Applying the Consolidated Framework for Implementation Research to Optimize Implementation Strategies for the Friendship Bench Psychological Intervention in Zimbabwe

Abstract

Scaling up an evidence-based mental health program such as the Friendship Bench (FB) Zimbabwe bares many difficulties. Guided by the Consolidated Framework for Implementation Research (CFIR), this study sought to understand the contextual determinants of FB performance and to identify and match novel implementation strategies to optimally overcome barriers. The CFIR was applied to guide twenty-five focus group discussions with n = 152 stakeholders in nine high- and four low-performing clinics across three cities in Zimbabwe to identify the constructs distinguishing clinic performance. Identified implementation barriers were included in the CFIR-Expert Recommendation for Implementation Change (ERIC) matching tool to inform strategies to optimize future FB implementation outcomes. Constructs peer pressure, goals and feedback, learning climate, planning, formally appointed leaders, and external change agents strongly distinguished between high- and low-performing clinics. Barriers to implementation were intervention complexity and organizational incentives and rewards; intervention-related constructs were identified as enablers. Strategies such as identifying and preparing champions, altering incentive structures, developing a formal implementation blueprint, and organizing regular clinician meetings were chosen to address barriers and optimize FB implementation. There was variability in the implementation performance of FB three years post-scale-up. High-performing clinics appear to be influenced positively by peer pressure, goal setting and feedback, better staff communication and integration of the program, overall learning climate, and clinic-level planning. A set of enhanced FB implementation strategies should be applied to improve implementation performance.