Friendship Bench implementation in Africa: a systematic review of strategies, barriers, and facilitators from Zimbabwe and Malawi with an exploratory analysis of person-centered care practices

Early Abstract:

Background: Common mental disorders (CMDs), are major contributors to global disability in Africa. The Friendship Bench (FB) is a scalable problem-solving therapy model that employs a community-based approach to addressing mental health disorders. However, evidence on its implementation strategies, contextual barriers, and integration of person-centered care (PCC) remains fragmented. This paper reviews evidence on the implementation of the Friendship Bench model in African health systems, highlighting key strategies, barriers, facilitators, and the integration of PCC principles.
Method: Following the PRISMA 2020 guidelines, a systematic review was conducted across selected databases. Studies were eligible if they implemented the FB intervention for CMDs in Africa. Studies were appraised using CASP and MMAT tools. Data were extracted on study characteristics, implementation strategies, PCC elements, and outcomes. Studies were appraised using appropriate tools, and results were synthesized narratively. 
Results: Twelve studies (from Zimbabwe and Malawi) met the inclusion criteria. Participants had common mental disorders (CMDs) with or without comorbid HIV or non-communicable diseases (NCDs). The FB was feasible and acceptable across all studies. Clinical effectiveness was consistently demonstrated for depression symptom reduction (PHQ-9) but was mixed for ART adherence and viral suppression, with one large trial showing no adherence benefit. PCC principles; empathy, respect for autonomy, confidentiality, and holistic support, were central to the implementation’s success. Facilitators included structured supervision, task-shifting, community engagement, and cultural adaptation. Barriers included stigma, limited supervision, logistical constraints, and inadequate incentives.
Conclusion: The FB intervention uses PCC principles to reduce depression symptoms in Zimbabwe and Malawi. Scale-up to other African settings is plausible but requires context-specific adaptation, external supervision, and routine fidelity monitoring. Cost-effectiveness was demonstrated under enhanced supervision but not under basic internal champion models
Keywords: Africa, common mental disorders, Friendship Bench, implementation, mental health systems, person-centered care, task-shifting.