Using Theory of Change to inform the design of the HIV+D intervention for integrating the management of depression in routine HIV care in Uganda

Abstract

There is growing recognition of the burden of depression in people living with HIV/AIDS (PLWHA), associated with negative behavioural and clinical outcomes. Unfortunately, most HIV care providers in sub-Saharan Africa do not routinely provide mental health services to address this problem. This article describes the process of developing a model for integrating the management of depression in HIV care in Uganda. Theory of Change (ToC) methodology was used to guide the process of developing the model. Three successive ToC workshops were held with a multi-disciplinary group of 38 stakeholders within Wakiso district, in the Central region of Uganda. The first 2 workshops were for generating practical ideas for a feasible and acceptable model of integrating the management of depression in HIV care at all levels of care within the district healthcare system; while the third and final workshop was for consensus building. Following meaningful brainstorming and discussions, the stakeholders suggested improved mental wellbeing among PLWHA as the ultimate outcome of the program. This would be preceded by short-term and intermediate outcomes including reduced morbidity among persons with HIV attributable to depression, allocation of more resources towards management of depression, increased help-seeking among depressed PLWHA and more health workers detecting and managing depression. These would be achieved following several interventions undertaken at all levels of care. The participants further identified some indicators of successful implementation such as emphasis of depression management in the district healthcare plans, increased demand for anti-depressants etc; as well as various assumptions underlying the intervention. All these were graphically aligned in a causal pathway, leading to a ToC map, contextualizing and summarizing the intervention model. The ToC was a valuable methodology that brought together stakeholders to identify key strategies for development of a comprehensible contextualized intervention model for managing depression within HIV care in Uganda; allowing greater stakeholder engagement and buy-in.

Economic burden of depressive disorders for people living with HIV in Uganda

“…The HIV+D trial was carried out in 40 public health facilities (PHFs) that provide HIV care in semi-urban and rural settings of central Uganda. The central region in Uganda has the second highest prevalence rate of HIV nationally, estimated at 7.6% (Ssebunnya et al 2021). The HIV+D study was a cluster-randomised trial (Kinyanda et al 2021) that examined effectiveness and cost-effectiveness of integrating the management of depression into routine HIV Care.…”

“…Despite access to free HIV care at point of delivery, PLWH spend close to 10% of their household income seeking health care and are at a risk of being pushed further into poverty because of catastrophic health expenditure (Chuma, Gilson, and Molyneux 2007;Kakaire et al 2016) The HIV+D trial was carried out in 40 public health facilities (PHFs) that provide HIV care in semi-urban and rural settings of central Uganda. The central region in Uganda has the second highest prevalence rate of HIV nationally, estimated at 7.6% (Ssebunnya et al 2021). The HIV+D study was a cluster-randomised trial (Kinyanda et al 2021) that examined effectiveness and cost-effectiveness of integrating the management of depression into routine HIV Care.…”

Protocol to develop and pilot a primary mental healthcare intervention model to address the medium- to long-term Ebola associated psychological Distress and psychosocial problems in Mubende District in central Uganda (the Ebola+D project)

“…We shall employ the Theory of Change (ToC) based approach by De Silva and colleagues (2014) (34)to adapt the HIV + D mental health intervention to the post-Ebola primary health care situation in Mubende district in Uganda. This participatory methodology has previously been used in the Ugandan setting by this research team (35) and will be used to achieve the following: i) describe the proposed causal pathway to impact; ii) increase the chances of success due to its sensitivity to the local context, stakeholder involvement and hence promotion of stakeholder buy-in; iii) help identify barriers and strategies needed to implement the HIV + D mental health intervention in post-Ebola Mubende district so as to ensure full integration and the achievement of the ultimate goal of recovery from Ebola associated mental health problems (depression, anxiety and Post-traumatic stress disorder); and iv) identify possible outcome indicators of the intervention.…”