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R E S E A R C H A R T I C L E Open Access
Trained lay health workers reduce common
mental disorder symptoms of adults with
suicidal ideation in Zimbabwe: a cohort
study
Epiphany Munetsi
1
, Victoria Simms
2*
, Lloyd Dzapasi
1
, Georgina Chapoterera
1
, Nyaradzo Goba
1
,
Tichaona Gumunyu
1
, Helen A. Weiss
2
, Ruth Verhey
1
, Melanie Abas
3
, Ricardo Araya
3
and Dixon Chibanda
1
Abstract
Background: Suicidal ideation may lead to deliberate self-harm which increases the risk of death by suicide. Globally,
the main cause of deliberate self-harm is depression. The aim of this study was to explore prevalence of, and
risk factors for, suicidal ideation among men and women with common mental disorder (CMD) symptoms
attending public clinics in Zimbabwe, and to determine whether problem solving therapy delivered by lay
health workers can reduce common mental disorder symptoms among people with suicidal ideation, using secondary
analysis of a randomised controlled trial.
Methods: At trial enrolment, the Shona Symptom Questionnaire (SSQ) was used to screen for CMD symptoms. In the
intervention arm, participants received six problem-solving therapy sessions conducted by trained and supervised lay
health workers, while those in the control arm received enhanced usual care. We used multivariate logistic regression
to identify risk factors for suicidal ideation at enrolment, and cluster-level logistic regression to compare SSQ scores at
endline (6 months follow-up) between trial arms, stratified by suicidal ideation at enrolment.
Results: There were 573 participants who screened positive for CMD symptoms and 75 (13.1%) reported suicidal
ideation at baseline. At baseline, after adjusting for confounders, suicidal ideation was independently associated with
being aged over 24, lack of household income (household income yes/no; adjusted odds ratio 0.52 (95% CI 0.29, 0.95);
p= 0.03) and with having recently skipped a meal due to lack of food (adjusted odds ratio 3.06 (95% CI 1.81,
5.18); p< 0.001). Participants who reported suicidal ideation at enrolment experienced similar benefit to CMD
symptoms from the Friendship Bench intervention (adjusted mean difference −5.38, 95% CI −7.85, −2.90; p<
0.001) compared to those who had common mental disorder symptoms but no suicidal ideation (adjusted
mean difference −4.86, 95% CI −5.68, −4.04; p<0.001).
Conclusions: Problem-solving therapy delivered by trained and supervised lay health workers reduced common mental
disorder symptoms among participants with suicidal thoughts who attended primary care facilities in Zimbabwe.
Trial registration: pactr.org ldentifier: PACTR201410000876178
Keywords: Suicidal ideation, Lay health workers, Common mental disorders
* Correspondence: victoria.simms@lshtm.ac.uk
2
MRC Tropical Epidemiology Group, London School of Hygiene and Tropical
Medicine, Keppel Street, London WC1E 7HT, UK
Full list of author information is available at the end of the article
© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Munetsi et al. BMC Public Health (2018) 18:227
DOI 10.1186/s12889-018-5117-2
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
Background
Suicide is a severe public health problem [1], which is
common in both males and females, especially males [2].
However nine independent epidemiological surveys, a
cohort study in Vietnam and a national survey in the
UK found that suicidal thoughts were more common in
women and 16 to 24 year olds [3–5]. A wide range of
mental disorders increase the risk of suicidal ideation
[6], also known as suicidal thoughts. Globally, depression
contributes significantly to suicidal ideation [7], which
increases the risk of death by suicide [8]. The estimated
number of suicidal deaths related to mental disorders
has increased from 138,000 in 1990 to 232,000 in
2010 [9].
Suicide data from the southern African region are limited
as data on deliberate self-harm are often not recorded [10].
In a cross-sectional survey of 842 women attending 6-week
postpartum clinics in Harare, Zimbabwe, 21.6% reported
suicidal ideation postpartum [11]. Being unmarried,
widowed, divorced or separated increased the risk of sui-
cide [4,12]. A cohort study in New Zealand discovered
that being unemployed was associated with a higher risk of
suicidality [13].
HIV status can contribute to risk of suicidal behaviour,
as shown by a systematic review [14]. People living with
HIV have a higher prevalence of suicidal ideation than
those who are HIV negative [15], however suicidal
thoughts have decreased considerably as a result of the
introduction of HAART [16]. Both of these studies were
conducted in high-income settings (the USA and
Switzerland).
Mental, neurological and substance use disorders
contribute significantly to the global burden of disease
[17]. In low and middle income countries many people
suffer from these conditions [18] but over 75% do not get
treatment due to lack of economic resources and mental
health services [19] and professionals [20]. Treatment
coverage ranges from 10 to 90% in these settings [21].
The patient-to-psychiatrist ratio on average in low
income countries is 1:1.7 million [22]. To address this
treatment gap, interventions have been developed that
tackle common mental disorders (CMDs) through task
sharing to lay health workers (LHWs) [23]. Task sharing
is the delegation of responsibilities to lower level cadres
who are supported and supervised by more senior
professionals [24].
A lay health worker may be any health worker offering
services related to health care delivery who has no for-
mal professional training but has received some basic
training [25]. LHWs are trained to provide selected
health services allowing more highly trained workers to
handle more complex tasks for which specialist training
is required [26]. Additionally, LHWs have in-depth
knowledge of a community and culture, which may
make them better equipped to handle certain health
challenges [27].
Interest in LHW programmes has increased [25], as they
can assist in HIV service delivery [28]. Evidence suggests
that non specialist workers are capable of providing coun-
selling and case management at community level [29]. A
systematic review from a number of health care facilities
show that positive health results for patients with HIV can
be attained by task sharing that involves LHWs [30].
Mental health care can be delivered effectively through
the use of trained and supervised LHWs [31,32]. A
Cochrane review found that the use of LHWs to deliver
mental health interventions may result in positive treat-
ment outcomes for patients with common mental disorders
(CMDs) [33]. A study in India concluded that trained
LHWs within a collaborative care model can reduce
prevalence of CMDs among those attending public primary
care facilities [34].
In a recently-completed cluster-randomised controlled
trial, a LHW intervention at primary care level in
Zimbabwe, the Friendship Bench LHW programme, was
effective in reducing CMD symptoms, disability, and
improving quality of life [35,36]. The prevalence of sui-
cidal ideation after 6 months was 2.3% in the intervention
group versus 12.3% in the control group, from a baseline
of 11–13% [36]. While the Friendship Bench was effective
in reducing suicidal ideation, it is not known whether
participants with suicidal ideation (which may be more
difficult for LHWs to manage) benefitted as much from
the intervention as other participants.
The objectives of this study were (1) to explore preva-
lence of, and risk factors, for suicidal ideation among men
and women with CMD symptoms attending public clinics
in Zimbabwe at enrolment to the Friendship Bench trial,
and (2) to determine whether problem-solving therapy by
LHWs can reduce symptoms of common mental
disorders among people with suicidal ideation.
Methods
Study design
We previously conducted a cluster-randomized
controlled trial of the Friendship Bench LHW counsel-
ling intervention. The trial took place in 24 Harare city
health primary care clinics, 12 randomly allocated to the
intervention and 12 control clinics delivering enhanced
standard care. Primary care clinics in Harare offer family
health services, opportunistic infection treatment, and
treatment of other physical non-complicated medical
cases.
Participants in the intervention arm received up to six
sessions of one-to-one counselling from a LHW and link-
ages to an optional peer support group with an income
generation component. The intervention has previously
been described in detail [36]. The counselling involved
Munetsi et al. BMC Public Health (2018) 18:227 Page 2 of 7
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problem-solving therapy, teaching participants a struc-
tured approach to identifying problems and workable
solutions. The six sessions were usually completed within
3 weeks after enrolment. Participants at the enhanced
standard care clinics received the usual care plus support
and information on common mental disorders, including
assessment for antidepressant medication or referral to a
psychiatric facility as needed.
Study sample
For 2 weeks per clinic, people attending the clinic for
any reason were randomly selected based on their number
in the queue. Those who were aged 18 years and above,
residing within the clinic’s geographic area, in possession
of a valid national identification card for age verification
and willing to give consent were screened using the Shona
Symptom Questionnaire (SSQ14). The SSQ measures
symptoms of common mental disorders, and was devel-
oped in Zimbabwe and revalidated for the study popula-
tion, with 84% sensitivity and 73% specificity against a
diagnosis of depression and/or anxiety [37]. Participants
who scored above 9/14 on the SSQ14 and answered yes to
a question about suicide thoughts in the past week which
was one of the 14 items were designated suicidal and also
had CMD symptoms [36].
Patients were excluded from the study if they were
considered too ill; pregnant and in their third trimester
or 3 months post-partum; did not have a traceable
address or a working phone; did not understand English
or Shona; had suicidal intent; were in psychiatric care; pre-
sented with psychosis, intoxication or dementia; or were
not willing to have home visits by study staff members.
Individuals with suicidal ideation but not subsequently
assessed as having suicidal intent were eligible to
participate.
The SSQ score and other outcomes for each participant
were collected at baseline and at 6 months after the day of
recruitment.
Data analysis
Data were exported to Stata 14.1 for analysis. The asso-
ciation between suicidality at baseline and other baseline
factors was estimated using logistic regression, adjusting
for clinic as a random effect. All variables associated
with the outcome at a significance level of p< 0.2 were
carried forward into multivariate analysis, plus age and
gender as a priori independent variables. Variables were
assessed for collinearity by comparison with the univariate
results and removed as necessary. Mean and 95% confi-
dence intervals of SSQ score were calculated at baseline
and follow-up by baseline suicidality and arm, adjusting
for clustering. Analysis of the effect of the intervention
was based on cluster-level summary measures because of
the small number of clinics per arm. The difference in
mean SSQ scores between arms at 6 months was esti-
mated using linear regression adjusted for HIV status, sex,
baseline score, age and education, as predetermined in the
trial analytical plan. In this paper, as an exploratory
analysis, we examined the intervention effect stratified by
suicidal ideation at baseline.
Results
A total of 573 participants screened positive for CMD
symptoms and took part in the trial, 286 in the intervention
arm and 287 in the control arm, the majority of whom
(86%) were female (Table 1). The most commonly reported
Table 1 Characteristics of participants by suicidal ideation
No
suicidal ideation
Suicidal
ideation
N%N%
Total 498 100.0 75 100.0
Gender Male 71 91 7 9
Female 427 86.3 68 13.7
Age 18–24 100 93.5 7 6.5
25–34 182 83.1 37 16.9
35–44 132 86.8 20 13.2
45+ 83 88.3 11 11.7
Earning salary No 272 85.3 47 14.7
Yes 224 88.9 28 11.1
Marital status Married/
cohabiting
335 86.8 51 13.2
Divorced/
separated/widowed
134 86.5 21 13.5
Single 28 90.3 3 9.7
Children aged < 16 at
home
0 89 85.6 15 14.4
1 115 86.5 18 13.5
2 133 86.9 20 13.1
3 96 87.3 14 12.7
4+ 63 88.7 8 11.3
HIV status Positive 199 83.6 39 16.4
Negative 229 88.1 31 11.9
Declined/missing 68 93.2 5 6.8
Household has an
income
Yes 408 88.5 53 11.5
No 75 78.9 20 21.1
Chronic condition Yes 122 87.1 18 12.9
No 374 86.8 57 13.2
Skipped at least one
meal in the past
month due to lack of
food
Yes 182 79.1 48 20.9
No 314 92.1 27 7.9
Went to sleep hungry
in the past week
Yes 120 80.0 30 20.0
No 376 89.3 45 10.7
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reasons for attending the clinic were bringing a sick relative
(40%) or HIV care (20%). Of the men in the sample, 29
(37%) earned a salary, 24 (31%) were self-employed or
casually employed, and 25 (32%) were not working.
Of the 573 participants, 75 (13.1%, 95% CI 10.4–16.1) re-
ported suicidal ideation in the past week at baseline (female
= 68; male = 7). At baseline the age range of 25–34 year
olds had the highest prevalence of suicidal thoughts
(16.9%). Participants who earned a salary were less at risk
of suicidal ideation (11.1%) as compared to the ones who
did not (14.7%) but the difference was not statistically sig-
nificant. Of the participants whose household did not have
an income 21.1% had suicidal ideation as compared to
11.5% of those who had an income (p= 0.01).
Participants who had separated with their spouses
through divorce or widowing had almost the same prob-
ability of suicidal ideation with 13.5% as the ones who
were married or cohabiting (13.2%). Participants living
with HIV had slightly higher prevalence of suicidal idea-
tion (16.4%) than the ones who were HIV negative
(11.9%). A fifth (20.9%) of participants who had skipped
at least one meal in the past month because there was
not enough food reported suicidal ideation, compared
to7.9% of participants without food insecurity (p< 0.01).
In univariate analysis suicidal ideation at baseline was
associated with age, HIV status, skipping meals due to lack
of food, going to sleep hungry, and lack of household in-
come (Table 2). In a multivariate model, risk factors for
suicidal ideation were skipping meals, lack of household
income and age. Hunger did not remain in the model due
to collinearity with skipping meals.
At 6-months follow-up, severity of CMD symptoms
were significantly less among participants who received
LHW Friendship Bench care than among participants in
the control arm. This difference was similar among
those who had suicidal ideation at baseline, and those
who did not (Table 3). The adjusted mean difference in
SSQ-14 score among participants with suicidal ideation
was −5.38 (95% CI −7.85, −2.90; p< 0.001) and among
those with common mental disorder symptoms but no
suicidal ideation the adjusted mean difference was −4.86
(95% CI −5.68, −4.04; p< 0.001).
Discussion
The aim of the study was to explore the prevalence of
suicidal ideation among men and women with CMD
symptoms attending public clinics in Harare and to deter-
mine whether the Friendship Bench LHW programme can
Table 2 Factors associated with suicidal ideation at baseline
Univariate Multivariate
OR (95% CI) pOR (95% CI) p
Gender
(reference: male)
Female 1.62 (0.71, 3.70) 0.25 1.34 (0.57, 3.15) 0.50
Age
(reference: 18–24)
25–34 2.90 (1.25, 6.77) 0.09 3.00 (1.26, 7.16) 0.09
35–44 2.15 (0.87, 5.31) 2.30 (0.91, 5.82)
45+ 1.88 (0.69, 5.10) 1.94 (0.69, 5.49)
Earning salary
(reference: no)
Yes 0.73 (0.44, 1.20) 0.21
Marital status
(reference: married)
Divorced/ separated/ widowed 1.02 (0.59, 1.77) 0.95
Single 0.70 (0.20, 2.39) 0.57
Children aged < 16 at home
(reference: 0)
1 0.94 (0.44, 1.98) 0.87
2 0.90 (0.43, 1.86) 0.77
3 0.88 (0.40, 1.94) 0.75
4+ 0.75 (0.30, 1.89) 0.55
HIV status
(reference: negative)
Positive 1.47 (0.88, 2.47) 0.14
Declined/ missing 0.54 (0.20, 1.45) 0.22
Has any household income
(reference: no)
Yes 0.49 (0.27, 0.87) 0.01 0.52 (0.29, 0.95) 0.03
Chronic condition
(reference: no)
Yes 0.97 (0.55, 1.72) 0.92
Skipped at least one meal in the past month
due to lack of food
(reference: no)
Yes 3.07 (1.85, 5.09) < 0.001 3.06 (1.81, 5.18) < 0.001
Went to sleep hungry in the past week
(reference: no)
Yes 2.09 (1.25, 3.47) 0.01
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reduce common mental disorder symptoms among people
with suicidal ideation. The results show that suicidal
ideation is high in this population, especially among
women. This outcome supports evidence from the litera-
ture that prevalence of suicidal thoughts is highest in fe-
males [3]. Participants from households without an
income had twice the odds of suicidal ideation compared
to those from households with an income. Similarly partic-
ipants with insufficient food for all meals had almost three
times the odds of suicidal ideation. This study confirms
existing evidence on the relationship between food inse-
curity and mental health [38].
The study found that 18–24 year olds had the lowest
prevalence of suicidal thoughts, contrary to a study con-
ducted in Vietnam in the general population [5], which
found the highest prevalence in people aged 16 to 24. The
study did not show a statistically significant association
between earning a salary and suicidality. This finding does
not align with a cohort study in New Zealand which
showed a close relationship between unemployment and
suicidality in the general population [13], but in this con-
text it could be because the Friendship Bench participants
mainly constituted of women with young children who
could probably have been depending financially on their
husbands or staying at home to be with their children.
Instead, lack of household income rather than lack of per-
sonal income was a risk factor for suicidal ideation. In this
mainly female population, those at increased risk of sui-
cidal thoughts appear to be women of the age most likely
to be caring for young children, whose partners were out
of work, and who did not have enough to eat. The
unemployment rate in Zimbabwe is extremely high, as
shown in this sample where 32% of men were unemployed
and 31% had possibly insecure income.
Widowed, divorced or separated individuals are at in-
creased risk of suicidal ideation [15]. This is contrary to
this study which found that participants in this category
were not at high risk of suicidal thoughts as compared
to the married or cohabiting individuals and this could
be attributed to financial constraints on families.
Limitations
The study has several limitations. Men are underrepre-
sented in this study. Only 78 men out of a total of 573
participants took part in this study. The reason why men
were few could be that there is always low uptake of
health programmes by men and when they report to a
health institution they express the need to attend to
other commitments. This aligns with a study conducted
in Australia which highlighted that young men would pre-
fer to assist themselves than seek professional aid [39].
This could be attributed to the stigma [40] associated with
attending a health facility as well as the need to maintain
their ego. Reaching men remains a major priority.
Conclusion
Among clinic attenders in Harare, those aged over 25 with
no household income and food insecurity are at increased
risk of suicidal ideation. Trained LHWs in primary care
clinics can reduce common mental disorder symptoms
among people with suicidal ideation in Harare. This finding
supports the effectiveness of task shifting from professional
health personnel so as to meet individuals at their point of
need in primary health care facilities as far as common
mental disorders are concerned.
Abbreviations
CMDs: Common mental disorders; LHWs: Lay health workers; SSQ: Shona
Symptom Questionnaire
Acknowledgements
The City of Harare gave assistance as they were the gatekeepers of primary
health care facilities. We acknowledge the research team who conducted
data collection as well as the Lay Health Workers who delivered problem
solving therapy and all participants who consented to take part in the study.
Funding
The study was funded by Grand Challenges Canada (grant KCU-0087-042).
Availability of data and materials
The raw dataset and analysis files used during this study are available in the
DataCompass repository curated by the London School of Hygiene &
Tropical Medicine: https://doi.org/10.17037/DATA.201.
Authors’contributions
EM and DC designed the study concept and drafted the manuscript whilst
LD and EM were involved in data collection. HAW, RV, MA, RA and DC
designed the Friendship Bench trial. LD, GC, NG, TG, HAW and MA were
involved in reviewing and editing the paper. VS analysed the data and also
assisted with the editing of the paper. All authors read the final paper and
approved.
Ethics approval and consent to participate
Participants provided written consent before enrolment and ethics approval
was provided by the Medical Research Council of Zimbabwe (MRCZ) and the
London School of Hygiene & Tropical Medicine.
Consent for publication
Not applicable
Table 3 Effect of the Friendship Bench intervention on CMD symptoms at 6 months, by suicidal ideation at baseline
Mean SSQ-14 score (95% CI) Unadjusted mean difference
(95% CI), p
Adjusted
a
mean difference
(95%CI), p
Intervention arm Control arm
Suicidal ideation at baseline 3.28 (1.67, 4.89) 9.82 (8.02, 11.61) −6.54 (−8.55, −4.53), p< 0.001 −5.38 (−7.85, −2.90), p< 0.001
No suicidal ideation at baseline 3.74 (3.11, 4.38) 8.76 (8.22, 9.30) −5.02 (−5.86, −4.18), p< 0.001 −4.86 (−5.68, −4.04), p< 0.001
a
Adjusted for age, sex, HIV status, SSQ-14 core at baseline, and education
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Competing interests
The authors declare that they do not have any competing interests.
Publisher’sNote
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
Author details
1
Zimbabwe AIDS Prevention Project, 92 Prince Edward Road Milton Park,
Harare, Zimbabwe.
2
MRC Tropical Epidemiology Group, London School of
Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
3
King’s
College London, Institute of Psychiatry, Psychology and Neuroscience, De
Crespigny Park, London SE5 8AF, UK.
Received: 13 June 2017 Accepted: 24 January 2018
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