The feasibility and acceptability of a task-shifted intervention for perinatal depression among women living with HIV in Malawi: a qualitative analysis

Abstract

Background Perinatal depression (PND) is prevalent and negatively impacts HIV care among women living with HIV (WLHIV), yet PND remains under-identified in Malawian WLHIV. Accordingly, this formative study explored perceptions of the feasibility and acceptability of an integrated, task-shifted approach to PND screening and treatment in maternity clinics. Methods We completed consecutive PND screenings of HIV+ women attending pre- or post-natal appointments at 5 clinics in Lilongwe district, Malawi. We conducted in-depth interviews with the first 4-5 women presenting with PND per site (n = 24 total) from July to August 2018. PND classification was based on a score ≥ 10 on the Edinburgh Postnatal Depression Scale (EPDS). We conducted 10 additional in-depth interviews with HIV and mental health providers at the 5 clinics. Results Most participants endorsed the feasibility of integrated PND screening, as they believed that PND had potential for significant morbidity. Among providers, identified barriers to screening were negative staff attitudes toward additional work, inadequate staffing numbers and time constraints. Suggested solutions to barriers were health worker training, supervision, and a brief screening tool. Patient-centered counselling strategies were favored over medication by WLHIV as the acceptable treatment of choice, with providers supporting the role of medication to be restricted to severe depression. Providers identified nurses as the most suitable health workers to deliver task-shifted interventions and emphasized further training as a requirement to ensure successful task shifting. Conclusion Improving PND in a simple, task-shifted intervention is essential for supporting mental health among women with PND and HIV. Our results suggest that an effective PND intervention for this population should include a brief, streamlined PND screening questionnaire and individualized counselling for those who have PND, with supplemental support groups and depression medication readily available. These study results support the development of a PND intervention to address the gap in treatment of PND and HIV among WLHIV in Malawi.

Acceptability of a Randomized Trial of Anti-depressant Medication or Interpersonal Therapy for Treatment of Perinatal Depression in Women with HIV

“…Some women in our study reported that group counseling might foster strong communication while others expressed concerns surrounding privacy, especially if the counselor were a member of her community. This is consistent with a qualitative study among women with perinatal depression in Malawi in which participants preferred individual to group therapy [24,25]. Future studies should nonetheless evaluate the acceptability of group IPT in Lusaka, as studies in Tanzania and Kenya have shown group therapy to be both feasible and acceptable among women with HIV and depression [26,27].…”

“…Studies on the acceptability of ADM treatment for depression among adults with HIV in SSA differ in their findings. Some report medication-based treatment is acceptable to patients, while others report challenges with medication-based therapy in low-resource settings, including limited knowledge of medication-based treatments for depression among patients and providers, challenges with reliably accessing medications, and a preference for psychosocial interventions [25,[30][31][32]. This study provided participants with medications, and we suspect the same barriers to access are present in Zambia.…”

Champion and audit and feedback strategy fidelity and their relationship to depression intervention fidelity: A mixed method study

“…Task-shifting is an implementation strategy focused on training non-specialists to deliver specialized services like prescribing antidepressant medication or providing psychosocial counseling ( Galvin and Byansi, 2020 ; Johns et al, 2018 ). In Malawi, task shifting efforts have proven feasible in integrating depression screening, psychosocial counseling, and anti-depressant medication prescription into routine HIV and perinatal care, but have been further hindered by lack of intervention fidelity and sustainability ( Kulisewa et al, 2022 ; Stockton et al, 2020 ; Udedi et al, 2018 ).…”

Estimating the effect of anticipated depression treatment-related stigma on depression remission among people with noncommunicable diseases and depressive symptoms in Malawi

“…(either due to material resources, transit access, or work/scheduling), and stressful life events (e.g., a dispute with a partner or family member) as key determinants to attending their care appointments [14][15][16]. Research in other social contexts has also demonstrated that suboptimal treatment engagement may reduce the effectiveness of depression treatment and increase time to depression remission [7].…”