between researcher and participant, which in the case of being a health professional and a patient, is even larger, was counteracted by letting a person not involved in the therapy conduct the interviews. To avoid the risk of interpretation errors in the analysing process leading to misrepresentation of participants, translators fluent in both Shona and English were engaged in the study. Participants were, in accordance with the Declaration of Helsinki (World Medical Association, 2013), given thorough, easily understandable information in their first language, entailing the purposes and nature of the study, and sufficient time to contemplate participation before giving oral and written informed consent. They were guaranteed confidentiality, and they were reassured that no statement would jeopardise their quality of future care. Participants were informed that the interview was not a therapeutic encounter, but a research contribution only. They were informed of their rights to not answer questions and terminate the interview at any time, without giving any reasons why. Recordings were made using an offline device and were permanently deleted post-transcription. Transcripts were stripped of participants’ legal identifiers and quotations were chosen where participants would not be recognised.

Participants had been reimbursed in accordance with local regulatory research and ethics bodies for prior participation in the YouFB pilot-study (Chibanda et al., 2018), and were also reimbursed for participation in the present study. The reimbursement consisted of a cold refreshment and 3 US dollars to cover transportation costs, which could be seen as an incentive to participate since some attenders of the YouFB group suffer economic deprivation. Ethical approval was granted from the institutional review boards Medical Research Council of Zimbabwe (MRCZ/A/2275); London School of Hygiene & Tropical Medicine (reference: 14468); the Joint Research Ethics Committee for the University of Zimbabwe College of Health Sciences and the Parirenyatwa Group of Hospitals; and City of Harare.

Results

Analysis revealed the overarching theme “Seeing a brighter future”, and three themes: “Being alone in an insecure place”, “Finding hope in therapy” and “Becoming resilient”. The themes and seven subthemes (Table 2) are described below, with quotations from participants (P).

Table 2. Overarching theme, main themes and subthemes.

Overarching theme
Seeing a brighter future
Main themes
Being alone in an insecure place	Finding hope in therapy	Becoming resilient
Subthemes
Struggling with distress	Trusting the counsellor and the method	Getting tools to handle life
Battling my issues alone	Sharing is helpful	Feeling empowered
Having lost hope

Seeing a brighter future

The overarching theme describes how participants, coming from a situation where they had to deal with most problems by themselves and being unsure of what the future would bring, experienced finding hope when talking to a YouFB counsellor. They experienced positive effects from PST, gained confidence and felt they became more fit to handle the obstacles of the future.

Being alone in an insecure place

Describing their situation before joining YouFB, participants expressed feelings of being alone in an environment where they did not feel safe and worried about the future. In times of kufungisisa, participants experienced social withdrawal, feeling that they had no one to share their feelings with. They described struggling with distress and battling their issues alone, eventually losing hope.

It was so hard for me… because all of my sisters eloped and no bride price was paid for them. So I would say to myself “alright, I am the last born and the only one staying at home with the parents, plus I only managed to complete the ordinary level at school…” I always wondered about what I was going to do in my life since my parents are unemployed… I thought the solution was to get married… (P1)

Struggling with distress

Participants described dysfunctional domestic relations, poor family economy where most persons were unemployed, and a stressful environment where people in their surroundings suffered various mental and socioeconomic problems. They experienced fear, insecurity and self-doubt, and felt that something was wrong with them.

I had numerous questions about myself, like who is going to help me and what should I do about my life? (P1)

Lighter, everyday issues were also experienced as important stressors and participants described not knowing how to battle these problems. Participants expressed a pressure to succeed in life, and a fear of the consequences if they did not. Generally, feelings of uncertainty were emphasised; about what the future would bring, about their own condition, and about how to get help.

I felt very hurt because I felt that I was a failure, and I was worried about how I was going to correct it. (P9)

Battling my issues alone

Participants did not know where to get help. They had no one to share their problems with, and many struggled by themselves even when having problems that they felt that they could not solve on their own. Participants experienced not wanting to be a burden to people in their families and communities, as they had their own struggles, and participants spoke of feelings of abandonment.

It was not that easy because you can tell someone [about your problems], and that person might laugh at you, the other one might not take you seriously, one might tell you: “ah, I don’t know”. So, going to consult someone was difficult. (P2)

In the participants’ communities, talking about mental issues was not normalised and before finding YouFB there were experiences of never having thought about seeking help, saying: “I used to think that there is no help meant for people who have mental illness” (P4).

Participants also experienced lacking trust in strangers and were therefore reluctant towards seeking support. They described personal mental health issues were gossiped about if one would open up, even in church, and they experienced fear of being judged by their community and peers. They were therefore sceptic and doubtful towards sharing their problems, especially with strangers, which the YouFB counsellors were initially seen as. Participants emphasised the importance of a counselling site where they could not be overheard, and where, if they were seen, it would not be deducible that they were getting counselling. Worried about confidentiality, they were hesitant to share personal information, saying: “at first I thought of lying to him, telling him things that had nothing to do with my life” (P3). Similarly, even after having completed CMD screening and being offered sessions, participants experienced fear of joining YouFB.

When I told people that we were doing sessions and given $5 USD reimbursement they would say “Be careful not to be signed into Satanism!” I was afraid to sign the papers when I thought about what people were saying. (P5)

In contrast to the strongly emphasised experience of struggling alone, other participants spoke of feeling support from family members, friends, teachers and their church; feeling safe with no trust issues.

Having lost hope

Participants described having given up, or given in to a pre-determined path that they felt that they had, being for instance academic and professional failure, or dependence in marriage, saying: “I used to think that getting married is just the final destination in our family” (P3). Participants expressed having suicidal thoughts prior to YouFB enrollment as they experienced seeing no progress in their lives. They experienced feelings of being hopeless, pointless and passive.

Sometimes I used to spend the whole day asleep not knowing what to do since I was idle. Sometimes, when I woke up, I would actually ask myself questions like: “Why am I awake?” (P3)

Participants experienced not being able to change their own fate and not being in control in their own lives. They described being dependent upon others, chance or God, and experienced giving up on trying to change their situation, one participant saying: “My mommy would tell me that I should just let it be since there was no one who could help me… So I ceased looking for assistance.” (P3).

I was someone who was thinking too much… I knew that if people think too much, they end up killing themselves or just not taking care of themselves… I thought I could not be helped and that this is the end of my life. (P7)

Finding hope in therapy

When finding out that they could talk to a counsellor about their problems, participants described becoming interested in YouFB. Learning that the organisation helped young people with depression and anxiety like themselves, participants expressed a willingness to try despite some initial fear and mistrust. When experiencing results from YouFB therapy, they found hope that their problems would come to an end. Participants then spoke of starting to plan ahead and about forthcoming happiness. As sessions progressed, they gained trust in their counsellor and the method. They experienced how they went from being doubtful to becoming comfortable talking with their counsellor and realising that they could share their problems with someone who understood them gave relief and hope for a better life.

I learnt it’s a good thing to have somebody guiding you rather than being on my own when faced with a problem. (P5)

Trusting the counsellor and the method

Participants showed trust in the methods used by YouFB and described how the confidence gave hope in further therapeutic success. Participants described letting their guard down as their counsellors gained their trust. They generally described this process as being fast, as they soon became comfortable and felt free to share their problems. Participants experienced their relationship with their counsellors as if they were friends who “knew each other from way back” (P2).

As you are free to talk about anything, the solution/…/will solve what you are really feeling in your heart. (P6)

Participants attributed the gain of trust both to the results that they experienced when implementing their counsellor’s advice, and to the feeling of being understood by and believed in by someone acknowledging them and their problems. They spoke of feeling a connection with their counsellor as they felt that they shared similar experiences, and that their counsellor might have been through similar problems as themselves. Having common ground was perceived as hopeful and one participant said: “maybe he still lives with his parents like me. I listened to him knowing that I could tell him everything” (P8). After being ensured that what they said would be confidential, participants experienced feeling safe to share personal problems.

I was feeling comfortable at the YouFB because there is no third part that will hear/…/Whatever you talk about ends there, so you will be free to open up your problems and the things that are bothering you. (P6)

When participants felt comfortable after their first sessions, they were eager to proceed, and looked forward for their next encounter,

When I know that I am going to have a session or CKT the next day, I know that I need to prepare… I make sure that I wake up early, clean the house and do the dishes and other chores, then I go to YouFB. (P1)

The time they invested in therapy sessions were seen as crucial as they were confident that the PST would help them. Focus was also given to the therapy being fun, and participants stressed how important it was that both the individual sessions and the CKT were enjoyable in therapy for young people. They described speaking excitedly about YouFB with friends and family, feeling hopeful that their life would take a new positive direction.

I decided to not be afraid and signed up. And when I started sitting on the bench, I realised there was nothing to be afraid of. (P5)

Participants described recommending YouFB to others so that also they could get help, and hoped the programme would expand to reduce depression, stress and prevent suicide.

I think this program should continue so that it solves problems for other people as well because there is no one without problems. If we help each other to look for solutions, problems will be solved. (P6)

Sharing is helpful

Participants expressed the value of talking to someone, and that they had had a need to share their problems also before going to YouFB.

I think sharing your problems to other people is the best solution… Honestly, drugs can never help because you can never tell drugs that “I am feeling this way” but you can tell a human being who will understand you. … l have realized that drugs don’t provide solution at all. (P4)

Participants experienced relief when talking about their problems in a supporting environment, saying: “I poured out everything that was in my heart” (P8). They described finding it valuable being believed in and understood, and that bottling things up could have harmful consequences. Feeling that they now could share their feelings gave hope. Participants also experienced the importance of sharing for the sessions to be effective in solving problems and for personal growth.

I think expressing myself made it easier for him to suggest meaningful solutions which were in connection with my problem. He was now aware of the kind of help that I really needed. (P4)

Becoming resilient

A main experience was becoming less vulnerable, and more capable at handling future setbacks. Participants experienced a permanent change expressed as “if I start to be stressed again, this will affect my life, and everything will just deteriorate since stress can lead to death… But personally, I don’t think I will ever get stressed again (laughs)” (P9). They described life as being more manageable after having attended YouFB and felt that they could handle future problems with their own abilities, yielding a sense of empowerment.

I am a changed person who is now able to get solutions to all the issues that will be troubling me. Right now, I don’t get confused after facing a challenge with issues, like “how am I going to solve this problem?” I was so clueless on how to handle stress! (P4)

Getting tools to handle life

Participants spoke of acquiring new skills and found new solutions to problems that they had struggled with. They described being better at handling setbacks, both by using the problem-solving tools that they had acquired and, when problems could not be solved, by being more able to endure the bad times, e.g. by having a different mindset. An example was expressed: “And right now if I come across things which annoy me, I just ignore and walk away… I have realised that it’s helpful”. (P1) When faced with problems and distress, participants described being able to recall and use the same advice again, to solve the problems.

The counsellor gave me this advice that I didn’t have to waste my energy in crying over somebody who was not even interested in me or didn’t even care about me… Right now, I don’t really tolerate a boyfriend who treat me as an option. … I am no longer forced by anyone or by the acts of somebody to do what they want. (P4)

They also felt that they could use the methods and advices that they learned to help others in similar situations. They emphasised, and appreciated, that they also were helped with specific support, e.g. on how to look for employment, entrepreneurship, and on economic thinking, aside from being helped with general problem-solving strategies. Participants experienced improvement in family relations and described being more constructive when having arguments. Participants perceived that they could handle anger better as they now were less short-tempered, and that the sessions made life more manageable overall.

I could become very angry… but I am now able to control myself. Now I understand that getting angry can lead to damaging property or ending up in jail… When I was still short tempered, I always fought with my sister and one of us could get injured, but now we don´t fight, we now get along nicely. (P6)

Feeling empowered

Participants acknowledged personal growth from the sessions and experienced a sense of skill and achievement; now seeing their own potential and having belief in their own abilities. Participants described gaining confidence, and that a feeling of autonomy instilled as they experienced becoming more independent than before. Participants expressed that they previously thought that one needed family assistance which they themselves did not have, to succeed in life but that they now thought that they could succeed more on their own.

On the issue that I was thinking of killing myself it helped me… I am an orphan, so I was thinking that this is the end of my life, but I could now see that there are people who lost their parents who work for themselves and could see that in the future things might work out. (P7)

Receiving encouraging words from their counsellors and witnessing their own abilities, participants described how they realised their own value. This, they told the interviewer, made them focus on themselves and participants stressed that they no longer would let other people make them feel bad, and no longer would question their worth. In all, this contributed to feelings of empowerment expressed by participants.

Earlier, getting married was my only solution… but currently m focused on running a business and getting money on my own… If I see myself worrying again, I think I will handle that because I think I am strong now, and I am now able to depend on myself since I am now a big girl (laughs). My mommy now realise that her daughter is capable of doing something in life so she is happy for me. And my sisters cherish me, and they say that a woman does not need to depend on a man to survive. So they are now excited about me since they now see that maybe I am going somewhere with a brighter future. (P3)

Although feelings of uncertainty were still present in the face of future setbacks, participants expressed that they were overall confident in being able to handle these problems and felt empowered also to help others.

Some understand, but some do not take/mental illness/as something important. But I will try to help them, those who will be thinking about killing themselves or marry when they are still young. (P7)

Discussion

In this first qualitative study on adolescents with depression and anxiety receiving PST at YouFB, the participants experienced that this brief intervention gave them tools to handle their lives, thereby giving hope and empowerment. The adolescent participants described how they came to trust their counsellors, that they experienced becoming more resilient to future problems and that PST made them hopeful about the future. This study is unique in that it was conducted on patients in a low-resource setting where the therapy method had been contextualised to the culture of a LMIC (Chibanda et al., 2011) and to adolescents. Participants in the present study described a mental health stigma, consistent with previous findings in Zimbabwe (Pitorak et al., 2012; Wallén et al., 2021). In a similar Zimbabwean study, ten adults with HIV were interviewed on their experiences of FB (Chibanda et al., 2017). They emphasised feelings of relief, problem-solving support, empowerment and achievement (Chibanda et al., 2017), in line with the results in the present study. The initial mistrust being transformed into a therapeutic alliance was experienced also by the YouFB counsellors (Wallén et al., 2021). Our results are also reflected in qualitative studies on adolescents’ experiences of depression and psychotherapy conducted in Western countries (Dundon, 2006; McCarthy et al., 2008; Weitkamp et al., 2016). Themes echoed are for example struggling in isolation, having resigned, being reluctant towards seeking professional help, finding it helpful and relieving to share, being proud of overcoming difficulties and being more optimistic after therapy (Dundon, 2006; McCarthy et al., 2008; Weitkamp et al., 2016).

Although the present study underlines the potential of a low-cost PST as implemented in FB and YouFB (Abas et al., 2016; Chibanda et al., 2011), these interventions are not meant to replace care provided by fully educated health professionals. One could easily argue that professionals with a longer education can offer more qualified help. On the other hand, “grandmothers” in FB as well as young LHW in YouFB, may offer valuable contributions as a first intervention in stepped care meeting individual’s acute needs. Thus, FB and YouFB could be compared to first aid for persons with mild or moderate depression and anxiety, saving resources for more severe cases. Still, applicability of such projects is naturally dependent on also offering positive experiences to the LHW counsellors, as recently explored in a qualitative study on YouFB (Wallén et al., 2021). The study found that YouFB counsellors described the experience as meaningful as it offered well needed therapy and education to their clients and contributed to their personal and professional growth (Wallén et al., 2021). However, problems of recruitment of clients, not reaching key populations, preconceptions among clients, stressful counselling environments, as well as experiences related to becoming too emotionally involved—affecting their own mental health— were negative aspects experienced by the YouFB counsellors (Wallén et al., 2021).

A difference between FB and YouFB is that the female counsellors, “the grandmothers”, in FB are exchanged for younger counsellors of both sexes in YouFB. In both cases, counsellors are trained to use empathy and listening skills in their FB work. The emotional closeness felt by participants with their counsellors in the present study could be attributed to the counsellors also being young, showing and sharing a vulnerability themselves. Mutual vulnerability was found to be important in the therapeutic alliance in another study on adolescents in psychotherapy (Binder et al., 2011). However therapeutic to the client, the close emotional connection can be a heavy burden to bear for the counsellor, and easily transcend into personal attachment and feelings of being inadequate, as recently demonstrated in the YouFB setting (Wallén et al., 2021). Likewise, adolescents seeking support from friends, and entrusting them with their personal issues, may put their friends in a fearful position where they feel that they lack the necessary knowledge and skills to help (Roach et al., 2021). Participants’ trust in peer counsellors is reflected in a quantitative study from rural Zimbabwe where an intervention with adolescent counsellors supporting HIV-positive 10-15-year-olds had significantly positive outcomes on quality of life, self-esteem and self-worth compared to controls (Willis et al., 2019). Likewise, a Harare study on 15–19 year old adolescents living with HIV concluded that different types of group-based and peer-led interventions was feasible for treating depression (Willis et al., 2018). Young counsellors therefore seem to be well-tolerated among adolescents in the Zimbabwean context.

The present findings could be put into context by applying them to the theory of salutogenesis presented by Aaron Antonovsky in the late 1970s. The theory contributes to an understanding of health endorsed by different Generalised Resistance Resources (GRR); properties in persons, groups, or environments that can defuse diverse stressors and thereby facilitate tension management. One GRR that Antonovsky highlights is cognitive and emotional resources, and another is interpersonal-relational resources comprising coping strategies and management of emotions. According to the theory, as individuals are exposed to daily stressors, activation of GRR will improve capacity for managing stressful situations, endorsing a Sense of Coherence (SOC); a life orientation helping people to perceive life as comprehensive, manageable and meaningful. A strong SOC improves resilience, the individual’s ability to adapt despite rough life circumstances (Mittelmark et al., 2017).

Participants in the present study described life experiences suggesting a weak SOC prior to YouFB enrolment, indicating a limited resilience. Through the PST sessions, the participants were able to reflect on their problems, and they pronounced how they became more certain about their present situation and future. Thus, they experienced the world around them more comprehensibly through PST—the first cornerstone of SOC. Guided by the counsellor, the participants felt that they were given internal tools to use in the process of change and that their life situation gradually became more manageable. Participants also expressed becoming less overwhelmed by their problems, and more autonomous, feeling that they participated in shaping outcomes to a greater extent. In all, these experiences increase the manageability component of SOC. Towards the end of treatment, several participants felt that their previous suffering was not pointless, but in the treatment process contributed to them now having a richer life; a feeling that could be applied to the salutogenic concept of meaningfulness. Similarly, several participants had set their sights on being able to use their experiences in the future to help burdened young people. It is likely that some GRR, for example cognitive and emotional, and interpersonal-relational resources, were positively challenged by PST and contributed to the participants not only being able to benefit from an increased SOC but in the long run also an improved resilience. Many testified to a strengthened self-confidence and an everyday life characterised by joy, meaning, prosperity and a feeling of being able to influence their own lives. This comes perhaps to no surprise since PST aims to build problem-solving skills and adaptive attitudes (Bell & D’Zurilla, 2009). In other settings, increasing resilience has been shown to mitigate symptoms and prevent future illness among adolescents with CMD (Skrove et al., 2013). This warrants further longitudinal studies on the effects of YouFB and other PST on resilience in adolescence and its relationship to CMD.

Related to the comprehensibility and manageability components of SOC, is the concept of locus of control (LOC). Believing that oneself controls one’s life events is referred to having a more internal LOC; conversely, when believing that chance or powerful others are in control, the LOC is more external. A study of people with CMD found that higher depression scores and more adverse life-events were associated with a more external LOC (Hovenkamp-Hermelink et al., 2019). Culpin et al. (Culpin et al., 2015) demonstrated that socioeconomic adversity in early life was associated with an external LOC at 16 years, which in turn was predictive of depression at 18 years. A recent study of university students in Botswana also found an external LOC to be associated with higher depression scores, while those with an internal LOC displayed lower level of symptoms (Khumalo & Plattner, 2019). Participants of the present study described hopelessness, feeling dependent on others, and falling into habits of passiveness before joining YouFB, consistent with having an external LOC. One could speculate that the YouFB PST, through its focus on specific and manageable problems (Verhey & Turner, 2018), could increase participants’ internal LOC by inciting feelings of autonomy when they experience solving these problems with their newly acquired competence. The results of the present study support this hypothesis in that participants experienced empowerment and increased manageability of problems. These experiences, consistent with gaining a more internal LOC, suggest participants may have gained protective factors against future depression. Further studies are warranted on the effects on LOC among YouFB attenders, since approaching this cognitive domain has shown promise in preventing depression in previous studies (Culpin et al., 2015; Khumalo & Plattner, 2019).

Strengths and limitations

The participants were purposefully selected, thereby increasing credibility and transferability. As purposive sampling may carry a risk of researchers being influenced by bias, resulting in themes inclined towards researcher preconceptions, pre-understandings of researchers were critically reflected upon to illuminate potential biases and bridle preconceptions. The diversity of professional backgrounds and perspectives provided the basis for rich discussions, seen as a strength.

Although the recruitment period was shortened, the nine interviews conducted before the pandemic lockdown provided rich data. Since most participants had ended their sessions several months before being interviewed, the risk of recall bias is evident, limiting credibility and dependability. On the other hand, participants had had more time to reflect upon the experience and could evaluate changes in a longer perspective. Only recruiting participants who completed at least three sessions may have resulted in a loss of negative experiences related to the intervention, as these presumably were more prevalent in the early drop-out group. The same assumption could be made about persons who declined participation in the study. Not knowing exactly how many invited persons who declined participation is a weakness limiting trustworthiness. The risk of study participation motivated by the reimbursement required by local guidelines may be a credibility barrier. On the other hand, giving reimbursement enabled participation for persons who otherwise could not afford transportation, increasing credibility.

Four participants had not participated in the additional CKT, described as an important part of YouFB following the individual sessions (Verhey & Turner, 2018). Beside the person who had finished PST the same day, the reason for not participating in CKT is unknown. This study may therefore lack some experiences of peer group support, primarily offering an account of clients’ experiences of one-on-one sessions with their counsellor. Reasons for not attending CKT may be a desire to keep their problems confidential, feeling that they had no need to attend further therapy, or having had to work or take care of family members, although the present study offers no insight into these mechanisms.

The interview guide was modified and contextualised by local researchers and the experienced interviewer had no relationship to the participants, strengthening credibility. Interviews were conducted in the participants’ first language (except for one interview, in which English was chosen on the participant’s request), enrichening data and thereby strengthening credibility. An interviewer of the same tongue, nationality, ethnicity and culture as the participants, a cultural insider (Birman, 2005), was considered a credibility strength, as this suggestively would yield more honest narratives, less influenced by out-group prejudices. When translating transcripts from the Shona language, rich in idioms, into English, nuances and valuable information may be lost (Chidarikire et al., 2018). This threat to trustworthiness was counteracted by co-operation with persons fluent in both languages.

Trustworthiness was strengthened by a systematic analysis where the content was de-textualized and then re-contextualised, a process including interpretation and abstraction (Lindgren et al., 2020). During sub-theme and theme formation, we moved back to the meaning units to verify that key messages had not been distorted in the analysing process (Lindgren et al., 2020). When all interviews had been analysed, SB went back to the transcriptions and re-did the original analysis, giving extra care where interpretations differed—a so-called code-recode procedure—to increase dependability (Krefting, 1991). To prevent researcher bias, researchers collaboratively analysed data, and results were yielded by reaching consensus (Graneheim et al., 2017). The transparent presentation of the study and the analysing process, and the provided quotations, allows readers to look for alternative interpretations, increasing credibility. Transparency also provides dependability by making the study repeatable. The degree of transferability of a qualitative study is the readers’ decision.

Clinical implications and conclusion

This study adds knowledge about experiences of the novel intervention YouFB. Participants experienced a reduced symptom burden concerning anxiety and depression and experienced that PST as offered in YouFB mediated hope and increased manageability of problems, contributed to participants’ feelings of autonomy, creating a sense of optimism about the future. The results motivate further interest in YouFB as a promising brief treatment model for adolescents with CMD in Zimbabwe and in other settings as well. YouFB should not replace mental health care provided by professionals, but a program such as this may be offer important contributions to a first treatment step in mild or moderate depression and anxiety in a setting where mental health care is still underserved as is the case in most LMIC due to the massive treatment gap (Lund et al., 2015). Spreading task-shifting approaches in mental health care to other LMIC, especially where resources are low and the mental health stigma is high, may be vital in closing the treatment gap for adolescents with CMD. The results may help guide future research and contribute to the development of YouFB; to our knowledge the first evidence-based, scalable and effective CMD treatment strategy for adolescents in Africa which is derived from the effective FB program. The effect size cannot be deduced from a qualitative study and quantitative assessments of treatment effect sizes and costs are warranted.

Disclosure of interest

The authors report no conflict of interest.

Author contribution

RV, part of the FB research team in Harare, Zimbabwe, planned the study together with co-authors. SB spent 5 weeks at the FB headquarters to collect data, attending LHW education to gain broader contextual understanding. SB composed the interview guide together with the FB research team, with input from co-authors. SB and KL analysed the data. All authors critically revised the work, and read and approved the final manuscript.

Abbreviations

CKT	=	Kubatana Tose circles (peer support group therapy)
CMD	=	Common mental disorder
FB	=	Friendship Bench intervention
LHW	=	Lay health worker
LMIC	=	Low- and middle-income country
LOC	=	Locus of control
PST	=	Problem-solving therapy
SOC	=	Sense of coherence
SSQ-14	=	Shona Symptom Questionnaire
YouFB	=	Youth Friendship Bench intervention

Acknowledgements

The authors want to thank Rhulani Chauke, Kelly Muzariri, Claudius Mugumba Mukoki, Nyasha Madziyauswa and Precious Shangwa of the FB research team in Harare for help with recruiting participants, translation and transcription of interviews. A special thanks to Mary Wadzanai Munetsi for conducting the interviews.

Funding

None.