Barriers and facilitators to integrating the friendship bench into non-communicable disease care in Malawi: A qualitative study

Comorbid depression is common among people living with non-communicable diseases (NCDs) in Malawi and is associated with reduced treatment adherence and increased NCD and depression symptom severity. This bidirectional negative relationship between NCDs and depression necessitates an appropriate intervention for addressing depression in those living with NCDs in low resource settings. To assess barriers and facilitators to implementing the Friendship Bench (FB) for depression management as part of NCD care, a convenience sample of 22 participants involved in the development, delivery, or receipt of the FB intervention were recruited for in-depth interviews from two facilities offering the FB. Participants included 12 NCD patients, 8 FB counsellors, and 2 of the original FB developers. Implementation facilitators included an understanding of emotional distress, positive patient-provider relationships, understanding the purpose and benefits of the FB, accessibility of FB, and positive collaborative relationships amongst providers. Major implementation barriers included a lack of mental health literacy among patients, providers, and institutions, a lack of acceptance of the use of mental health interventions, misinterpretations of the scope of practice of the FB counsellor, and limited institutional support for the integration of FB into NCD care. While FB is a promising intervention for addressing depressive symptoms in people with NCDs in Malawi, major implementation barriers may impact its feasibility and acceptability for this patient population. These findings can inform future research on adapting the FB for feasible and acceptable implementation for NCD patients in low resource settings.