Mpata Yathu Trial for Young Women in Zambia

Randomized Pilot Trial of Church-Based Problem-Solving Therapy for Adolescent Girls and Young Women With a History of Gender-Based Violence in Zambia

This randomized controlled trial evaluates Mpata Yathu ("Our Space"), a trauma-informed, church-based counseling intervention for adolescent girls and young women in Lusaka, Zambia who have experienced gender-based violence and are living with or at risk for HIV. The intervention is delivered by lay counselors who provide individual problem-solving therapy and referrals for mental health, HIV, and GBV-related services. Participants are assigned to receive counseling immediately or after a three-month waitlist period. The study examines mental health, HIV-related outcomes, and the feasibility, acceptability, and fidelity of delivering this community-based intervention.

Adolescent girls and young women in Zambia experience intersecting risks related to gender-based violence (GBV), mental health concerns, and HIV. Exposure to physical, sexual, emotional, or controlling violence is associated with psychological distress and may also create barriers to HIV prevention, treatment engagement, medication adherence, and clinic attendance. Limited availability of specialized mental health providers creates a need for culturally relevant, community-delivered approaches that can expand access to psychological support.

Mpata Yathu is a culturally adapted, lay counselor-delivered problem-solving therapy intervention based on the Friendship Bench model originally developed in Zimbabwe. The intervention was adapted through community-partnered processes for adolescent girls and young women in Lusaka with experiences of GBV and HIV-related vulnerability. Adaptations include trauma-informed and survivor-centered counseling practices, training on responding to GBV-related concerns, participant choice of lay counselor when feasible, and structured referral pathways for mental health, HIV, and GBV services. The intervention does not replace clinical or emergency care; participants requiring services beyond the scope of lay counseling are referred to appropriate providers.

The study uses a hybrid type 1 implementation-effectiveness randomized controlled design. This design assesses preliminary intervention effects while also examining implementation in real-world community settings. Participants are randomly assigned in a 1:1 ratio, using permuted blocks stratified by HIV status, to the intervention or waitlist control conditions. Allocation is generated and concealed through REDCap after completion of baseline procedures. Because counseling participation is apparent to participants and lay counselors, masking is not possible for intervention delivery; however, follow-up outcome assessors remain unaware of study assignment when feasible.

Intervention participants are offered up to six individual problem-solving therapy sessions during the first three months after enrollment. Waitlist control participants receive available usual care during this period and are offered the same intervention after the 3-month assessment. Each counseling session lasts approximately 45-60 minutes. Although sessions are intended to occur weekly, participants may complete sessions within a three-month period to accommodate school, work, caregiving, mobility, illness, and other barriers to participation. Counseling is delivered in private spaces at participating churches in the Matero and Chawama areas of Lusaka.

Lay counselors receive training in problem-solving therapy, trauma-informed and survivor-centered care, research ethics, confidentiality, GBV response procedures, referral protocols, and recognition of concerns requiring escalation. Ongoing supervision and fidelity monitoring support consistent delivery of the intervention. Session completion, counselor adherence to intervention procedures, participant experiences, and contextual barriers and facilitators are documented throughout implementation.

Assessments occur at baseline and at 3- and 6-month follow-up. The three-month assessment serves as the primary comparison point between immediate-intervention and waitlist-control groups. By six months, both groups have been offered Mpata Yathu; analyses at this time focus on change over time and intervention implementation. Quantitative and qualitative process data are used to assess feasibility, acceptability, fidelity, retention, referral uptake, and factors influencing delivery within church-based settings. Findings will inform intervention refinement and the design of a future fully powered trial evaluating community-based mental health and HIV-support approaches for young women affected by GBV.

Inclusion Criteria:

To be eligible for enrollment in the RCT, participants must meet the following criteria:

1. aged 15 to 24 years;

2. Speak Nyanja, Bemba, and/or English fluently;

3. Reside in the Matero or Chawama constituency area during the time of recruitment;

4. Report lifetime exposure to GBV, as assessed by the following sections of the WHO Multi-country Study on Women's Health and Domestic Violence Against Women instrument:

   • Section 7 (Physical Violence by Intimate Partner): Reports of being slapped, pushed, hit with a fist, kicked, dragged, choked, or threatened/attacked with a weapon by a husband or partner.
   • Section 8 (Sexual Violence by Intimate Partner): Reports of being physically forced to have sex, having sex out of fear, or being forced to engage in degrading sexual acts by a husband or partner.
   • Section 9 (Emotional Abuse by Intimate Partner): Reports of being insulted, belittled, intimidated, or threatened by a partner.
   • Section 10 (Physical Violence by Non-Partner): Lifetime experiences of being beaten or physically mistreated by someone other than a partner since age 15.
   • Section 11 (Sexual Violence by Non-Partner): Forced sex or sexual acts since age 15 by a non-partner, and childhood sexual abuse before age 15.

5. Exhibit moderate depressive symptoms indicated by a score of 10-14 on the 9-item Patient Health Questionnaire (PHQ-9), or common mental disorder (CMD) symptoms (e.g., depression, anxiety) as indicated by a score of 9 or higher on the 14-item Shona Symptom Questionnaire (SSQ-14); and

6. Be living with HIV or demonstrate HIV risk behaviors, as defined by validated items from the World AIDS Foundation survey,25 including unprotected sex, multiple sexual partners, coerced sex, or transactional sex.

Exclusion Criteria:

Women will be excluded if they:

1. Require emergency treatment for any crisis (mental, physical, emotional) at the time of screening
2. Report severe symptoms of depression (score > 14 on PHQ-9) or no to mild depression symptoms (PHQ-9 score <10), and/or severe anxiety symptoms using the Generalized Anxiety Disorder 7-item scale or GAD-7 (score >14 on GAD-7)
3. Have intellectual or cognitive disabilities that limit their ability to complete the screening tools, interact with a lay counselor and/or provide informed consent; and/or
4. Are considered in immediate danger (e.g., reoccurring physical violence) during time of the study.
5. Are currently receiving formal mental health counseling or psychotherapy (to avoid duplication of care and potential confounding effects).