Context

This component of the study was conducted in Mpigi district as part of the formative phase for developing and piloting the intervention model. This is a peri-urban district, with the headquarters about 25 kilometres from the capital city. The district has socio-demographic and health indicators similar to those of most other districts in the country. For example, the population is predominantly semi-literate (80%); and mostly involved in subsistence farming. Fifty five (55%) of the population is aged below 18 years [31]. The district has one of the highest HIV prevalence rates in the country at 8.0%; above the national average of 5.3% [32].

The district has a well-established and facilitated health service network comprising of 41 health facilities. At the apex is a private-not-for-profit general hospital, which also serves as the referral centre. Below this are Health Centres IV, III, II and I. Health Centre I, which is the lowest level comprises of Village Health Teams (VHTs) or Community Health Workers who are individual health volunteers, often expert clients who may or may not be formally trained who link the community to the formal health service. HIV care is formally provided from Health Centre IIIs to hospital level, with varying range of patient loads. HIV specialized clinics are mostly ran at facilities at the level of Health Centre IV and the district general hospital. However, there is currently no mental health care in HIV care services provided at the public health facilities. This is partly attributed to shortage in staffing levels (both mental health professionals and primary care staff), low demand for formal mental health services as well as reluctance of the primary care providers to engage in mental health care [33, 34].

Study design

This was a qualitative exploratory study, based on workshops as the primary method for data collection. The design was considered ideal as there are no previous studies in Uganda that have used ToC as a tool to guide planning and delivery of integrated mental health and HIV services.

The ToC process

The ToC process hinges upon defining the necessary preconditions required to bring about a given long term outcome. The stakeholders identify the long-term goal (impact of the programme) and think in backward steps to identify the intermediate changes that would be required to cause the desired change, thereby creating a set of connected outcomes (pathway of change). The outcomes are operationalized by identifying indicators which will determine whether the outcome has been achieved. In addition, the evidence base or rationale of how one outcome leads to the next is articulated and the interventions/preconditions required to achieve this. The participants also articulate several assumptions about the change process, and decide a ceiling of accountability where the programme is no longer directly responsible for the outcomes achieved. The ultimate ToC should be plausible, do-able and testable and able to be represented graphically in a ToC map [35, 36].

Participants and their selection

Selection of the stakeholders to participate in the process was purposive. They were a diverse sample identified and invited by the District Health Officer and the HIV focal person in the district; which gave the process local legitimacy, while capturing the required expertise. They included district health service managers, members from the political leadership and administrative officers, health facility managers, primary health care service providers, district HIV focal person, staff from NGOs involved in health, mental health specialists, religious leaders, Community Health Workers and HIV care service users/expert clients. There are quite a number of people who hold positions in each of these groups/categories, and the privacy of the participants cannot be breached. The process sought to develop a model which would not be deemed cumbersome in terms of resource needs for the implementation. Furthermore, political buy-in was considered crucial for the success of the program. It was thus imperative that the district political leadership was involved in the process.

The ToC workshops

The workshops aimed at developing a ToC map, also viewed as a visual map reflecting the structure of the HIV+D intervention, and contextualizing the intervention. A total of three (3) ToC workshops were held with a range of stakeholders over a 4-month period (between November 2017 and February 2018). The workshops focused on 5 key areas that pertain to the intervention, including intervention activities, outcomes, indicators, assumptions, and impact. The workshops were facilitated by the first author (JS), assisted by JM as a co-facilitator and were all conducted in a spacious venue at the district headquarters. Cautious of the possible impact of power differential, the participants were split into two groups.

The first workshop had a total of 18participants, mostly at managerial level. These included representatives from the District Council, members from the District Health Management Team, representative from other sectors and NGOs involved in health as well as expert clients (PLWHA). The workshop was conducted a few weeks after the official launch of the project in the district. The workshop began with the Principal Investigator (EK) making a general presentation on depression among PLWHA, highlighting the need to integrate management of depression in HIV care. The Project Coordinator (RM) would then make a summarized presentation highlighting the project outline. The lead facilitator for the ToC then introduced the concept of ToC as ‘a system of ideas intended to explain how we think change will happen in the area we want to address, and how we intend to work to influence these changes’; further explaining the key elements of a ToC map. After setting the scene, a discussion followed, during which participants gave their views based on their expertise and experience. This began with participants identifying the intended impact of the HIV+D program. The brainstorming continued with participants working backwards towards identifying various key outcomes and other preconditions for the program, as described earlier under the ToC process. There was note-taking in order to record information from all stakeholders. In addition, the discussions were audio-recorded and later transcribed verbatim, to ensure that all relevant data is captured. The scope of the discussion considered 3 levels of health care at district level, including health care management level, health facility level and community level.

The second workshop had 20 participants including frontline health workers, religious leaders, community health workers and HIV service users/expert clients. A similar procedure (as for workshop 1) was followed. The research team then held internal meetings to synthesize and analyze the views generated from both ToC workshops. A draft ToC map was consequently developed as a major output of the process clearly specifying the causal pathways leading to the desired impact of the program. The map highlighted the activities/interventions to undertake, indicators, assumptions and the expected outcomes.

The third workshop brought together29 participants who had been involved in the first 2 workshops, and a technical officer from the HIV control program at the Ministry of Health headquarters, making a total of 30 participants. The research team presented findings from the previous workshops and the draft ToC map, which formed the basis for a further discussion and review of the draft ToC map until there was consensus towards refinement of the ToC map. Thus, the first 2 workshops were for brainstorming and generating ideas from different groups, while the third workshop was largely for review of the draft ToC map and consensus building.

All the workshops were conducted in the district headquarters council hall; each being a day-long workshop, with participation as summarized in Table 1 below.

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Table 1. Participants per ToC workshop.

https://doi.org/10.1371/journal.pone.0259425.t001

Data collection

The proceeding of each workshop was audio-recorded so as to capture all relevant contributions and suggestions from the participants. As the transcribing of recordings is itself an interpretive process, it was undertaken by the ToC workshop facilitator, assisted by another member of the research team.

Data analysis

After the transcription, conventional content analysis was done by the 2 workshop facilitators who have expertise in qualitative research and data analysis, thereby ensuring rigour. They subjectively interpreted the content of the transcripts through coding and identifying themes [37, 38]. The initial coding of the transcripts was undertaken by the first author, with the coding categories directly derived from the content of transcripts, without imposing any preconceived theoretical perspectives. The key components of the ToC (outcomes, indicators, assumptions and activities) were treated as the main categories that served as themes and sub-themes, to guide the coding process. The coded transcripts were shared with the first co-author for common interpretation, improvement and consensus. We focused on what the informants actually said and consequently elicited meaning and valid inferences under each category, to feed into the ToC causal pathway.

Ethical considerations

Ethical approval was obtained from the UVRI Research and Ethics Committee, the LSHTM Ethics Committee and the Uganda National Council for Science and Technology (ethical clearance number: HS645ES). All stakeholders who participated in the ToC process gave written informed consent to participate.

a) Impact

The stakeholders agreed on the overall impact of the intervention being improved mental wellbeing among HIV patients. This was based on the expectation that the interventions undertaken under the programme would circumstantially address any other probable co-occurring common mental disorders in addition to depression.

b) Outcomes

The participants mapped out several outcomes (both long term and short term) that would have to be realized and eventually lead to the above desired impact. The long term outcomes included: having depression managed alongside HIV care, reduced morbidity attributable to depression in HIV, reduction in HIV related stigma and better clinical outcomes for HIV patients. These would follow the intermediate and short-term outcomes such as allocation of more resources for depression management following increased political buy-in and support for the programme; reduced incidence and prevalence of depression in HIV patients once patients with HIV and depression receive appropriate treatment. This would be preceded by health workers handling HIV patients being able to detect and treat depression, appreciation of mental health issues in HIV care and having more psychiatric nurses involved in HIV care. Other short-term outcomes include increased help-seeking for depression among HIV patients and empowerment of persons living with HIV. These would be preceded by increased and demand for services.

They asserted that managing depression would promote the quality of life for persons living with HIV/AIDS and promote their mental wellbeing; and hence the need to routinely assess for depression among all PLWHA.

“…We want to promote wellbeing because what we have now is quality of life. So one of the things, it takes away their mental wellbeing… because when you manage depression you have managed anxiety as well because we are looking at the common mental disorders. We want to promote mental wellbeing” (Health facility manager)

Another participant added:

“…we are talking of assessment. We need the health workers to understand the signs and symptoms of depression so as to be able to identify those patients easily. Otherwise, they will keep missing. As you know, in our culture, there is no word like depression” (Health Educator)

c) Interventions

The participants identified several interventions/activities to be undertaken at the different levels so as to realize the outcomes.

At the health management level, there was need for sensitization of the district leadership and implementing partners on the need to integrate mental health care in HIV care especially to ensure support in terms of resource allocation and buy-in, building capacity for monitoring, supervision and follow up as well as strengthening the referral system.

At the health facility level where the bulk of work is expected, the activities to undertake include training of the PHC workers in mental health care, with particular emphasis on depression management; availing health facilities with screening tools for depression (PHQ-2 and PHQ-9); mandatory screening and assessment for depression at the triage desk, availing a start-up package of anti-depressants to support the program, building capacity of health workers to offer psychotherapy, involving psychiatric nurses in HIV care as well as regular monitoring and support supervision.

At the community level, activities include sensitization of expert clients and support groups of PLWHA, sensitizing the communities and emphasizing the management of depression during the health talks, training the community health workers to be able to screen for depression in the community as well as monitoring and follow up of the clients in the community.

d) Indicators

The participants further identified a number of indicators to measure both short-term and long term outcomes, and tell whether the intervention is on course. First, having the management of depression in HIV care emphasized in the district health plans was identified as an indicator to measure political buy-in and support for the programme as well as allocation of resources towards management of depression. An increase in disclosure and positive living would be an indicator that depression is managed alongside HIV, consequently leading to better clinical outcomes for patients with HIV. An increase in demand for anti-depressant medicines at the health facilities would signify an increase in the number of patients receiving appropriate treatment for depression; as would be reflected in the Health Management Information System (HMIS). Similarly, increase in the number of patients recovering from depression, as reflected in clinical audit reports would be an indicator of reduced morbidity attributable to depression among PLWHA. Furthermore, an increase in the number of patients receiving treatment and the number of referrals would signify improvement in the help-seeking and case detection for depression in PLWHA.

e) Assumptions

According to the participants, implementation of the activities to lead to the desired outcomes would be successful on the assumption that there is:

1. political buy-in and support towards the program
2. supportive policies and plans in place
3. an efficient Health Management Information System (HMIS), with the district Bio-statistician active and involved
4. effective monitoring and supervision by the District Health Management Team
5. the required medicines and logistical supplies are in place
6. competent health workers with a positive attitude
7. an efficient HIV care system

All these core elements were conceptualized and summarized in a causal pathway, to produce a Theory of Change map that conceptualizes the HIV+D program presented in Fig 1 below.

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Fig 1. The HIV+D ToC map.

https://doi.org/10.1371/journal.pone.0259425.g001

The stakeholders reported that because of poor mental health literacy in the community including among PLWHA, there was generally low recognition of depression as an illness that is treatable and hence poor help seeking behavior, which negatively impacted the prognosis of their HIV/AIDS illness. The PLWHA on the other hand expressed their reluctance to engage with Community Health Workers due to the latter’s weakness in maintaining confidentiality. These were believed to be potential threats to successful implementation of the program. They believed that persons with lived experience (HIV expert clients), were a better alternative as they tend to be more reliable and efficient in providing the much needed peer support. Their availability and involvement was thus considered an opportunity.

The stakeholders further reported that most PLWHA have numerous mental health problems, which often go undetected and unattended to, due to limited awareness and inadequate mental health services. The ToC process identified mentoring, monitoring and supervision of the health workers as crucial inputs for the intervention; and this was considered to be a direct oversight role of the district health managers and the psychiatric nurses.

They further argued that depression among PLWHA can be attributed to several factors including the fear of the disease itself, the associated stigma and several others related factors; mostly co-occuring with some other mental health problems. They thus suggested a need for capacity building in mental health care to enable the service providers understand the likely causes and intervene appropriately.

“…I don’t know whether it is a concern. But in your beginning, you talked about identifying the barriers and then eventually we come up with the strategies–you drew that picture am seeing you as someone who has stopped at the strategies. What about the “why?”, the why question. How are we answering it. Like we can ask ourselves what brings depression…||…we might think the depression is because of HIV, but there might be certain other factors that are contributing to it”(District Health Officer)

The health workers in particular emphasized the need for building their competence, citing the challenges in detection and management of depression.

“…you see, this depression in most cases is a feeling inside a person that you are not able to see. No patient will come and tell you that they are depressed. So, it requires some level of competence to be able to detect the ones that are depressed” (General Nurse)

Some of the participants expressed concern over inadequate staffing and resources at the health facilities, affecting the efficiency and service delivery.

If am a patient, I will want go where I can find drugs. So I want it to be a functional health … where one can find all the drugs, the health workers, the health providers and other things. But sometimes, this is not the case (Representative from other sector)

Another participant added:

The understaffing is serious. The triage is supposed to be done by a nurse; but at our place, it is us [expert clients] who do it. That is the reality (frontline health worker)

Furthermore, they believed the planned shift to community health worker-led antiretroviral therapy delivery (CLAD) would mean more responsibility and engagement of the community health workers and expert clients. In light of this, they recommended that it would be imperative for the program to build the capacity of community health workers and peer-support providers to improve case detection and provision of appropriate support.

The participants further noted that under a decentralized system of service delivery, districts have several implementing partners and resources to leverage and promote this integration, making it important to have political buy-in and support. They thus emphasized the need for health system strengthening to ensure support and sustainability, not only at policy level but also in practice.

“By and large we need a system that will support what we have said the removal of depression. How do we want that system to look like-that system that will support the removal of… we need a system that will support those processes. We need the medicines, infrastructure in place, tools and job aids—that complex thing” (District Health Officer)

Limitations

One major limitation was the number of workshops conducted. Although the total number of participants (38) may be deemed adequate and a representative sample of stakeholders involved in mental health and HIV care in the district, only 3 workshops were conducted in light of the busy schedule of most participants. However, there was adequate time for all stakeholders to actively participate, and enrich the discussions given that these were day-long workshops.

Despite the limitation, one important key lesson was the importance of separating participants by level of seniority and its impact on their active participation. Furthermore, the intervention revolves around use of the existing resources (in light of the limited resources for health) which should ideally facilitate the implementation.