Impact statement
This study provides compelling evidence for the feasibility, acceptability and preliminary effectiveness of a culturally adapted Problem-Solving Therapy-Friendship Bench Intervention delivered by nonspecialists through mother-to-mother support groups (MMSGs) to address perinatal psychological distress in Sierra Leone. The intervention, designed to bridge the treatment gap for perinatal mental health in low- and middle-income countries, demonstrated a two-fold reduction in psychological distress scores compared to the control group. This study highlights the importance of culturally adapted mental health interventions, delivered in community settings by nonspecialists, in improving maternal mental health outcomes. Trust and confidentiality within MMSGs were critical in the success of the intervention. The findings underscore the potential for this intervention model to be scaled up for broader use in Sierra Leone and similar low-resource settings. Given the promising preliminary results, further randomized-controlled trials are recommended to confirm the intervention’s effectiveness and guide its potential nationwide implementation. This study contributes to global efforts in closing the mental health treatment gap, particularly for vulnerable populations such as pregnant women and new mothers in resource-constrained environments.
Introduction
Mental health disorders are among the most prevalent and challenging health problems globally, particularly impacting low and middle-income countries (LMICs), where a significant burden of untreated conditions persists. In LMICs, it is estimated that as many as 90% of individuals who could benefit from mental health treatment do not receive it (Van Ginneken et al., Reference van Ginneken, Tharyan, Lewin, Rao, Romeo and Patel2011), largely due to inadequate healthcare infrastructure and a shortage of specialists. Sierra Leone exemplifies these challenges, facing a staggering 98% treatment gap for severe mental disorders (Alemu et al., Reference Alemu, Funk and Gakurah2012), compounded by historical conflicts and health crises such as the Ebola outbreak and the COVID pandemic. Globally, depression is the leading contributor to the burden of mental and neurological disorders among women of childbearing age (Liu et al., Reference Liu, Ning, Zhang, Zhu and Mao2024). Beyond the significant economic and personal toll of maternal depression, common perinatal mental disorder (CPMD) is associated with preterm delivery, low birth weight, stunting, infant malnutrition, difficulties in mother-infant bonding, neurocognitive developmental delays and behavioral problems (Slomian et al., Reference Slomian, Honvo, Emonts, Reginster and Bruyère2019). Therefore, this situation perpetuates a cycle contributing to intergenerational disadvantage that accumulates throughout the life span.
Consequently, enhancing mental health care can significantly impact the maternal and child health (MCH) agenda. However, mental health services are notably absent in many large-scale global MCH initiatives, including Sierra Leone (Atif et al., Reference Atif, Lovell and Rahman2015). The Sustainable Development Goals (SDGs) which was launched in 2015, just 1 year after the launch of the Lancet series on perinatal mental health, call on all actors to leave no one behind in addressing the unfinished business of MCH (Duffy et al., Reference Duffy, Churchill, Kak, Reap, Galea, O’Donnell Burrows and Yourkavitch2024). Despite the fact that the SDGs included mental health in their agenda, CPMDs continue to be a significant public health problem (Dadi et al., Reference Dadi, Miller, Woodman, Bisetegn and Mwanri2020a). CPMDs contribute significantly to the morbidity and mortality associated with the perinatal period (Duffy et al., Reference Duffy, Churchill, Kak, Reap, Galea, O’Donnell Burrows and Yourkavitch2024), despite it is treatable when detected early. Yet women in Sierra Leone as elsewhere in sub-Sahara Africa lack access to routine detection and treatment (Mokwena and Masike, Reference Mokwena and Masike2020).
Sierra Leone is a very important context to research in perinatal mental health care as a study conducted in Kono, a district in Eastern Sierra Leone, indicates that one in two postnatal women met screening criteria for postnatal depression (Bah et al., in preparation). Among the risk factors that are prevalence in Sierra Leone include sex- and gender-based violence; intimate partner violence; food insecurity; low literacy rate among women; poverty and gender norms; patrilineal family structures including polygamy, early child marriages and high teenage pregnancy (Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2024b), which have been identified as risk factors for CPMDs (McNab et al., Reference McNab, Dryer, Fitzgerald, Gomez, Bhatti, Kenyi, Somji, Khadka and Stalls2022). Gender inequality is one of the most important vulnerability factors for CPMDs – with an impact on almost all aspects of a woman’s life throughout her life course, especially in LMICs. In Sierra Leone, where women carry a disproportionately high burden of household financial responsibility, chores and child-rearing and live with the additional burden of multigenerational households, they are more likely to experience CMPDs (McNab et al., Reference McNab, Dryer, Fitzgerald, Gomez, Bhatti, Kenyi, Somji, Khadka and Stalls2022).
For close to two decades, experts in the mental health field have advocated for the integration of mental health programs into primary care settings (Eaton et al., Reference Eaton, McCay, Semrau, Chatterjee, Baingana, Araya, Ntulo, Thornicroft and Saxena2011; Stein et al., Reference Stein, Pearson, Goodman, Rapa, Rahman, McCallum, Howard and Pariante2014). Despite recommendations from the World Health Organization (WHO) and growing evidence of the high prevalence of maternal mental health issues and their detrimental effects on mothers and infants, most LMICs have yet to integrate maternal mental health into their primary health care systems. While the physical health of women and children is emphasized, the mental aspects of their health are often ignored by MCH programs, especially in LMICs. Barriers to providing maternal mental health care in these regions include insufficient human and financial resources (Kakuma et al., Reference Kakuma, Minas, van Ginneken, Dal Poz, Desiraju, Morris, Saxena and Scheffler2011) and the competing challenges of both communicable and noncommunicable diseases, which often push mental health concerns to the periphery of health care (Patel et al., Reference Patel, Saraceno and Kleinman2006). Maternal depression is by far the mental disorder with the highest public health impact (Herba et al., Reference Herba, Glover, Ramchandani and Rondon2016).
Integrating maternal mental health into MCH programs could help bridge this treatment gap by facilitating early identification, prevention and management of issues like depression (Rahman et al., Reference Rahman, Fisher, Bower, Luchters, Tran, Yasamy, Saxena and Waheed2013a, Reference Rahman, Surkan, Cayetano, Rwagatare and Dickson2013b). This integration necessitates collaboration across various sectors and a comprehensive health system approach that emphasizes prevention and treatment throughout the life course, utilizing evidence-based interventions (Collins et al., Reference Collins, Patel, Joestl, March, Insel, Daar, Bordin, Costello, Durkin and Fairburn2011). The WHO has recommended task sharing to improve mental health care in primary care settings in LMICs. This approach involves nonspecialist healthcare workers (NSHWs) delivering evidence-based interventions, which have shown potential in reducing the treatment gaps (Tj et al., Reference Hoeft, Fortney, Patel and Unützer2018). Research indicates that these interventions enhance maternal mental health and positively impact infant health and development (Joshi and Rajarshi, Reference Joshi and Rajarshi2018). Community-based psychosocial interventions led by NSHW have been effective in alleviating symptoms of CPMDs compared to standard care (Clarke et al., Reference Clarke, Saville, Shrestha, Costello, King, Manandhar, Osrin and Prost2014).
PST, endorsed by the WHO’s Mental Health Gap Action Programme (mhGAP), is suitable for task-sharing and has proven effective for common mental disorders in various sociocultural contexts (Cuijpers et al., Reference Cuijpers, de Wit, Kleiboer, Karyotaki and Ebert2018; Kardaş et al., Reference Kardaş, Kardaş, Saatçioğlu and Yüncü2023; Lund et al., Reference Lund, Schneider, Davies, Nyatsanza, Honikman, Bhana, Bass, Bolton, Dewey, Joska, Kagee, Myer, Petersen, Prince, Stein, Thornicroft, Tomlinson, Alem and Susser2014). A randomized-controlled trial by Chibanda et al. (Reference Chibanda, Weiss, Verhey, Simms, Munjoma, Rusakaniko, Chingono, Munetsi, Bere, Manda, Abas and Araya2016) found significant mental health improvements among participants receiving the Friendship Bench intervention, indicating that community-based approaches can serve as viable and sustainable alternative to pharmacological treatments in low-resource settings. While evidence for PST in LMICs is growing, more research is needed on integrating such interventions into MCH services (Le et al., Reference Le, Eschliman, Grivel, Tang, Cho, Yang, Tay, Li, Bass and Yang2022). The feasibility, acceptability and effectiveness of incorporating mental health interventions in perinatal care remain underresearched globally, particularly in Sierra Leone. This study seeks to explore these factors for a culturally adapted form of PST-FBI aimed at perinatal psychological distress in Sierra Leone.
Method
Study settings
This study was conducted in two randomly selected communities, Campbell Town and Lumpa, within Waterloo, a peri-urban area of the Freetown metropolitan area in Sierra Leone, located 20 miles from the capital. Waterloo was selected due to logistical reasons and proximity to the research team. It has a population of approximately 55,000 according to the 2015 census (Statistics Sierra Leone, 2019) and is characterized by its ethnic diversity and agroeconomy. The primary language spoken is Krio. The community has limited healthcare infrastructure, with a secondary hospital and eight community health centers (CHCs) serving around 5,000 households each (Statistics Sierra Leone, 2019). Community health officers (CHOs) staff these centers, managing a list of pregnant women and new mothers. Although more than 100 CHOs have undergone training on the WHO’s mhGAP, many have not received follow-up supervision or refresher courses, and the effectiveness of this training remains to be assessed (Harris et al., Reference Harris, Endale, Lind, Sevalie, Bah, Jalloh and Baingana2020). At the community level are MMSGs, who are unpaid laywomen who facilitate early antenatal contacts before referrals for further care (Bah et al, Reference Bah, Wurie, Samai, Horn and Ager2025). They help address the high rates of infant malnutrition in the country.
Study design
This was a 4-week randomized-controlled, feasibility, waitlist pilot study (Chibanda et al., Reference Chibanda, Bowers, Verhey, Rusakaniko, Abas, Weiss and Araya2015), and three-time point assessments: at baseline (T0), 2 weeks after initiation of the intervention (T1) and at the end of the intervention (T2). A quantitative and later a qualitative study was nested within the pilot study to assess the implementation-related factors – feasibility, acceptability and preliminary effectiveness (Spedding et al., Reference Spedding, Stein, Naledi, Myers, Cuijpers and Sorsdahl2020).
Randomized-controlled feasibility trial
The randomized-controlled feasibility pilot study compared the adapted PST-FBI with usual care. The following sections will describe eligibility criteria, sample size, participant recruitment procedures, randomization procedures, intervention delivery, assessment and data analysis.
Eligibility criteria
Inclusion criteria: Perinatal women were included if they (1) scored eight or more on the locally developed and validated Sierra Leone Perinatal Psychological Distress Scale (SLPPDS; Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2024a); (2) are between 12- and 34-weeks’ gestation for pregnant women (Bitew et al., Reference Bitew, Keynejad, Myers, Honikman, Medhin, Girma, Howard, Sorsdahl and Hanlon2021), and new mothers are between 2 weeks and 12 weeks postdelivery (Kakyo et al., Reference Kakyo, Muliira, Mbalinda, Kizza and Muliira2012); (3) are aged 18 years and above, which is the age of consent in Sierra Leone; and (4) are planning to live in the study area for at least 3 months.
Exclusion criteria: Perinatal women were excluded if they (1) present with acute medical illness or evidence of severe mental illness; or (2) other comorbid medical conditions such as hypertension, renal disease or diabetes; (3) failed to give informed consent; or (4) have a condition that impairs their capacity to understand the interview (e.g., diagnosed with severe intellectual disability).
Sample size
This feasibility pilot study enrolled 50 participants, 25 of whom were assigned to the intervention arm and 25 to the control arm. We estimated that this sample size would allow us to identify a dropout rate of 7% with a 95% confidence interval and a 5% margin of error (Viechtbauer et al., Reference Viechtbauer, Smits, Kotz, Budé, Spigt, Serroyen and Crutzen2015). According to recommendations, a sample size of 24–50 is suitable for feasibility studies (Abbas Tavallaii et al., Reference Abbas Tavallaii, Ebrahimnia, Shamspour and Assari2009).
Participant recruitment and screening
An outreach was conducted in Lumpa and Campbell Town, involving stakeholder meetings that included chiefs, chair ladies, MMSGs, nurses, CHOs and community members. During these meetings, we outlined the purpose of the pilot study, community expectations and potential benefits for the community. To recruit perinatal women, we employed systematic sampling of houses, with the CHCs as a reference point. Trained research assistants conducted the screenings in both communities. Eligible women were provided with detailed information about the study and guided through the informed consent process.
Following the consent, participants underwent an initial psychological distress screening using the SLPPDS (see Supplementary Table S2). Those who met the criteria received verbal details about the study. Data collected from the perinatal women included contact information, sociodemographic details and their SLPPDS symptom scores. These data were reviewed by the research lead (AJB), who communicated the information of the perinatal women with scores ≥ 8 on the SLPPDS to the MMSGs to engage them and start the intervention. Participants were compensated for their time but not for attending PST-FBI sessions to prevent incentivizing intervention participation.
Randomization
Randomization was done at the community level, therefore the perinatal women were assigned either to the intervention or control arm, depending on whether they were living at Campbell Town or Lumpa respectively.
Treatment of participants
Experimental intervention: In the intervention arm, five MMSGs delivered a structured PST-FBI consisting of four counseling sessions, tailored specifically for Krio-speaking women experiencing perinatal psychological distress (see Supplementary Table S1). Qualitative formative research highlighted strong links between symptoms of distress and various stressors, including poverty, lack of partner support, abuse, loss of loved ones, unplanned pregnancies and health issues (Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2024b; Horn et al., Reference Horn, Arakelyan, Wurie and Ager2021). Local idioms of distress such as “stress (stres)” and “thinking too much (tink tu much)” were identified among others that guided the cultural adaptation of the intervention manual to enhance resilience and coping strategies for these women (Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2025). The PST-FBI focused on psycho-education, problem-solving and behavioral activation (see Table 1) and aimed to build resilience and social support amid social and interpersonal challenges among perinatal women in the intervention arm.
Intervention summary of contents
The cultural adaptation of the intervention used the Assessment, Decision, Adaptation, Production, Topical expert, Integration, Training & Testing (ADAPT ITT) framework (Wingood and DiClemente, Reference Wingood and DiClemente2008) and the ecological validity model (Bernal et al., Reference Bernal, Bonilla and Bellido1995) to modify the original FBI manual from Zimbabwean to the Sierra Leonean context (Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2025). Five MMSGs, recruited from the Directorate of Nutrition, delivered the intervention after receiving 3 days of residential training on the PST-FBI. The intervention consisted of four PST-FBI sessions (Table 1). Session 1 involved identifying possible stressors and ranking then in the order of priority. Sessions 2 and 3 involved developing context-specific and need-driven solutions. Finally, session 4 involves evaluating the client’s progress. This was followed by a peer-led group session called col at sacul (see Supplementary Figure S1). This circle was a peer-led support group that provides a safe space for them to share their experiences and coping strategies related to perinatal psychological distress. It was meant to be sustained after the intervention, and the perinatal women could adapt it to meet their evolving needs and priorities. Sessions were flexible, conducted either at the MMSG’s location or in the participant’s home, based on preference. For quality assurance, the research team, including the lead, conducted supportive supervision for the MMSGs to ensure fidelity to the intervention.
Control: Participants allocated to the control arm received usual care.
Assessment of perinatal women’s outcomes
Perinatal women were assessed by trained research assistants at baseline (T0), 2 weeks after initiation of the intervention (T1) and at the end of the 4 weeks of the intervention (T2). The assessments included sociodemographic and psychological distress scores of the perinatal women. The primary outcome for preliminary effectiveness was a change in SLPPD scores. The SLPPDS is an indigenous instrument developed in Sierra Leone to detect CPMDs (Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2024a). It is a 10-item screening tool eliciting symptoms over the past 14 days, which is a culturally relevant tool for the detection of CPMDs in Sierra Leone. A score of ≥ 8 (out of a maximum score of 30) yielded a sensitivity of 80.0% and specificity of 85.7% in identifying cases of perinatal psychological distress that are clinically significant (Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2024a).
Outcomes
Future clinical trials feasibility
To explore the feasibility of a future clinical randomized control trial, we collected data on the following feasibility indicators: (1) recruitment, (2) eligibility and consent rates and (3) the attrition rates.
Psychological distress outcomes
The reduction in psychological distress was the primary outcome, and this was measured using the SLPPDS (Bah et al., Reference Bah, Wurie, Samai, Horn and Ager2024a). Respondents rate the frequency of the experience with psychological distress in the previous 2 weeks on a 4-point Likert scale, ranging from “not at all” (0) to “all the time” (3) to give a cumulative score ranging from 0 to 30. A score of 8 and above is considered moderate to severe psychological distress.
Implementation parameters
We conducted in-depth interviews with the perinatal women who completed the four PST sessions (n = 20) and the MMSGs (n = 5) in Krio. Interviews lasted 30–60 min and were digitally recorded and transcribed verbatim. We used the Consolidated Framework for Implementation Research (CFIR; Table 2) to identify and operationalize the implementation parameters (Proctor et al., Reference Proctor, Silmere, Raghavan, Hovmand, Aarons, Bunger, Griffey and Hensley2011). A topic guide was adapted from a semistructured interview guide used in a previous study (Dambi et al., Reference Dambi, Norman, Doukani, Potgieter, Turner, Musesengwa, Verhey and Chibanda2022) to assess the feasibility, acceptability, appropriateness and fidelity of a previously adapted FBI in Zimbabwe.
CFIR implementation parameters
Data analysis
For the quantitative part of the study, we used descriptive statistics to summarize the sociodemographic data of the perinatal women. We used the Shapiro–Wilk test to assess data normality before conducting parametric tests (such as t-tests) or nonparametric tests (like the Mann–Whitney U test). We used the chi-squared test for categorical outcomes and the t-test for continuous outcomes. A significance level of p ≤ 0.05 was established for all tests at a 95% confidence interval. We used SPSS (Version 25.2; IBM Corp) for the data analysis. For the qualitative part of the study, the transcripts from the in-depth interviews of the MMSGs and the perinatal women were coded using deductive and inductive approaches. We used thematic content analysis (Silverman, Reference Silverman2015) to analyze the acceptability, appropriateness, feasibility and fidelity of data based on the CFIR. The first step involved “open coding,” where the research team analyzed transcripts to identify patterns and themes relevant to the research questions. In the second step, categories were formed to connect the data back to these questions, with each category receiving specific labels and definitions, supported by quotes from the transcripts, using both deductive and CFIR implementation parameters-driven codes. The final step was axial coding, which explored the relationships between these categories to draw data-supported conclusions. NVivo qualitative analysis software (QSR International, 2010) was used for data management and analysis. To mitigate bias and ensure objectivity, two independent coders analyzed 10% of the transcripts, comparing their coding for consistency. To enhance trustworthiness, data from individual MMSG and perinatal women’s interviews were compared to triangulate the findings (Silverman, Reference Silverman2015).
Ethics approval and consent to participate
This study was approved by Queen Margaret University Research Ethics Committee and the Sierra Leone Ethics and Scientific Review Committee, Ministry of Health and Sanitation. Ethical considerations included informed consent, ensuring participants understood their rights, the nature of the study and the potential risks and benefits. The control group received the intervention after a designated waiting period, allowing for a comparison of outcomes between the two groups.
Results
Participants’ characteristics
The sociodemographic characteristics of the perinatal women are illustrated in Table 3. The mean age of the perinatal women in the intervention and control groups are 23 (SD = 6) and 24 (SD = 5), respectively. No statistically significant differences were observed in the baseline sociodemographic characteristics between the intervention and control arms. In the intervention arm, 60% had no formal education, 45% were single/separated and 30% practice Christianity.
Sociodemographic characteristics of perinatal women (n = 39)
Outcomes
Future clinical trials feasibility
Figure 1 shows the participant flow chart: the number of participants screened, enrolled, allocated to interventions and control arms, lost to follow-up and analyzed. One hundred and seven participants were evaluated for the inclusion criteria and screened over 10 days for both arms of the study. Of these, 52 were screened at the intervention site, and 31 (60%) scored above the cut-off score. Among these, 27 (87%) were eligible based on the remaining inclusion criteria, and 93% consented, while the attrition rate (20%) was low. However, the attrition rate was much lower, as most of them were because the MMSGs could not locate them; only one participant was lost to follow-up.
Flow chart of the perinatal women in the pilot study.
Psychological distress outcomes
Figure 2 is a bar chart that compares the CPMD score that correspond to mental health outcomes of the two groups at T0, T1 and T2 of the intervention. Both the intervention and control groups were comparable at baseline but here was a consistent decrease in the CPMD score for the intervention compared to the control arm. The SLPPDS scores significantly dropped by 58.9% (17.1–8.4) in the intervention group, while the control group showed a 31.6% (18.0–12.3) decrease. There was a statistically significant difference between the two groups (F = 7.25; p < 0.05), with a moderate effect size (d = 0.40).
Mean SLPPDS score for the intervention and control group.
CFIR implementation outcomes
Below are the findings from the qualitative analysis, using the CFIR reference frame on the acceptability, appropriateness, feasibility and fidelity. The following describes the findings from the qualitative evaluation:
Acceptability
The perinatal women and the MMSGs alluded to the fact that the PST- FBI was an acceptable model for CPMD. The most salient aspects of the intervention were the ability to access the MMSGs, confidentiality, and having someone to talk to and brainstorm to profer solutions to their problems. The perinatal women were happy with the intervention, as posited by a new mother:
This is a good programme because we have never had this kind of programme in our community before, and it is not easy for someone to come to you, and some people need this kind of support. You will be sitting at home with your problem not knowing how to solve it. If a person comes to you, and you tell them about your problem, and both of you put your heads together and find a solution, that is good. I think before you give me money, this is better … this kind of help is more than money. (NM 5)
The perinatal women valued confidentiality and the fact that they had someone to listen to them and help them address their problems, as recounted by this pregnant woman:
Well, the programme you brought is fine because sometimes we think about bad things when we do not have someone to advise us. So, it is a good programme that you came up with. You have made us sit together and discuss ideas for ourselves. It is a good programme. So, we want to thank you for that, it is a good idea. [P1]
Regarding the col at sacul, the perinatal women appreciated knowing others were experiencing similar or worse problems than them. Another aspect they enjoyed was that they learned from other perinatal women how they managed their problems with support from their friends, family, and the wider community. This pregnant woman describes this:
When we are gathered, everyone has their explanation, you know that you are not alone, and you will gain different things from others. So, I think the group session works better for me, based on my experience from the col at sacul. [P10]
Feasibility
The perinatal women and MMSGs agreed that they could successfully use the culturally adapted PST-FBI to address problems that contribute to their social suffering. A new mother stated that the PST session was a two-way visit, rather than just perinatal women visiting the MMSGs, and provided the intervention with greater flexibility. This approach contributed to improved adherence, as she recounted:
The last time she came to meet me, she found me sitting here with my baby. I had forgotten to visit her because my baby’s food had run out. I was sitting here thinking because the father of my baby is living at a district in the East. While I was thinking, she visited me, and sat beside me, spoke nicely, and engaged me. [NM 2]
A MMSG also explained how easy it was for them to support pregnant women and new mothers and the way they were able to work through their shared interests:
Well, sometimes I visit them, and sometimes they come to meet me, but most of the time, I visit them. When you call them, they will tell you they are busy, “I am working,” “my child is this or that.” I will say to them, OK, I will come …. [ ] … like this other lady here, plenty of people were there, so when she sees me, she will wink her eyes to me and go inside and say, “aunty Fatmata has come.” So, her partner will excuse us, I will talk to her inside her house, and after talking with her, we will come outside. [MMSG 4]
Appropriateness
The MMSGs expressed that the PST-FBI was congruent with their role’s expectations as volunteers. They were happy that the PST-FBI offered them skills and a structured way of supporting perinatal women that they never had before: listening, nonjudgmental, dealing with a difficult client, and problem-solving skills. According to one of them, the MMSG claimed that they were able to form a therapeutic alliance with the perinatal women and support them throughout the four sessions of the intervention:
I felt good because, firstly, through this training, it gave us the confidence to go and talk to perinatal women in the community. Some homes nearly fell apart, but because we went and talk with them, with the help of God, they came back together. So, that in itself is a good thing … [ ]. After all, we told them that if they have this problem, it is not nice to lock themselves in their rooms. Sometimes, you “play music,” “watch movies,” or “dance,” which is good for their wellbeing. [MMSG 6]
According to this new mother, the problem-solving approach of the intervention addressed the issues that pregnant women and new mothers faced that contributed to their social suffering:
My partner was not close to me, and I was sick. It was difficult for me to eat, but now it is better. Sometimes, within the week, it is just two times, but before I was sick and pregnant, having food to eat was very difficult for me. So, since you came and engaged me about the problem, and I also put in the effort to find a way to solve it, I thank God for plenty of things now. God has solved them for me. [NM 3]
Fidelity
We evaluated MMSG adherence to protocol during the supportive supervision by reviewing their notes and discussing randomly selected cases. For each MMSG, we observed one of their sessions, noting the duration, adherence to activity order, joint activities, handout provision, next session scheduling and the relationship with the perinatal women. Feedback from participants was gathered to assess their engagement and the relevance of the content delivered. This comprehensive approach helped to ensure that the intervention maintained its integrity, while also providing insights into areas for improvement. A debrief with the MMSG followed each observed session. One MMSG described how she handled the PST-FBI with a particular perinatal woman:
We followed what you trained us. We used to advise people, but quite different from your approach. You came and taught us a new method, that they should talk to us, and we should listen. And after they finished, we work on the problem disturbing them, so I think this is better. The method is good. When someone is talking about their issue, that is not backbiting. You are the one who said it, and you suggested how we should go about it through the brainstorming process, I am here just to guide. [MMSG 8]
Discussion
This study used a pilot, randomized, waitlist control design to explore the feasibility, acceptability and preliminary effectiveness of the culturally adapted PST-FBI delivered by nonspecialists, MMSGs. Overall, the findings showed that the culturally adapted PST-FBI for CPMD is feasible, acceptable and demonstrated evidence of preliminary effectiveness.
This study demonstrates the feasibility of the PST-FBI intervention for perinatal women experiencing psychological distress in Sierra Leone. Over 10 days, 107 participants were screened, with 60% scoring above the cut-off for psychological distress. This rate is higher than a similar study conducted in Zimbabwe (Dambi et al., Reference Dambi, Norman, Doukani, Potgieter, Turner, Musesengwa, Verhey and Chibanda2022). The high recruitment rate may be due to the high burden of CPMD, which translates to what perinatal women may perceive as a problem (Kamvura et al., Reference Kamvura, Turner, Chiriseri, Dambi, Verhey and Chibanda2021). Among those, 87% met the remaining eligibility criteria, and a high consent rate of 93% was achieved, indicating strong community interest in the intervention (Patel et al., Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, De Silva, Bhat, Araya and King2010; Rahman, Reference Rahman2020). The attrition rate of 20% is relatively low, primarily due to MMSGs being unable to locate participants rather than participant disengagement, as only one individual was lost to follow-up. This suggests that the intervention is feasible for a randomized-controlled trial within the local context (Xu et al., Reference Xu, Samu and Chen2024), aligning with evidence that highlights the importance of community-based support in low-resource settings.
The psychological outcomes of the PST-FBI intervention, delivered by MMSGs to perinatal women in Sierra Leone, indicate significant improvements in mental health. The consistent decrease in CPMD scores for the intervention group illustrates the effectiveness of community-based support in addressing psychological distress. Such findings align with previous research emphasizing the crucial role of peer support and lay health worker interventions in LMICs (Chibanda et al., Reference Chibanda, Mesu, Kajawu, Cowan, Araya and Abas2011; Fernando et al., Reference Fernando, Brown, Datta, Chidhanguro, Tavengwa, Chandna, Munetsi, Dzapasi, Nyachowe, Mutasa, Chasekwa, Ntozini, Chibanda and Prendergast2021; Rahman et al., Reference Rahman, Surkan, Cayetano, Rwagatare and Dickson2013b). The substantial reduction in distress levels corroborates the notion that tailored, context-specific programs can effectively meet the mental health needs of vulnerable populations. Additionally, the slight decrease in symptoms in the control group could be explained by spontaneous improvement or regression to the mean (Fuhr et al., Reference Fuhr, Calvert, Ronsmans, Chandra, Sikander, De Silva and Patel2014), and the moderate effect size observed suggests that the intervention has the potential for broader application in similar settings. These results advocate for the continued integration of community-driven mental health strategies (Akkineni et al., Reference Akkineni, Rao and Ganjekar2023; Lasater et al., Reference Lasater, Murray, Keita, Souko, Surkan, Warren, Winch, Ba, Doumbia and Bass2021), which can significantly enhance well-being among perinatal women facing psychological challenges in resource-limited environments.
An important component of the PST-FBI intervention was the individual and then peer-led group session, known locally as the col at sacul, which was positively received by the perinatal women and lay health workers (MMSGs), who valued the safe space for dialog and problem-solving it provided (Chibanda et al., Reference Chibanda, Weiss, Verhey, Simms, Munjoma, Rusakaniko, Chingono, Munetsi, Bere, Manda, Abas and Araya2016). The positive reception of this group session highlights the potential of peer support to enhance the effectiveness of individual interventions, particularly in collectivist cultures where social support plays a critical role in coping with psychological distress (Beard et al., Reference Beard, Cottam and Painter2024). Peer-led interventions have been increasingly recognized for their ability to empower individuals, reduce stigma and promote sustainable mental health outcome (Sun et al., Reference Sun, Yin, Li, Liu and Sun2022). The emphasis on confidentiality and shared experiences among women reinforced its acceptability, supporting existing literature that underscores the role of social support in alleviating perinatal mental health challenges (Rahman et al., Reference Rahman, Fisher, Bower, Luchters, Tran, Yasamy, Saxena and Waheed2013a). Additionally, MMSGs and participants noted the intervention’s feasibility within community settings, due to its flexible structure, which allowed for adaptable engagement. This flexibility proved crucial in resource-limited environments, where strict frameworks can impede participation (Rahman et al., Reference Rahman, Fisher, Bower, Luchters, Tran, Yasamy, Saxena and Waheed2013a). The findings indicate that PST-FBI can be effectively integrated into the daily lives of perinatal women, aligning with previous research advocating for community-based interventions that resonate with local contexts (Patel et al., Reference Patel, Weiss, Chowdhary, Naik, Pednekar, Chatterjee, De Silva, Bhat, Araya and King2010; Prom et al., Reference Prom, Denduluri, Philpotts, Rondon, Borba, Gelaye and Byatt2022). This finding aligns with research on the benefits of group-based interventions for perinatal mental health (Chibanda et al., Reference Chibanda, Shetty, Tshimanga, Woelk, Stranix-Chibanda and Rusakaniko2014; McLeish et al., Reference McLeish, Ayers and McCourt2023), where peer support has been shown to enhance treatment engagement and long-term well-being.
Limitations and future directions
Several limitations of the current study should be noted. First, the small sample size limits the generalizability of the findings and the ability to draw definitive conclusions about the effectiveness of the intervention. Second, the study relied on self-reported measures of psychological distress, which may be subject to reporting and recall bias. Thirdly, the study was conducted in peri-urban settings, which may limit the generalizability of the findings to more rural or urban populations in Sierra Leone. The study also failed to assess secondary variables such as the functional capacity of these perinatal women, which would have served as a proxy with regards the severity of psychological distress on them. In addition, the study did not include a formal long-term follow-up, making it difficult to assess the sustainability of the intervention’s effects. Future studies should incorporate follow-up assessments to determine whether the reductions in psychological distress are maintained over time. This is particularly important in LMICs, where continued exposure to stressors such as poverty, gender-based violence and poor healthcare access may contribute to relapse. A notable strength of this study was the successful implementation of the intervention by lay counselors. Task shifting represents a low-tech, cost-effective model for delivering mental health care services.
Implications for scaling up the PST-FBI
The findings of this study have significant implications for the future of perinatal mental health care in Sierra Leone and other LMICs. The demonstrated feasibility, acceptability and effectiveness of the PST-FBI intervention suggest that it could be scaled up to reach a larger population of perinatal women. However, scaling up will require careful consideration of several factors, including the need for integration with existing health services and sustainable funding mechanisms.
The success of the MMSGs in delivering the intervention highlights the potential for community-based organizations to play a central role in scaling up mental health care in resource-limited settings. However, as noted by Patel et al. (Reference Patel, Boyce, Collins, Saxena and Horton2011), scaling up mental health interventions requires not only the engagement of local communities but also the commitment of governments and international organizations to provide the necessary resources and infrastructure.
Furthermore, the integration of mental health interventions into existing MCH services could help to ensure that mental health care is accessible to women during their critical perinatal period. The use of the CFIR in this study provided valuable insights into the factors that facilitated the successful implementation of the intervention, such as the fit between the intervention and local cultural norms, and the supportive role of MMSGs. These factors should be carefully considered in future efforts to scale up the intervention.
Conclusion
This study provides preliminary evidence that a culturally adapted, nonspecialist-delivered PST-FBI is feasible and effective in reducing psychological distress among perinatal women in Sierra Leone. The findings underscore the potential of task-shifting and community-based support systems to address the significant mental health treatment gap in LMICs. While further research is needed to confirm the long-term effectiveness of the intervention, and to explore its scalability, the current study represents an important step toward improving perinatal mental health in Sierra Leone and similar contexts.
Abbreviations
- CFIR
-
Consolidated Framework for Implementation Research
- CHC
-
Community Health Centre
- CHO
-
Community Health Officer
- CPMD
-
Common Perinatal Mental Health Disorder
- COMAHS
-
College of Medicine and Allied Health Sciences
- FBI
-
Friendship Bench Intervention
- LMIC
-
Low- and Middle-income countries
- MoHS
-
Ministry of Health and Sanitation
- MMSG
-
Mother to Mother Groups
- NEMS
-
National Emergency Medical Services
- QMU
-
Queen Margaret University
- PPD
-
Perinatal Psychological Distress
- PST
-
Problem Solving Therapy
- RCT
-
Randomized Control Trial
- SLPPDS
-
Sierra Leone Perinatal Psychological Distress Scale
- UNICEF
-
United Nations International Children’s Emergency Fund
- USL
-
University of Sierra Leone
Open peer review
To view the open peer review materials for this article, please visit http://doi.org/10.1017/gmh.2025.6.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/gmh.2025.6.
Data availability statement
The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.
Acknowledgments
We acknowledge the contribution of the research assistants, who demonstrated high levels of commitment and professionalism throughout the data collection process, which included: Ajaratu Kamara, Mamadu Jalloh, Sinava B. Lamin, Simeon S. Sesay and Malik Sulaiman Daewood. We extend our heartfelt gratitude to Ms. Aminata Shamit Koroma, Director of Nutrition at the MoHS, for her invaluable support and for assigning the MMSGs to our study. We also recognize the dedication and passion exhibited by the MMSGs in delivering the intervention.
Author contribution
AJB conceived of and designed the study, led on the data collection and analysis and the drafting of the manuscript. HRW and MS contributed to study design and the intellectual content of the manuscript. AA and RH supported study design, contributed to the data analysis and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.
Financial support
This research was funded by the National Institute for Health Research (NIHR) Global Health Research Programme 16/136/100. The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the UK Department of Health and Social Care.
Competing interest
The authors declare none.
Open access
Comments
Dear Editor,
I am pleased to submit our manuscript titled “Feasibility, Acceptability, and Effectiveness of a Culturally Adapted Non-Specialist Delivery Problem-Solving Therapy-Friendship Bench Intervention for Perinatal Psychological Distress in Sierra Leone” for consideration for publication in the Global Mental Health Journal.
Abstract:
[Background
There is a notable treatment gap for perinatal mental disorders in low—and middle-income countries. This study assessed the feasibility, acceptability, and effectiveness of a culturally adapted Problem-Solving Therapy—Friendship Bench Intervention (PST-FBI) delivered by non-specialists through Mother-to-Mother Support Groups (MMSGs) in Sierra Leone.
Method
MMSGs provided four weeks of home-based PST-FBI to peri-urban perinatal women screened for psychological distress. We evaluated psychological distress levels pre- and post-using the Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) and explored the feasibility and acceptability of the intervention through in-depth interviews.
Results
Twenty of twenty-five women completed all four PST-FBI sessions delivered through five separate MMSGs. For participants in the intervention arm there was a significant reduction pre- to post- in mean SLPPDS score - from 17.1(5.3) to 8.4(7.7) (corresponding to 58.9% decrease in symptoms). Scores for the control arm also reduced pre- to post-, but to a lesser degree: from 18.0(6.5) to 12.3(8.2) (representing a 31.6% decrease in reported symptoms). The estimated effect size of the intervention was d=0.40 (p<.05).
Conclusion
The MMSG-delivered PST-FBI, including the col at sacul group session, proved feasible, acceptable, and effective in enhancing the mental well-being of peri-urban perinatal women in Sierra Leone.]
This study addresses a critical gap in the treatment of perinatal mental health disorders in low- and middle-income countries, specifically focusing on the implementation of a culturally adapted Problem-Solving Therapy – Friendship Bench Intervention delivered by non-specialists through Mother-to-Mother Support Groups in Sierra Leone. The findings demonstrate the feasibility, acceptability, and effectiveness of the intervention in improving the mental well-being of peri-urban pregnant women and new mothers.
We believe that this research contributes valuable insights to the field of global mental health and has significant implications for future interventions targeting perinatal psychological distress in resource-limited settings.
We confirm that this manuscript has not been submitted for publication elsewhere and that all authors have approved the submission to the Global Mental Health Journal.
Thank you for considering our manuscript for publication. We look forward to the opportunity to share our findings with the readers of the Global Mental Health Journal.
Sincerely
Abdulai Jawo Bah