In the sprawling urban landscape of Harare, Zimbabwe, where adolescent mental health resources have historically been scarce, a groundbreaking study has emerged, shedding light on innovative community-based interventions aimed at tackling the pervasive issue of common mental disorders (CMDs) among youth. Mental health experts and public health officials alike have long grappled with the challenge of delivering effective mental health care to young people, whose engagement with existing services has been notably low. Against this backdrop, researchers have undertaken a rigorous, cluster-randomized trial to compare two distinct task-shifted models of mental health care delivery: the traditional Friendship Bench (FB) facilitated by adult community health workers and a novel Youth Friendship Bench (YouFB) led by trained university student peers.
This hybrid type-2 implementation trial involved 26 primary care clinics scattered across Harare and the surrounding communities. The study’s innovative design sought not only to evaluate the clinical effectiveness of these interventions but also their implementation outcomes, including uptake, reach, fidelity, acceptability, and overall cost. With an enrolment of adolescent participants aged 16 to 19 years, the trial took an open-label approach, embracing real-world conditions to capture the nuanced dynamics of intervention delivery and utilization within the community setting.
Central to the study was the hypothesis that peer-driven approaches, exemplified by the YouFB model where young university students deliver mental health support, would achieve higher uptake and potentially greater clinical benefit compared to the conventional adult-run FB model. This peer-focused approach is grounded in the premise that adolescents may relate better and feel more comfortable engaging with individuals closer to their own age, thereby overcoming barriers of stigma, mistrust, or social distance that often impede mental health service utilization.
The primary outcome metric was uptake, defined as the proportion of eligible adolescents who initiated treatment by completing at least one Friendship Bench session. Strikingly, the data revealed uptake rates of 95.6% in the YouFB group compared to 86.6% in the standard FB group, confirming significantly enhanced engagement under the peer-delivered model. This finding underscores the potential of harnessing peer networks and youth empowerment as means of amplifying mental health service reach in resource-constrained settings.
Equally compelling was the measure of feasibility, assessed by session completion rates. Adolescents under the YouFB paradigm demonstrated a higher rate of session completion, with nearly 97% finishing all scheduled sessions as opposed to approximately 86% in the FB arm. This suggests that not only does the peer-led model encourage initial participation, but it also fosters sustained involvement over the course of treatment, a critical factor for achieving clinical remission of CMD symptoms.
Clinical effectiveness was gauged using the Shona Symptom Questionnaire (SSQ-14), a culturally validated tool for assessing psychological distress in Zimbabwean populations. Six months post-intervention, the proportion of participants exhibiting clinically significant symptoms (SSQ-14 score ≥8) was statistically similar across both arms, suggesting that while YouFB optimized engagement and delivery, it did not confer superior symptom reduction compared to the adult-led FB. This raises pertinent questions about the mechanisms through which peer support influences mental health and signals the need for further optimization of intervention components to boost efficacy.
Cost considerations also featured prominently within the trial’s framework. The YouFB program incurred higher total expenses when viewed through a societal cost lens, reflecting the resources required for training, supervision, and sustaining a cadre of university student peers. This financial dimension highlights the complex trade-offs between scalability, effectiveness, and economic viability that public health programs must navigate, especially in low- and middle-income countries where resources are limited.
Qualitative process evaluations, conducted through in-depth interviews with adolescent participants, painted a picture of high acceptability for the YouFB intervention. Young people valued the relatability and accessibility of peer counselors, emphasizing how shared experiences and demographic proximity fostered trust and open communication. These insights illuminate the psychosocial mechanisms by which peer-led programs may mitigate stigma and encourage candid dialogue about mental health, which are instrumental in sustaining engagement in care.
Despite promising indicators of uptake and acceptability, the study’s conclusions emphasize that further refinement is essential. The youth-focused Friendship Bench, while feasible and well-received, requires targeted enhancements to its clinical protocols and cost-effectiveness models to fully realize its potential in reducing CMD morbidity. The nuanced balance between offering youth-driven care and ensuring evidence-based, impactful therapeutic outcomes calls for ongoing iteration and research.
This trial stands as a testament to the potential embodied in culturally grounded, task-shifted mental health strategies, particularly those that empower youth as agents of change within their communities. As mental health burdens among young populations escalate globally, especially in low-resource settings, innovative frameworks like YouFB present a scalable blueprint for integrating mental health care into primary and community health systems with relevance and resonance.
By navigating the intricate interplay of uptake, fidelity, clinical outcomes, and resource allocation, this study contributes key empirical data that can inform policymakers, mental health practitioners, and community stakeholders seeking to elevate adolescent mental health care accessibility and effectiveness. In the face of complex challenges surrounding mental health stigma and service delivery gaps, such evidence-based innovations hold promise for transforming the therapeutic landscape.
Ultimately, the findings advocate for a continued commitment to involving youth peer counselors as integral contributors to mental health services, advocating that their unique positionality can bridge divides often encountered in conventional care models. However, these interventions must be combined with rigorous clinical oversight and tailored adaptations to optimize their therapeutic impact sustainably.
The Zimbabwean context, with its blend of sociocultural dynamics and resource limitations, offers a fertile ground for pioneering such approaches. This trial paves the way for broader application and refinement of peer-led mental health care models across Africa and beyond, aligning with global health priorities to meet the unmet mental health needs of adolescents in innovative, cost-conscious, and culturally attuned ways.
As the global health community continues to grapple with burgeoning adolescent mental health crises, evidence from this robust cluster-randomized trial underscores the vital role of participatory, peer-centered care approaches. It challenges existing paradigms, igniting new conversations on how to effectively harness community assets and youthful agency to bolster mental well-being in high-need populations worldwide.
Subject of Research: Interventions for adolescent common mental disorders comparing adult community health worker-led Friendship Bench and peer-delivered Youth Friendship Bench models in Zimbabwe.
Article Title: A cluster-randomized trial of interventions for adolescent mental disorders in Zimbabwe.
Article References:
Beji-Chauke, R., Simms, V., Abas, M. et al. A cluster-randomized trial of interventions for adolescent mental disorders in Zimbabwe. BMC Psychiatry 25, 673 (2025). https://doi.org/10.1186/s12888-025-06755-x
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