Building a Community Based Mental Health Program for Adolescents in Botswana: Stakeholder Feedback

Abstract

Background

When planning interventions for adolescents, adult interventions should not be used ‘as is’ in youth settings. Stakeholder engagement can help understand the overall adolescent mental health ecosystem and adapt existing evidence-based interventions for the youth.

Objective

To understand the overall mental health needs of adolescents in Botswana and the necessary adaptations required for an adolescent lay counselor based intervention in the country.

Methods

We used the theory of change model and the nominal group technique in five stakeholder meetings. Meetings were held to discuss the mental health needs of youth in Botswana and identify priorities for a lay counsellor based intervention modelled after the Friendship Bench intervention, an existing mental health intervention for adults.

Results

The root causes of mental health problems among Botswana’s youth identified by stakeholders included limited mental health knowledge among the youth and the community, family problems, poor communication, low self-esteem, the rapid growth of technology, and biological/genetic predisposition. Structurally barriers included: mental illness-related stigma, lack of psychosocial support, incomplete follow up for health services, cultural beliefs about mental illness, and fragmented mental health services. The stakeholders envisage a program that could empower adolescents and youth counselors to address mental health concerns for a healthier community. The group identified and prioritized several key elements of an effective lay counselor intervention.

Conclusions

A diverse group of community stakeholders can illustrate critical mental health needs and elements that countries could use to adapt and contextualize a lay counsellor based mental health intervention for new populations such as the youth.

Introduction

Botswana is a country with a population of approximately 2.3 million people that has a geographical size approximately the size of France. The country’s health system prioritizes widespread community clinic outreach, reaching many rural communities, and a central Ministry of Health and Wellness that provides guidelines and policies for the nation’s health. Like many other Low- and Middle-Income Countries (LMIC), Botswana has a severely limited mental health professional infrastructure (Maphisa, 2019; World Health Organization, 2011). There is one 300-beds pediatric psychiatric hospital 80 km located away from the capital city of Gaborone. The republic has only 17.7 mental health practitioners per 100 000. There are mental health nurses (4.05 mental health nurses) and community health workers available, but few professional psychologists (about 1.52 per 100,000 people) (World Health Organization, 2011) and psychiatrists (about 0.29 per 100,000 people) (Maphisa, 2019). Social workers are more numerous (217 per 100,000), but have differing levels of comfort with providing therapy, especially to youth (Jongman, 2020) (World Health Organization, 2011). The youth bear the brunt of the nation’s mental healthcare professional shortage since available professionals often lack the training needed to work with youth effectively (Kutcher et al., 2019; Olashore et al., 2017). Furthermore, the Botswana society also has cultural norms that include communication nuances that make talk therapy between generations diffcult (Ntsayagae et al., 2008).

Lay counselors trained in basic therapy techniques have been introduced in various LMIC settings managing adult patients with mood disorders to alleviate similar shortages (Chibanda et al., 2015; Rajaraman et al., 2012). The Friendship Bench, started by Dr Dixon Chibanda, a psychiatrist in Zimbabwe, is a problem-solving therapy (PST)-based intervention administered by trained lay counsellors. PST is a cognitive behavioral-based intervention that focuses on teaching patients positive approaches to solve identified stressors (Chibanda et al., 2015). The successful Friendship Bench model used in Zimbabwe consists of a bench located in or adjacent to a clinic, staffed by older adult community health workers trained in PST.

Given the unmet mental health care needs of adolescents in Botswana and the dearth of skilled mental health professionals, a task-shifting model such as the Zimbabwean Friendship Bench is an appealing intervention to pilot among adolescents. However, due to cultural and health system differences, certain aspects of the un-adapted Friendship Bench model are less likely to be successful for this population. Thus, we used a stakeholder engagement approach to adapt the Friendship Bench intervention for use among adolescents.

Stakeholder engagement in research and program implementation is a valuable approach to gain both ideological and logistical insight to adapt an intervention for a new community (Barrera Jr. & Castro, 2006; Kohrt et al., 2018). Limited research has explored the subject of mental health service provision for adolescents with and without HIV in LMICs. Limited research has explored the subject of mental health service provision for adolescents with and without HIV in LMICs, and this is equally true in Botswana where most research work has been cross sectional and about 90% of it focused on adult concerns (Opondo et al., 2020). We sought to describe adolescents’ needs and stakeholder perspectives on the country’s overall mental health services landscape and adapt a lay counsellor-based program modelled after the Friendship Bench. This project is part of our foundational work to contribute to implementing mental health interventions for adolescents in LMICs where both evidence and interventions are limited.

Methods

To inform our adaptation of the Friendship Bench, we established a 21-member community stakeholder group consisting of health professionals, youth, parents, educators, and other key informants from Gaborone City (18), Mochudi (2) and Tlokweng (1) (Table 1). The community stakeholder group met over five two-hour meetings in the largest city in Botswana, Gaborone, to discuss details regarding the Friendship Bench intervention. One meeting was an introductory meeting, and the other four were feedback sessions. Each meeting was structured using a targeted theory of change map to provide feedback on the country’s mental health system context and describe the overall goals for a lay counsellor-based mental health intervention for the youth. We informed the group that we wished to adapt the Friendship Bench for an adolescent population and thus centered their discussions on these premises. The meetings targeted the following specific areas: (1) The overall state of adolescent mental health care in Botswana, including its strengths and challenges; (2) The outcomes that the group wished to achieve with an adaptation of the Friendship Bench model for Botswana; (3) How to reach young people, and (4) What elements of the Friendship Bench would need to be adapted to suit adolescents with mental health needs. One of the primary investigators, MB, facilitated the meetings using the nominal group technique (NGT) (Olsen, 2019; Roth et al., 1995; Van de Ven & Delbecq, 1972). In this study, the nominal group technique was adapted to adjust for group hierarchy. This meant that all ideas were first written by participants and handed in anonymously. They were then all equally presented, discussed and ranked by the group members. This technique allowed the group to list all potentially relevant ideas, debate each idea after equitable sharing, and prioritize salient points until they reached a consensus for each goal. All agreed upon priority areas are documented in this paper verbatim. Our initial goal was to understand the mental health needs of youth living with HIV; however, the group reiterated that Botswana’s limited mental health services impact all the youth in the country. We then decided to expand our target population since our stakeholders were at liberty to guide the meeting outcomes via a community-centred approach. The group followed the theory of change methods outlined in De Silva et al, 2014, that involves working backwards from outcomes to inputs to create the change map (De Silva et al., 2014). To ensure that the opinions of older participants did not overshadow the youths’ opinions, we solicited all participants feedback from both the focus group discussions and individual writing activities using the nominal group technique(Hutchings & Raine, 2006; Olsen, 2019; Roth et al., 1995).

Table 1.

Demographies of stakeholder group (N = 20)

Demographic	Features
Age
Mean	33 years
Median (IQR)	37 years (25–42 years)
Range	15–60 years old
Income status *
< P72,000	6 (30%)
P72,000–P108,000	2 (10%)
> P108,000–P144,000	0
> P144,000	11 (55%)
Missing	1 (5%)
Gender
Male	3 (15%)
Female	17 (85%)
Occupation
Unemployed/unpaid	3 (15%)
Employed Professional**	12 (60%)
Employed non-professional	2 (10%)
Student	3 (15%)
Interaction with Mental Health ***
Patients	4
Caregivers	6
Providers/Professional Advocates	11
Current location
Gaborone City	18
Mochudi	2
Tlokweng	1

^*Income brackets based on Botswana governments Income Tax Rate P10 Pula is roughly equivalent to $1 USD (Ref Burs 2018)

^**Self-Report, includes those who required licensing or post-secondary education for their occupation

^***Self report, participants choose all that applied

Ethical Considerations

The study was approved by the Botswana Human Resource Development Council (approval number: HPDME 13/18/1), the University of Pennsylvania IRB (approval number, 829,783) and the Botswana Baylor Children’s Clinical Centre of Excellence IRB (approval number, BBCOE IRB 1802–01). We obtained written consent from all participants. Meetings were held in confidence, with participants using pseudonyms to introduce themselves and refer to one another during the meetings instead of their names or affiliations. We only documented participants’ names in consent forms collected in private. Demographic information was collected using ranges (as opposed to exact numbers) to prevent the inadvertent identification of a participant when reading publications from this study.

Results

The State of Adolescent Mental Health in Botswana

When asked to share their thoughts on the importance of mental illness in adolescents in Botswana, several stakeholders noted that the mental health problem is “as high as it is in the rest of the world” and at “epidemic levels” due to several reasons. Stakeholders identified that most youth, but especially those living with HIV, concurrently deal with major family problems such as chronic grief from the loss of parents and other caregivers. Additionally, most youths were not close to one or both of their parents due to work-related family separation or single parenthood. The same challenge was highlighted by the young participants in the stakeholder group. The youth’s low socioeconomic status and limited access to money to meet the demands of school and social experiences were also root causes of distress. In the meeting, the mental health and HIV providers stated that sexual and physical abuse was also common root causes of mental illness among the youth.

Other causes listed by younger participants included the rapid growth of technology, including social media, that enabled them to “make comparisons” or experience cyber-bullying. Furthermore, the youth’s biology and genetics (i.e. mental illness running in families) were mentioned as root causes of the mental health concerns among the Botswana youth.

Root causes of mental health concerns in adolescents considered common among youth living with HIV included low self-esteem and interpersonal dynamics related to future relationships, such as disclosing a positive HIV status and its potential repercussions. Youth living with HIV have concerns about both HIV-related stigma and mental health-related stigma. For all youth, mental health-related stigma was a barrier to being “accepted” for who they are by their families and themselves. When mental health concerns were identified among the youth, they did not follow through with referrals to the few mental health providers available due to stigma. Incomplete follow thorough was a common occurrence based on reports from those in the stakeholder group who worked with youth.

Barriers and Facilitators to Care

Stakeholders listed several barriers faced by adolescents when accessing mental health care services. All youth faced these barriers, but stakeholders noted additional concerns regarding youth living with HIV. Youth are often uneducated about mental health-related matters and thus cannot identify their concerns as those that the health system can address. Caregivers may also lack sufficient information regarding how mental illness is present in adolescents and may downplay emotional experiences expressed by adolescents. Cultural beliefs were also an essential point of discussion; the group agreed that Botswana slowly realized that depression, anxiety, and other mental illnesses exist in their society and are not something that "only foreigners have to deal with". The group also noted that mental health care is often "not available" for adolescents. There were no full-time child psychiatrists but only a few practicing clinical psychologists trained on and comfortable working with teens. The available providers often sent youth into a “fractured system” where referrals often required significant time and travel. When adolescents finally accessed the available mental health services, they often found them "unfriendly" to their unique needs and preferences. The young patients often did not attend follow-up appointments. Moreover, adolescents living with HIV already had the burden of appearing at regular HIV-related appointments, making it diffcult to participate in scheduled mental health appointments.

There were a few strengths that Botswana could leverage to support adolescents in need of mental health services. Strengths included the government’s interest in mental health issues following an on-going extensive review and update of the nation’s mental health act and policies. Additionally, Batswana cultures involve robust family support systems that the health system could leverage for mental health services provision. Potential assets also included a commitment to enhancing sports in co-ed schools due to the power of sports in developing self-esteem.

Types of Interventions

Stakeholders listed potential solutions that could work to help adolescents tackle their mental health needs. They prioritized community-level and individual-level interventions that could help bridge the adolescents’ treatment gap. Community mental health education was considered one of the most critical interventions that could close this gap. Community mental health education had the potential to help identify youth in need of mental health services and provide support to adolescents in need instead of chastising or misinterpreting their actions. Family- and client-centred therapy and counseling services were important family- and individual-level interventions for those with major symptoms and limited health care options, respectively. Lastly, support groups for those with mental illness and their caregivers could combat both social and self-stigma.

Goals of a Client-Centered Lay Counselor Service

The stakeholders envisaged a program that could empower adolescents and youth counselors to address mental health concerns to create a healthier community. Stakeholders agreed to have "youth" defined as persons aged 18 to 35 years old serving as lay counsellors for adolescents with mental health needs. Younger lay counsellors (1) could overcome cultural barriers to intergenerational communication, (2) could relate to the problems expressed by adolescent, and (3) would not lecture, judge, or “parent” adolescents with mental illnesses. Additional characteristics considered appropriate for these "near-peer" youth lay counsellors are outlined further below. In addition, stakeholders identified other priority elements for any lay counselor intervention targeting the youth. These included identifying priority target groups for appropriate referrals, elements important for maintaining engagement during the intervention, and counsellors’ training and supervision requirements.

Regarding potential areas from which we could recruit youth to participate in a Friendship Bench-like intervention, stakeholders agreed that the community and not health care settings would be better suited to refer youth for this intervention. They felt that youth-specific mental health behaviors might be easily identified in the community by friends, family, and youth support staff who could directly refer them for the intervention. They agreed that “youth champions”, defined as the youth who had previously participated in the program and could tell others about it, would be ideal for referring youth to the Bench. Parents, peers, and teachers could also be involved in referring youth to the Bench. The group also agreed that mass media (i.e. Radio and Television) could promote self-referral.

To maintaining the youth’s interest in four to six sessions of PST, there was a need to include creative, engaging and fun activities, to have flexible schedules, to allow youth to bring their friends to sessions, and to choose friendly and skillful lay counselors to provide quality helpful counseling. These suggestions had been used by stakeholders to enhance adolescent engagement in their own programs or were options preferred by the youth. Other methods of engagement that the group supported as “items to motivate the youth to return” included tokens such as snacks, small incentives, and certificates of completion.

The group also defined Lay counselor pre-training qualifications. These included a preference for youth diagnosed with a similar illness; for instance, the program would recruit a HIV-positive lay counsellor to serve youth with chronic diseases such as HIV. In addition, they thought completion of secondary school would be a minimum educational requirement for a skilled lay counselor to learn PST skills and get the attention of their adolescent clients. Moreover, the stakeholders also stated that previous experiences were vital in counselor recruitment. These included having worked with young people in the past, having demonstrated good interpersonal skills and professionalism, particularly on maintenance of confidentiality, having portrayed a nonjudgmental approach, and having been considered a model patient. Model patients were defined as patients with chronic illnesses, like HIV or Type I diabetes, who had excellent adherence to medical advice/prescriptions and had had favorable treatment outcomes. In addition to these attributes, young adult lay counselors would agree to attend all training sessions, regular debrief and review sessions, and receive personal counseling.

Stakeholders wanted to ensure that young lay counsellors would be comprehensively trained using the translated version of the Friendship Bench manual in the local language. The group then described what ‘adequate support’ should entail. The group’s recommended that lay counsellors ought to have psychosocial support in the form of regular mandatory ‘debriefs’. These ‘debrief sessions’ would include either group or individual counselling sessions related to the effects of being a counsellor on the counsellor’s mental health. Such sessions were in addition to weekly technical meetings that would provide regular “booster trainings” on the PST techniques they used. Weekly sessions would also periodically review cases and share complex issues with supervisors and other lay counselors to find solutions to challenging clients. Figure 1 illustrates intervention priority areas.

Fig. 1.

Stakeholder identified key areas and recommendations in each key area, for adapting a lay counsellor based intervention for adolescents in Botswana

Notably, two young participants stressed that adapting the intervention to target the youth in urban areas would leave out the youth living in rural areas with different recruitment, engagement and retention challenges. All participants then agreed that future adaptation plans would focus on young people living in rural areas.

Discussion

In Botswana, several approaches have been piloted to develop community health care models (Glenshaw et al., 2016; Seloilwe & Thupayagale-Tshweneagae, 2007). However, providing community mental health care remains a challenge (Seloilwe & Thupayagale-Tshweneagae, 2007). This is particularly true regarding mental health services for adolescents, a special population with unique service-delivery needs². Using a stakeholder-informed theory of change-guided process facilitated by the nominal group technique, we documented vital aspects regarding the needs and capacities for providing mental health care services to adolescents in Botswana. The feedback we received accords us opportunities to understand the gaps and prospects for in youth mental health services in Botswana and how a lay counselor-based intervention may fit in the existing health system. Stakeholders listed current policy, community, and organizational levels strengths that we could leverage to support mental health services for the youth. These strengths included policies put in place by the Botswana Mental Health Act, enhancing youth sports infrastructure, and strong family networks.

The stakeholders’ insights also allowed us to understand how individual-level interventions such as counselling, could work in conjunction with community-level awareness efforts to enhance adolescent mental health and wellness. This work allowed us to appreciate the value of community-based lay counselor interventions such as the Friendship Bench within the Botswana context and how we can adopt such interventions for youth by leveraging the country’s existing health infrastructure. The Friendship Bench and other mental health interventions are more likely to succeed when stakeholders leverage different strategies across socio-ecological levels. This is particularly important when focusing on youth and adolescents who may be hard to reach using conventional lay counsellor-based interventions including the original Friendship Bench model (Chibanda et al., 2015). In other settings, the socio-ecological factors contributing to mental distress in adolescents are used to inform mental health interventions for youth in LMICs. De Jong (2015) noted that in humanitarian crisis settings, interpersonal and community-level factors often contribute to the success of mental health interventions (de Jong et al., 2015; Kohrt et al., 2018). Our stakeholders identified key interpersonal and community-level strategies that we could use to initiate youth engagement to improve their mental health. The feedback provided by the stakeholders concurred with international guidance on comprehensive mental health programs that document stakeholders pursuing a mentally healthy population using a multifaceted approach (Patel et al., 2013; World Health Organization, 2008). This study also provided a practical foundation on which to build a community-based mental health intervention for youth that integrates lay counselors into a broad mental health promotion and treatment program to fill the existing gaps in mental health services for the youth.

Our stakeholders made it clear that task-sharing models such as those employing lay counselors ought to be integrated into the larger mental health system. Nevertheless, clear guidelines for lay counselors should be provided. The stakeholders in the Programme for Improving Mental health care (PRIME) study from several countries across Asia and Africa noted that mental health interventions with task-sharing models should be comprised of the appropriate staff volume, and should cater for adequate supervision, and training and compensation (Mendenhall et al., 2014). Our stakeholders in Botswana specifically prioritized not burdening youth counsellors and providing on-going lay counsellor supervision/mental health support, and training. In addition to the work with the PRIME study, the emerging data from the Youth Friendship Bench in Zimbabwe also supports these recommendations regarding the necessity for youth mental health support, adequate training, and prioritizing youth lay counsellors. Given the similarities between our stakeholders’ recommendations and those implemented in the YouFB, we anticipate that these recommendations would be associated with similar positive outcomes for our clients (Broström et al., 2021). Our study builds on the feedback provided in the PRIME study and the YouFB by providing detailed feedback regarding the features of strong adolescent-friendly lay counselors in a Southern African context. It expands on ways to maximize the use of lay counselors, including using them to help identify and recruit youth in need of individual mental health services and providing support to lay counsellors. The YouFB from Zimbabwe also corroborates the importance of prioritizing the lay counsellors well-being (Wallén et al., 2021).

The feedback we received in this study has the potential to provide insights to other LMICs with similar contexts, small population countries with public health orientated health systems, and a low density of mental health professionals may find our stakeholders feedback relevant to their own plans for adolescent mental health promotion contexts. It not only informs the implementation of a lay counsellor-based intervention like the Friendship Bench, it also could inform family based, school based, or community center-based interventions that could be adapted to work in an LMIC setting (Klasen & Crombag, 2013). Other budding mental health systems with some government policies in place may also find our data supportive of some of the a priori ideas they are prototyping in their countries (Lund et al., 2012, 2015).

There were some limitations. Our stakeholder group consisted of several mental health professionals, general clinical services providers, and a few clients drawn from an urban setting. Another limitation is that most members of the group lived in Gaborone, the capital city. We did not enquire about where participants grew up or invite those who might have added nuances to the geographical diversity of the participants. Though the meetings took place in Gaborone, we did provide email updates asking for additional thoughts or feedback to a few invited psychiatrists in Lobatse where the psychiatric hospital is located. We did this because though several invitations were sent to Lobatse, invitees were unable to make it due to other commitments. The information we gathered may appear to have been drawn from a common source due to participant’s similarities. We attempted to overcome this bias by focusing on unique elements of the Botswana culture and the country’s settings. The relatively higher socioeconomic status and professional categories in the stakeholder group compared to the general population imply that the priorities they selected may not fully reflect those of lower socioeconomic status. We invited only professionals who attend to patients living with mental illness in the public sector and asked them to focus their responses on their clinical and personal experiences with their patients to enhance generalizability. We attempted to choose participants who were both knowledgeable about and representative of the target set for the proposed intervention. However, among 20 stakeholders, only three were aged less than 24 years. To ensure that the opinions of older participants did not overshadow the youths’ opinions, we solicited all participants feedback from both the focus group discussions and individual writing activities using the nominal group technique (Jeffery, 2009). For the nominal group activity, we required each participant’s feedback, thus allowing equal representation of each individual’s opinion. The Nominal group technique de-identified recommendations, and all priority areas were established by group vote. However, the nominal group technique limited our data to prioritized participant-generated ideas without further quotations for context. Additionally, qualitative methods like nominal group technique are inherently limited by their lack of generalizability. However, they can offer a foundation that can be transferrable to similar contexts. The fact that the final recommendations fit a logical socio-ecological theoretical framework, as well as their concordance with PRIME and YouFB observations, increases our confidence that the group provided high-quality insights and recommendations.

Despite these limitations, our study provides a stakeholder-created multi-level set of recommendations for providing mental health interventions to the youth in Botswana and other countries with similar strengths, barriers, and contextual dynamics. Using the theory of change model to guide stakeholder meetings provided a framework to do a needs’ assessment for intervention adaptation. Going forward, we will utilize these recommendations to create and pilot high-quality mental health support services for adolescents living with HIV in Botswana. If successful, we will further adapt this strategy to serve other adolescents in need, including those in rural settings. Future research could focus on integrating feedback obtained from this study and implementing its recommendations (as adaptations or as guidance) in novel interventions for youth in Botswana and similar settings.