Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 https://doi.org/10.1186/s13033-021-00486-8 International Journal of Mental Health Systems

RESEARCH Open Access Stakeholders’ perspectives on integrating the management of depression into routine HIV care in Uganda: qualitative fndings from a feasibility study Rwamahe Rutakumwa1* , Joshua Ssebunnya1,2, James Mugisha3, Richard Steven Mpango1, Christine Tusiime1,2, Leticia Kyohangirwe1, Geofrey Taasi4, Hafsa Sentongo5, Pontiano Kaleebu6, Vikram Patel7 and Eugene Kinyanda1,8

Abstract Background: HIV/AIDS continues to be a major global public health problem with Eastern and Southern Africa being the regions most afected. With increased access to efective antiretroviral therapy, HIV has become a chronic and manageable disease, bringing to the fore issues of quality of life including mental wellbeing. Despite this, the majority of HIV care providers in sub-Saharan Africa, including Uganda’s Ministry of Health, do not routinely provide mental health care including depression management. The purpose of this paper is to explore stakeholders’ perspec- tives on the feasibility and acceptability of integrating depression management into routine adult HIV care. The paper addresses a specifc objective of the formative phase of the HIV D study aimed at developing and evaluating a model for integrating depression management into routine HIV+ care in Uganda. Methods: This was a qualitative study. Data were collected through in-depth interviews with 11 patients at enroll- ment and follow-up in the pilot phase, and exit interviews with 11 adherent patients (those who completed their psychotherapy sessions) and six non-adherent patients (those missing at least two sessions) at the end of the pilot phase. Key informant interviews were held with four clinicians, fve supervisors and one mental health specialist, as were three focus group discussions with lay health workers. These were purposively sampled at four public health facilities in Mpigi District. Data were analysed thematically. Results: Patients highlighted the benefts of treating depression in the context of HIV care, including improved adherence to antiretroviral therapy, overcoming sleeplessness and suicidal ideation, and regaining a sense of self- efcacy. Although clinicians and other stakeholders reported benefts of treating depression, they cited challenges in managing depression with HIV care, which were organisational (increased workload) and patient related (extended waiting time and perceptions of preferential treatment). Stakeholders generally shared perspectives on how best to integrate, including recommendations for organisational level interventions–training, harmonisation in scheduling appointments and structural changes–and patient level interventions to enhance knowledge about depression.

*Correspondence: [email protected] 1 MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellowship, Mental Health Section, 50‑59 Nakiwogo Street, Entebbe, Uganda Full list of author information is available at the end of the article

© The Author(s) 2021. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creat​ iveco​ ​ mmons.org/​ licen​ ses/​ by/4.​ 0/​ . The Creative Commons Public Domain Dedication waiver (http://creat​ iveco​ mmons.​ org/​ publi​ cdoma​ in/​ ​ zero/1.0/​ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 2 of 14

Conclusions: Integrating depression management into routine HIV care in Uganda is acceptable among key stake- holders, but the technical and operational feasibility of integration would require changes both at the organisational and patient levels. Keywords: Depression, HIV, ART​, Mental health, Uganda

Background facilities [8, 16, 17]. Indeed, global predictions indicate HIV/AIDS continues to be a major global public health that both HIV/AIDS and depression will be the frst problem, having claimed over 33 million lives so far, two leading causes of disability globally by 2030 [18, 19]. and with an estimated 38 million people living with the Despite this, the majority of HIV care providers in sub- disease globally [1]. Te Eastern and Southern Africa Saharan Africa do not routinely provide mental health regions are the regions most afected by HIV, being home services including depression management [12, 20]. to more than a half (54%) of the total number of people In a recent meta-analysis, a 31 percent pooled depres- living with HIV in the world and with a growing number sion prevalence was found among PLWHA in Uganda, of new infections [1]. almost 10 times higher than the estimated prevalence in With increased access to efective anti-retroviral ther- the general population [21]. With an estimated 1.4 mil- apy (ART), HIV is gradually becoming a chronic and lion people living with HIV/AIDS in Uganda, this poses manageable disease with prolonged survival bringing a major challenge in HIV care despite the success in the issues of quality of life including mental wellbeing into scale up of ART and consequently increasing mortal- the forefront [2–4]. Indeed, HIV/AIDS has been asso- ity [8, 22]. In response to this absence of mental health ciated with a number of mental health problems that care in HIV programs, the Uganda National HIV and include depression, anxiety disorder, alcohol use disorder, AIDS Strategic Plan (2015–2020) has called for the inte- suicidality and neurocognitive disorders [5, 6]. In previ- gration of mental health and other chronic conditions in ous studies undertaken in the study area by this research HIV care so as to further improve the quality of care and group, rates of depression among HIV patients of 8 per- treatment [22]. To operationalise this policy recommen- cent in urban areas [5, 7], and 19.5 percent in rural areas dation, the Ministry of Health released guidelines for the [7] were observed. In both these studies the rates were treatment of HIV calling for the assessment and manage- higher in females than in males, at 15.6 percent versus ment of depression as an integral part of HIV care pro- 8.2 percent [7], and at 9.6 percent versus 4.1 percent [5]. grams [23]. Depression in HIV/AIDS not only leads to severe psy- Although the need for integrating HIV and men- chological distress, it has been associated with a number tal health services is indisputable, challenges exist in of negative clinical and behavioural outcomes [8]. implementing a service integration model that is efec- Despite the importance of mental health problems, tive against mental disorders and is cost-efective to the particularly depression, the majority of HIV care services health system [24]. Such a model should also be accept- in sub-Saharan Africa lack mental health care including able and feasible for improving both mental health and services for treating depression [9]. Depression among HIV treatment outcomes. It is thus imperative that the people living with HIV and AIDS (PLWHA) continues model is informed by the perceptions and experiences of to be a threat to the success of ART, hindering adherence relevant stakeholders. Tere is limited data on the inte- and subsequently negatively afecting clinical outcomes gration of depression management in HIV/AIDS in sub- [10, 11]. Tere is growing evidence of the high prevalence Saharan Africa. To date we are aware of only two studies of depression and its damaging efects among PLWHA, that have been undertaken, the frst being the INDEPTH- and that this is partly attributable to absence of depres- Uganda Trial that was implemented in Uganda and eval- sion treatment in HIV care programs, severe shortage uated two task-shifting approaches to depression care–a of mental health professionals and understafng of the protocolised model versus a model that relies on the clin- HIV clinics [5, 9, 12]. Indeed, in sub-Saharan Africa up to ical acumen of trained providers to provide depression 30 percent of depressive disorders have been associated care [9]. Te second study was the COBALT Trial, with HIV/AIDS [8]. Depression among PLWHA not only which was undertaken in South Africa, and evaluated a afects quality of life [3], but has been associated with a nurse led depression integration model in HIV care [25]. number of other negative behavioural and clinical out- While the COBALT trial has not published its results, the comes such as more rapid HIV disease progression and INDEPTH-Uganda trial found that protocolised delivery mortality [13–15], poor adherence to HIV treatment, of therapy was superior to merely providing treatment risky sexual behaviour and increased utilization of health guidelines. Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 3 of 14

In support of the Ministry of Health policy recom- were drawn in order to verify what aspects of integration mendation, the Mental Health Section of the Medi- were considered acceptable/unacceptable. Second, inte- cal Research Council/Uganda Virus Research Institute gration within realist frameworks is targeted at specifc & London School of Hygiene and Tropical Medicine programmes/services (in our case, integrating the man- Uganda Research Unit in partnership with the STD/ agement of depression into routine HIV care). AIDS Control Program of the Ministry of Health is Accordingly, our concept of integration for the purpose implementing a 5-year study named HIV + D Trial. Te of this paper is the one that engenders establishment of HIV + D Trial aims to develop and evaluate at trial a multi-purpose health service delivery points in one loca- model for integrating the management of depression into tion, providing diferent clinical and related services to routine HIV care in Uganda [26]. Tis proposed HIV + D a catchment population [29]–in this case, HIV patients Trial will evaluate the efectiveness and cost-efectiveness who may need depression-related care in addition to of a stepped care depression integration model that will their regular HIV-related services. Such integration be delivered by the HIV care team at Public Health Care therefore is essentially aimed at addressing disjointedness Facilities (PHCFs) in partnership with lay health work- and promoting coordinated care in the provision of ser- ers who will be derived from either members of the vil- vices so that the user can easily navigate the varied ser- lage health team (VHT; the frst level of the Ugandan vices that they need on a single trip to the facility [29]. health care system) or lay health workers (expert clients We also fnd Benzer and colleagues’ [30] theoretical living with HIV). Te intervention will be coordinated perspectives on factors infuencing success of integrated by the existing HIV counsellors (general nurses who care pertinent to our purpose. In their grounded theory have received training in HIV counselling, working at on integration of mental health services into primary PHCFs), and will be supported by mental health profes- care the authors identify, among others, organizational sionals (psychiatric clinical ofcers or psychiatric nurses) factors (including resources, training and work design), based at Health Centre IVs (health sub-districts serving provider experiences (such as time pressures arising from as referral centres for lower health facilities), district and redistribution of workloads) and patient factors (concep- regional referral hospitals. Tis paper is based on data tualized as the surrounding environment) as key in shap- from the formative phase of the HIV + D intervention ing success of integration. that has already been implemented, whose principal aim In this paper we will draw on these theoretical perspec- was to develop an intervention model for the HIV + D tives to interpret and discuss our fndings. trial. In this paper, we explore stakeholders’ perspec- tives on the feasibility and acceptability of integrating the management of depression into routine adult HIV care in Methods Uganda. Design Tis was a qualitative study, part of the broader forma- Theoretical framework tive phase of the HIV + D intervention whose general Our choice of theoretical model of integrated care objective was to develop and evaluate a model for the derives from what has been referred to as realist mod- integration of depression management into routine HIV els. Although we did not identify previous similar studies care in Uganda. Te formative phase was guided by three that have used the realist model, we consider the model specifc objectives: i) to adapt the MANAS intervention– suitable for guiding the research. Realist models generally a stepped-care collaborative model for the integration highlight the signifcance of context in developing inte- of mental health care into primary health care that was grated care programmes that achieve desired outcomes successfully evaluated in India–to the Ugandan HIV care [27]. With a grounding in empirical evidence these mod- context; ii) to adapt the Healthy Activity Program (HAP) els seek to lay out realistic pathways to successful integra- [31], a form of Behavioural Activation Terapy. Te HAP tion by, for example, identifying the contextual variables is a brief psychological treatment for depression that was (such as strong leadership and organisational culture) successfully evaluated in India–to the Ugandan HIV care that would be key for successful integration in a specifc context; and iii) to evaluate the acceptability and feasi- programme area (for instance institution of multidiscipli- bility of an intervention that will integrate the manage- nary teams) [28]. ment of depression into routine HIV care in Uganda (the Two main considerations infuenced this choice. First, “HIV + D” intervention). By exploring stakeholders’ per- realist models provide for contextual specifcity. Tis ena- spectives on the feasibility and acceptability of integrat- bled us to draw on our observations during the forma- ing the management of depression into routine adult HIV tive study (on which this paper is based) undertaken at care in Uganda, this paper directly addresses Specifc four public health facilities, from which practical lessons Objective III of this formative phase. Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 4 of 14

The HIV D intervention and lay health workers (expert clients who live with HIV + and support other PLWHA). At the lowest level (HCI) Te HIV + D intervention was a stepped care collabora- tive model that was initially conceived to be delivered within each village, volunteers from within the com- in three steps, and uniformly across the three levels of munity are nominated by community members to form health care (III, IV and district hospital) where the inter- Village Health Teams (VHTs) entrusted with taking care vention was implemented. At all these levels the focal of health matters of villages where they live. Tere is no point was the HIV clinic. Te intervention is summarised built structure or qualifed health staf at this level. in Fig. 1 below. It was important to get a perspective from each of these levels of care for two reasons. First, these diferent levels Study setting represent the range of HIV care services in the country. Tis formative study was undertaken at four public Second, the perspectives from the diferent levels were to health care facilities (PHCFs) in Mpigi District in central inform the proposed HIV + D trial that was to be under- Uganda, a district that has had a long term relationship taken in 40 PHCFs represented by these levels of care. with MRC/UVRI and LSHTM Uganda Research Unit. Te four selected PHCFs represented three levels of the Study participants Ugandan health care system: Butoolo and Buwama, with Multiple stakeholders including mental health specialists, level three health centres (HCIII); Mpigi, with level four healthcare workers (clinicians), and service users (includ- health centres; and Nkozi, with a hospital level health ing PLWHA) were purposively sampled for inclusion in facility. Mpigi district is a semi-urban, densely populated development of the HIV + D intervention. Tese were district with both urban and rural populations. Te dis- involved at the diferent levels (HCIII, IV and the district trict comprises 19 PHCFs which ofer varying levels of hospital) of the health care system where the study was care, graded as HCI, II, III, IV and a hospital, with the undertaken. For the depressed PLWHA, eligibility for latter three HC levels (where the intervention was deliv- inclusion in the study was (i) an HIV positive status with ered) ofering the same services. Te HCIV (Health sub- evidence of a certifcate, (ii) registration with an HIV district) serves as the referral point for the lower HCs. clinic in Mpigi district, (iii) being 18 years and above, Te health facilities run HIV clinics weekly. Tese clin- (iv) ability to communicate in either English or Luganda ics are stafed with general health workers, counsellors (the local language) and (v) a score on the Patient Health

Assessment of clients’ depression scores. Those with scores of ≥10 on Patient Health Questionnaire-9 (PHQ-9)to be Step I given psychoeducation by lay health workersor referred to mental health specialist if with scores of ≥20

Week 4 Week 4 If PHQ-9 score ≥ 5, lay health workers If PHQ-9 score ≥ 5, HIV clinicians at the 3 HC levels to start Behavioural at the 3 HC levels to start Step II or Activation/psychotherapy for clients antidepressants for clients who opt who opt this, whorich would be this, which would be delivered daily delivered in 6 sessions over 12 weeks for 6 months

A client who remains symptomatic at the end of treatment (offered at Step II) or presents with scores of ≥20 at Step 1 is referred to a mental health Step III specialist (a psychiatric clinical officer or psychiatric nurse). If the specialist not available on site, client is referred to nearest PHCF where such specialist is available Fig. 1 The stepped care (HIV D) intervention + Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 5 of 14

Questionnaire-9 (PHQ-9) [32] of 10 and above. For the antidepressants. Tese exit interview participants were a other stakeholders, those eligible for inclusion were subset of PLWHA attending ART clinic but who had not the ones participating in the delivery of the HIV + D been interviewed. More information on data collection intervention. processes and topics covered is highlighted on Tables 1 In pursuit of Specifc Objective III of the formative and 2 below. phase (to evaluate the acceptability and feasibility of an All interviews and focus group discussions were con- intervention to integrate the management of depres- ducted/moderated by research assistants who were psy- sion into routine HIV care in Uganda) which we directly chiatric nurses, and were audio taped and transcribed address in this paper, data were collected from three cat- verbatim. Interviews and focus group discussions with egories of participants: (i) the Healthy Activity Program/ patients and lay health workers were conducted/moder- Behavioural Activation (BA) core team that delivered ated in the local language (Luganda). Tese were then BA psychotherapy–these were the lay health workers transcribed in Luganda and translated to English by the who were also living with HIV and supervised by an HIV interviewers/moderators who conducted the respective counsellor or nurse; this core team was supported by interview/focus group discussion. Interviews with clini- mental health specialists, (ii) clinicians who delivered cians and supervisors were conducted and transcribed antidepressants and (iii) study participants (depressed in English. Te interviews on overage lasted 45 to 60 min PLWHA) who were attending ART clinic (at the four while focus group discussions lasted one to two hours. selected public health care facilities) with moderate/ severe symptoms of depression (those scoring 10–19 on Data analysis the Patient Health Questionnaire-9 [PHQ-9], which was Two experienced qualitative researchers conducted validated in Uganda) and had been purposively selected the data analysis at diferent time periods. Te frst to participate in the HIV + D intervention. Information researcher conducted a data-driven analysis aimed at on sample sizes for the diferent categories of partici- an initial in-depth exploration of the data. Building on pants is summarised on Table 1 below. the output from this analysis, the second researcher conducted an analysis driven by the specifc research Data collection procedures objective related to the feasibility and acceptability of Using semi-structured interview topic guides, in-depth integrating the management of depression into rou- interviews were conducted with PLWHA, key informant tine HIV care. Te outputs of the analysis from the two interviews were conducted with clinicians, supervisors researchers were reviewed by the study team and found and a mental health specialist, and focus group discus- to be generally consistent and accurate. sions were held with lay health workers (expert clients). Te data were analysed using thematic analysis tech- Additionally, exit interviews were conducted with adher- niques, which involve the identifcation, analysis, organ- ent and non-adherent HIV patients–it is worth noting isation, description, and reporting of themes found that we registered non-adherence among the PLWHA within a data set [33]. Te data were coded with the help receiving psychotherapy and none among those on of a thematic framework initially developed from the

Table 1 Summary of participant recruitment and data collection exercises Participants Number enrolled Source of data Baseline Midline Endline Exit (month (3rd (6th interview 0) month) month) (6th month)

HIV patients (PLWHA) 131 (100 females; 31 males) Serial in-depth interviews with 6 HIV 11 11 8 patients on psychotherapy and 5 on antidepressants Exit in-depth interviews with 11 adherent 17 (those who completed all the psycho- therapy [n 9] and antidepressant [n-2] sessions) and= 6 non-adherent (those who missed 2 sessions) HIV patients. These had not≥ been interviewed Lay health workers 8 (5 females; 3 males) Serial focus group discussions (FGDs) 1 FGD 1 FGD 1 FGD Clinicians 4 males Serial key informant interviews 4 4 4 Supervisors 4 (3 males; 1 female Serial key informant interviews 4 3 3 Mental health specialists 4 Serial key informant interviews 0 0 1 Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 6 of 14

Table 2 Topics covered during interviews/focus group discussions with participants Participant category Topics covered during interview/focus group discussion

PLWHA At baseline: depression awareness, depression treatment experiences and feasibility of integration At midline: experiences with those delivering the treatment, challenges during treat- ment and recommendations for change At endline: changes in health since the last therapy session, challenges encountered, what worked/did not work well and recommendations for change Adherent and non-adherent HIV patients (a subset of PLWHA Experiences and reasons for adherence/non-adherence who had not been interviewed) participating in exit inter- views Lay health workers At baseline: perspectives on depression and psychotherapy, the process of delivery of psychotherapy, and feasibility of integration At midline: experiences and challenges of delivering psychotherapy and recommen- dations for improving the treatment, ease of applying decision support algorithm At endline: experiences of managing depression and with patients, challenges of man- aging depression and perspectives on integration, ease of applying decision support algorithm Clinicians and supervisors At baseline: depression prevalence, patients’ care-seeking behaviour, experiences with depression patients, perspectives on antidepressants and its delivery, and integration At midline: experiences and challenges of delivering antidepressants, ease of applying decision support algorithm and recommendations for improvement in treatment delivery At endline: experiences of depression management, barriers of treatment delivery and recommendations, ease of applying decision support algorithm and perspectives on challenges and opportunities of integration Mental health specialists Experiences of depression management, barriers of treatment delivery and recommen- dations, and perspectives on challenges and opportunities of integration

emerging themes and refned based on concepts bor- rowed from our theoretical framework. Using MS Excel, the key themes and sub-themes in the thematic frame- work were classifed on a matrix, which was then used to capture relevant pieces of data that illustrated the themes.

Results In the fndings below we present perspectives of the cross section of stakeholders on the acceptability and feasibility of integrating the management of depression into routine HIV care in Uganda. It is worth noting that stakeholders’ perspectives on feasibility related to only two aspects: the technical aspect, in which we sought to assess whether Fig. 2 Conceptual fgure highlighting the themes emerging from the the organisation has the necessary technical resources, data and their relationships including expertise, for successful implementation of the integrated model; and the operational aspect by which we examined how integration fts within the existing envi- Benefts of treating depression within the context of HIV ronment, with a focus on suitability of the public health care care facilities’ physical infrastructure for implementing the integrated model. Also noteworthy is that while there Irrespective of choice of treatment, participants gener- was no noticeable variance in perspectives among the ally had a positive view about the impact of depression diferent stakeholder categories, concurrence was most treatment within the context of HIV care. Tis view was evident among patients and clinicians who were the most mainly expressed by PLWHA but was notably also ech- outspoken with regard to their positive attitudes towards oed by other stakeholders including supervisors and lay acceptability and feasibility of integration (Fig. 2). health workers. It is against this backdrop that PLWHA Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 7 of 14

persistently called for the harmonisation of HIV and Tis hope was usually accompanied by a renewed dis- depression services as expressed in the following two position on the part of participants to adhere to their excerpts: ART regimen. Refecting on her own depression treat- ment experience, the same participant credited the treat- “I think it would be good [to] see how best you can ment for improved ART adherence, and ventured further integrate depression treatment into our routine HIV to strongly recommend the treatment to anyone living care. I am sure that after this study, these medical with HIV as a way to avoid poor adherence to ART treat- forms will eventually be put into our ART fles so ment which may lead to the clinician putting you on sec- that those health workers will be able to know that ond line ART. we are on treatment for depression. So the treat- ments can be harmonized such that we are given the “Depression treatment [counselling] is very helpful same appointment dates for antidepressants and among people living with HIV/AIDS. If you have not ART” (Nkozi, Antidepressants, Patient 1, Midline been taking your medication well it helps you to take Interview). it and you end up feeling well…. So I would strongly recommend that all people living with HIV/AIDS “I suggest that at every ART facility there should be should receive this [depression] treatment. If that is enough health workers trained to handle depression done we shall have few people on second line treat- … because it would be fair if every person coming ment regimen which is hard to get… yet the number for their ART reflls can be assessed and treated for of people on second line is increasing” (Buwama, depression. It will also help patients who are failing Psychotherapy 1, Endline Interview). to suppress because of depression” (Buwama, Psy- On the other hand, one of the indirect pathways chotherapy 1, Endline Interview). through which depression treatment would lead to We viewed these fndings as a strong indicator of the improved ART adherence, according to some patients, acceptability of integrating depression treatment within was by easing disclosure in discordant relationships. HIV care. Non-disclosure was considered to be a signifcant bar- We also note that the positive feedback from stake- rier in ART adherence in a sense that treatment doses holders as earlier noted was shared mostly at endline were sometimes administered late or even skipped if and often at midline, although there were a few cases in the environment was not discreet enough to facilitate which patients shared the feedback at the baseline inter- administration of the dose without the partner’s aware- view (immediately preceding the start of psychotherapy ness. For patients in this situation therefore, disclosure or antidepressant medication). In these cases, the patient was an imperative for enhancing adherence and their had registered early benefts from the psychoeducation own health. Yet for one of these patients, for example, the (as described earlier in the methods), an initial single act of disclosing was complicated further by earlier indi- session depression therapy that was ofered to all partici- cations from the partner that she would abandon him if pating patients as a frst step towards the intervention. they were found to be discordant and she is negative. Tis Patients consistently highlighted a number of physical participant credited the psychotherapy associated with and mental health benefts of depression treatment. depression treatment for having equipped him with the skills and courage to disclose.

Improving ART adherence “For my case the cause of depression was that I was Perhaps the most pertinent beneft of depression treat- in a discordant relationship in which I was HIV pos- ment was that it potentially enhanced HIV treatment itive yet my wife was negative [and she did not know outcomes by improving ART adherence. With regard to my status]. So that kept me worried about how I improving adherence, our analysis reveals both direct would break such disturbing news to her…. And also and indirect pathways through which this occurred. basing on the statements that she used to make that One of the direct pathways was that depression treat- “in case we test… and I am found negative when he ment helped the despondent patient regain hope in their is positive, I will just divorce him”…. It is from this wellbeing. study that I acquired skills to disclose to her. Eventu- ally I informed her about my status…. (Nkozi, Psy- “[As a result of my treatment for depression] I have chotherapy 2, Nkozi, Baseline Interview). also been able to regain my hope. I no longer fall sick very often like how it used to be earlier on before Besides improving ART adherence, participants being enrolled into this study”(Buwama, Psychother- described other experiences in which psychotherapy apy 1, Endline Interview). enhanced HIV treatment outcomes. Tis was particularly Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 8 of 14

so in instances where a patient was adhering to the ART depression treatment] is that I used to have bad regimen and still would not register viral suppression, but thoughts of taking many ART tablets [attempting did show viral suppression after psychotherapy, in which suicide] so that I die since I was living alone. For- case psychotherapy was considered as having enabled the tunately, I no longer have them, and feeling lonely body to respond better to ARVs. has reduced” (Mpigi, Antidepressants, Midline Interview). “Tey used to tell me that I was taking my ARVs badly; they even thought I was taking alcohol yet “I used to lack sleep but right now I sleep well, I I was not. But after receiving psychotherapy, I was used to lack appetite but now I have a lot of appe- amazed when the clinicians told me that I was tak- tite…. Te tablets also helped me to overcome the ing my medication well. Tat amazed me a lot many thoughts that I used to have such as suicidal because for seven years I had never suppressed, ideations and thoughts on self-isolation” (Nkozi, not until now. However, I realized that [before psy- Antidepressants, Patient 1, Endline Interview). chotherapy] I used to take my ARVs but would still worry a lot and even keep thinking about sui- cide – so that made me not to suppress the virus” (Buwama, Adherent 2, Exit Interview). Regaining a sense of self‑efcacy Te other notable beneft of depression treatment was that treatment recipients regained a sense of “self-ef- Overcoming sleeplessness and suicidal ideation cacy,” that is, a belief in one’s own ability to infuence Another reported beneft of depression treatment was events that afect their lives [34]. Tis was perhaps that it helped overcome sleeplessness. Tis apparently not surprising given the generally positive outlook was the most frequently cited beneft. With the excep- that majority of participants projected in their feed- tion of one who experienced acute side efects from back on the treatment. Participants observed that the antidepressants and had to discontinue the therapy, par- treatment enabled them to regain control over their ticipants from both the antidepressant and the psycho- lives by empowering them with knowledge about a therapy groups were unanimous in their view that the health condition (depression) they sufered from but treatment had markedly improved their sleep and general did not understand, and by instilling in them a belief in wellbeing. their own agency in the eforts to resolve their health problems. “Before I was initiated on that [depression] treat- ment, I would go to bed and keep awake –with no “I used to think a lot and I would end up falling sick sleep and I would have intrusive thoughts of why I do because of those many thoughts but nowadays that not die and leave this world. I used not to have sleep no longer happens, because I have applied some of at all. I would only sleep when it was approaching the skills that I learnt during counselling [psycho- daytime, but when I started the treatment, I can therapy] such as, letting things go, avoiding over- now sleep soundly and the bad thoughts I used to thinking, breathing in and out in order to relax…. have are no more” (Butoolo, Antidepressants, Mid- However, I also believe that if I happen to experience line Interview). any signs and symptoms I will be able to overcome them before they cause much harm to me. I now also Tis view was echoed by supervisors, as one noted: understand depression illness in detail, I have learnt “Yeah because those on treatment… were not sleep- how to overcome it” (Buwama, Psychotherapy 1, ing at frst but after putting them on treatment they Endline Interview). were now sleeping well. Some were not eating after Tis sentiment was also highlighted during a group dis- treatment they started eating well and doing their cussion with lay health workers, with one of the partici- work as usual” (Buwama Supervisor, Endline Inter- pants noting: view). “Counselling [psychotherapy] has helped patients a Perhaps as a knock-on efect of being able to sleep lot because… those who are being discharged act as normally and to avoid too many thoughts, several par- ambassadors after they have learnt how to overcome ticipants also talked about having overcome suicidal their problems. Psychotherapy helps to empower ideation. someone with skills that help them to encounter any “Te [antidepressant] tablets are good…. I never future challenges/problems” (Focus Group Discus- used to sleep but now I can. Te second beneft [of sion with Lay Health Workers, Midline). Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 9 of 14

Challenges arising from managing depression with HIV age depression it will be like a short cut for you care to get a suppressed patient. So as for me, I do not While the feedback from those receiving treatment for see it as a work load, we just need to appreciate depression was overwhelmingly positive, our analysis it and when we do it well we shall be saving the of data revealed potential barriers to the integration of time which we would have spent on the non-sup- depression management into routine HIV care. Draw- pressed…” (Butoolo Clinician, Midline Interview). ing on their own experiences from the study, clinicians Another clinician highlighted the magnitude of the from the four study sites were unanimous in their view increased workload but implied that this was acceptable that the integration presented some challenges that since the workload was expected to reduce with time. impacted both patients and clinicians. Tese chal- lenges were mainly organisational factors, particularly “Tat is a challenge because sometimes you have increased workload for clinicians, and patient factors over 100 clients in a day – you have to get time and including extended waiting time at the health facility also attend to others [and] counselling [psychother- and patients’ perception of preferential treatment. apy] needs time …. You know it is quite challenging… like you have just started to come in, you feel that you have added some extra work. But as time goes Organisational factors on, you get used actually, you go on adjusting slowly Clinicians cited a key organizational factor in the form by slowly in fact at the end of the day you fnd that of increased workload and associated time pressures you have not added any extra work. So the screening as one of the key challenges to integrating depression process becomes simple and easier, then the counsel- management into routine HIV care. Tey acknowl- ling process [psychotherapy] is also decreasing and edged that the addition of depression care onto their you get used to it” (Mpigi Clinician, Endline Inter- already stretched schedule of HIV care would increase view). burnout, at least in the short term. Tis ordinarily would have engendered the clinicians’ disinclination Patient factors towards the integrated service delivery model. How- ever, what was also notably apparent in the clinicians’ narratives around increased workload was that they maintained a positive attitude towards integration of Extended waiting time. Te extended time spent wait- the two services, and expressed willingness to adopt ing at the clinician’s ofce was identifed as one of the the model. For some clinicians, adoption of the inte- key patient related challenges of integrating depression grated model despite the increased workload was justi- into HIV care. Clinicians worried that longer waits than fed given that this would likely beneft them by making was the case before integration would in turn generate work less demanding in the longer term than under discontent among patients who might perceive this as a the current model. One clinician noted, for example, deterioration in the quality of care. Tis perception was that the increased workload would be easier to man- particularly likely among those visiting for a simple pro- age than having patients whose HIV viral load was not cedure, such as an HIV viral load check, but are being suppressed, itself the function of untreated depression made to wait much longer. One clinician observed: among the HIV patients. “So now it could be time for the [other] client to get “Ah… work load! I do not want to say it because the assessment but the time you spend assessing it is easier to manage. As for me the time I have depressed clients you alter the time for the other cli- managed this depression and HIV and now a third ent who just came probably for a viral load check element of non-suppression [non suppression of and should be gone quickly. So someone who would HIV viral load], it is easier to manage a depres- have spent 15-20 minutes at the facility may end up sive patient, and it is very important to deal with waiting 30 minutes. So I think that will afect the a depressive patient than with one whose HIV viral routine fow and again that is waiting time mainly” load is not suppressed…. When someone’s HIV (Buwama Clinician, Baseline Interview). viral load is suppressed it saves time; we just give On the same note, a lay health worker observed: them drug reflls. However for those whose HIV viral load is not suppressed we have to go into “You actually need a lot of time to speak to a clinical management including investigating why depressed client… some cry during the sessions and their HIV viral loads are high. So when you man- as such you have to give them time to do so…. Some- times you would have like three patients waiting for Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 10 of 14

you to see them, and as a result these other patients grated services], they should be able to know that would end up waiting for long periods of time” really this [depression] happens, people with HIV (Focus Group Discussion with Lay Health Workers, can have depression concurrently, and then as I said Endline). we need continuous refresher trainings… because mental health is not an easy thing though you can Patients’ perception of preferential treatment. Another look at it and you think it is easy. It is not an easy key patient related challenge of integration was the thing” (Buwama Clinician, Baseline Interview). patients’ perception that clinicians were giving preferen- tial treatment to other patients, which resulted in longer Training was also considered critical in the area of waits at the clinician’s ofce. For example, one clinician depression medications. In this case clinicians were con- was concerned that some patients, especially those that cerned about their current inability to provide the best have already been waiting for long, might feel ignored advice given their limited knowledge about the available when they see their counterpart who is depressed and in drugs, particularly their side efects, their potential inter- need of urgent doctor’s attention being prioritised over actions with ART and their toxicity. One clinician high- them. lighted some of these concerns: “…that was a challenge–for example I have a queue “… of course as you know about the tricyclic antide- there, clients have been waiting and this client comes pressants they have [a] side efect–they can cause in and of course she may need immediate attention death; they are fatal if given in overdoses [and] for which I was not able to give to them…. Te other the [HIV] clients there is also taking Nevirapine and ones may see it as [giving others preferential treat- antidepressants. Now for Nevirapine, it reduces the ment]” (Nkozi Clinician, Midline Interview). concentration so you need to give a high dose of anti- depressant” (Nkozi Clinician, Baseline Interview). How best to integrate depression management Te same clinician speaks to the current knowledge into routine HIV care gaps among clinicians: While stakeholders spoke highly about the benefts of “Tese drugs… do not have a clear literature about integrating depression management into routine HIV them. Tough [for] fuoxetine they say it is safe in care, they also identifed some necessary conditions for pregnancy they do not [provide] clear literature, so the successful operationalisation of this service delivery my challenge may come in giving antidepressants to model. We identifed mainly two of these conditions, pregnant mothers and lactating ones….” namely organisational (including training to enhance clinical expertise, harmonisation in scheduling appoint- Harmonisation in scheduling appointments. In their ments, and structural changes) and patient level inter- narratives on changes needed at the organisational level, ventions to enhance knowledge of depression. We viewed stakeholders–including patients and supervisors–essen- the possible fulflment of these conditions, which might tially talked about the need for harmonisation in HIV not require heavy resource investment, as indicative of and depression care. Tis, they proposed, would be the feasibility of integrating depression treatment into achieved in diferent ways, including a departure from routing HIV care. the current system in which the scheduling of clinician’s appointments assumes no correlation between HIV and Organisational level interventions depression. Tey argued that appointments for these two Training to enhance clinical expertise. At the organisa- conditions need to be coordinated so that the patient can tional level, one of the key conditions for the success- access treatment for both conditions on a single trip to ful operationalisation of the integrated service delivery the health facility. model was training to enhance clinicians’ competence in “It [clinician’s appointment for depression care] delivering both HIV and, especially, depression care. Tis should actually depend on the period that you are suggestion came particularly from clinicians, who had a given for the ART, say if you are given for three background in HIV care and would be expected to man- months, also the antidepressants should be given age depression among their HIV patients. Te training for three months such that the appointment dates reportedly would address the current knowledge/skills are harmonized” (Nkozi, Antidepressants, Patient 1, gap among clinicians, including an understanding of Midline Interview). depression as a common comorbidity among HIV clients. “I think everything will be based on the staf and “Te biweekly [psychotherapy] appointments [for they should acknowledge the new program [inte- depression care] might be a challenge but I believe if Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 11 of 14

we make it on a monthly basis so that if the patients that is the only way. Health education packaging… come for ART treatment they even get depression you know [so the] client understands why he takes treatment on the same day it will be easy for them to the medicine and for how long. Ten you make sure keep the appointment dates” (Focus Group Discus- you make constant follow-up. You ensure follow sion with Lay Health Workers, Endline). up, they will be ok…” (Buwama Clinician, Baseline Interview). Structural changes. Consistent with patients’ perspec- tives, some clinicians suggested structural changes in Aside from the organisational and patient level inter- order to resolve the current disjointedness in service ventions that are necessary for success of integration, our delivery, whereby HIV clinics are physically delinked formative research yielded some pertinent fndings that from those for managing depression. Tese argued for pointed to necessary changes in the mode of delivery more coordinated service delivery in the form of central- of depression management. Tese changes, which have ised physical spaces or what they referred to as one-stop now been incorporated in the HIV + D trial, relate to the centres, where patients would conveniently access both decision support algorithm for the stepped care HIV + D HIV and depression care. intervention. While implementing the three-step inter- vention during the formative research, we observed that “I would prefer to have a one-stop centre for care. majority of participants who proceeded to Step II of the Like I am depressed, I need ART, [and] I get them algorithm (57 out of 66 patients) preferred Behavioural from this dispensing window. Are you getting it? Activation (psychotherapy) to antidepressant medication. [But] now I would have to go to OPD to get the anti- For the purpose of the HIV D trial, we have designed depressants because it can be dispensed in the OPD + a more client-friendly decision support algorithm that unlike the HIV drugs which cannot be dispensed provides for delivery of psychotherapy at Step II to all anywhere…. I am suggesting that the dispensing log the participants who do not improve at Step I. Tis is should also include the amitriptyline [antidepres- instead of the earlier algorithm which gave patients the sants] here at the ART clinic so that when a client… choice between psychotherapy and antidepressants at comes here [s/he] does not need to go to another dis- Step II. Consequently, antidepressant medication will pensing point” (Buwama Clinician, Midline Inter- now be provided together with psychotherapy at a higher view). level (Step III) for those patients whose depression scores remain high. Under the current algorithm, the stepped Patient level interventions to enhance knowledge care intervention has four levels with referral to a mental of depression health specialist being done at Step IV. We consider this Another necessary condition for successful integration adjustment in the decision support algorithm a necessary of depression management into routine HIV care was to step in enhancing the feasibility of integrating depression do with service users/patients. Stakeholders, particularly into HIV care. clinicians and patients, recognized that patients were sometimes not informed about depression as a health Discussion condition and needed to appreciate this reality in order In this paper we explored stakeholders’ perspectives on for them to embrace the appropriate treatment. Te the acceptability and feasibility of integrating the man- stakeholders recommended enhancement of knowledge agement of depression into routine HIV care in Uganda, of depression among patients through educational and drawing on data from PLWHA, clinicians, supervisors, other awareness-raising interventions. Tey emphasized lay health workers, and a sub-group of PLWHA, that the need for health education targeted at the patients and is, adherent and non-adherent patients. Our fndings the broader public through mass media, village sensi- demonstrate that integration, modelled along a realist tization meetings as well as patient follow-up to ensure approach that allows for contextual specifcity and targets understanding of depression and the related medication particular services, is acceptable among the stakehold- they were being asked to take. ers. Tis was more evidently so among those stakehold- “I think informing the public through mass media ers who held the most direct stake in integration (service such as televisions and radios can be of help…. Also users [PLWHA] and clinicians), who credited the pilot holding sensitization meetings in the villages can be intervention for improving ART adherence, overcoming of great help” (Buwama, Antidepressants, Patient 2, sleeplessness and suicidal ideation, and regaining a sense Midline Interview). of self-efcacy. Tese fndings lend further credence to broader calls for integration of mental healthcare into “… we have to strengthen our follow up strategies primary healthcare as the strategy for addressing the Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 12 of 14

signifcant unmet need for efective mental health ser- perspectives on factors infuencing success of integrated vices in low and middle income countries [35]. care, we were able to identify organizational factors In the sub-Saharan African context where research on (namely training to develop clinical expertise), provider integrating services is still limited [36], the fndings from experiences (such as time pressures arising from redis- this study contribute in strengthening the current evi- tribution of workloads) and patient factors (improv- dence base to inform best practices in integrating depres- ing depression awareness) as some of the key areas that sion management in HIV care. We have shown that needed to be addressed as a precondition for the success stakeholders’ positive attitude towards integration was of integration. Tese fndings, particularly on the need driven by a number of associated benefts, key among for training, build further on those from earlier studies which was that the management of depression in the con- that have cited absence of depression care and expertise text of HIV care resulted in enhanced adherence to ART. in HIV care programs [9, 36, 39, 40], and highlighted the Similar fndings have been refected in previous studies. need for HIV care providers to develop capacity to diag- In a 2017 cluster randomised controlled trial conducted nose and manage depression [36]. Consistent with these in Uganda by Wagner and colleagues [37], depression fndings, studies in Tanzania and Cameroon have shown treatment was associated with not only improved ART that training HIV care providers in prescription and adherence but also retention in HIV care. Likewise, in a management of antidepressants is efective at improving 2014 meta-analysis by Sin and DiMatteo [38] examining depression outcomes [41, 42]. the same association, it was found that the odds of ART Stakeholders also echoed fndings from earlier work adherence were 83% better if the HIV positive individual [43] by advocating change in the form of raising patient received depression treatment. (and the broader community) awareness about depres- But also worth noting is that while the association sion as a way of improving understanding of the disease between depression treatment and ART adherence has and uptake of relevant services in the context of HIV been noted in previous studies, our study builds further care. Tis fnding lends further credence to Benzer and on this evidence base by characterising some of the path- colleagues’ [30] theoretical perspectives on the role of ways through which such treatment leads to adherence. patient factors (in this case, knowledge about depression) Tese notably included enabling disclosure in discordant or what they conceptualise as the surrounding environ- relationships, which created an environment in which ment in shaping success of integration. the HIV positive spouse was no longer encumbered by Furthermore, the overwhelmingly positive attitude that the need for secrecy in administering ART, and was also clinicians expressed towards integration was notable in able to leverage the support of the spouse, for example in light of their concerns about the increased workload. We the form of reminders, to ensure they do not miss their consider this attitude signifcant inasmuch as it raises the dose. We view this as an important contribution insofar prospect of uptake of the innovation among clinicians as facilitating better programming for HIV counselling to whose support is critically important for the success of minimise the incidence of depression among PLWHA. the innovation. We also highlighted self-efcacy as one of the benefts In terms of informing the HIV + D trial, our formative accruing from depression treatment. Stakeholders, par- work has informed the design of a more client-friendly ticularly PLWHA, credited the treatment for having ena- decision support algorithm that provides for four steps bled them to regain control over their lives by acquiring rather than the three that were delivered during the knowledge about a hitherto unknown disease (depres- formative research. Te current algorithm provides for sion) they were sufering from, and by believing in their screening and psychoeducation at Step I; delivery of psy- own agency in addressing their health problems. Tis chotherapy at Step II to all participants whose depression fnding echoes previous work as reported by Wagner scores remain high; delivery of both psychotherapy and et al. [37] in identifying the positive association between antidepressants at Step III to those who scores are still self-efcacy and ART adherence. But while Wagner et al. high after Step II; and a referral to a mental health spe- [37] point to the mediating role of self-efcacy, suggest- cialist at Step IV for those whose scores are persistently ing no efect of depression treatment on self-efcacy, we high after Step III. show in this paper that self-efcacy itself can be one of the benefts of depression treatment. Limitations of the study But our fndings notably also highlight stakeholders’ Our study had some limitations. One of these is that data view that while acceptable, the feasibility of integrating were collected from only four HIV clinics in one district the management of depression into routine HIV care in central Uganda. While we make inferences from this would necessarily be predicated on some key interven- study that may be generalizable to HIV care in Uganda– tions. Guided by Benzer and colleagues’ [30] theoretical especially given the commonalities across the broader Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 13 of 14

public health care system in the country, including the Acknowledgements We acknowledge the contribution of the staf of the Mental Health Section of profle of the clientele normally attending these public the MRC/UVRI & LSHTM Uganda Research Unit, and Staf and persons living facilities–we caution that these results may not exhaus- with HIV/AIDS attending the following health facilities in Migi district: Butoolo tively depict stakeholders experiences and perspectives health centre, Buwama health centre, Mpigi health centre and Nkozi Hospital. across the country. Authors’ contributions Another limitation of the formative study on which RR analysed data, drafted the original manuscript and subsequent revisions. this paper is based is that the data collected on feasibil- JS, JM, RSM, CT, LK, GT, HS, PK, VP, EK contributed to review the diferent ver- sions of the manuscript. All authors read and approved the fnal manuscript. ity of the HIV + D integration model was qualitative and therefore did not include the economic aspect – the cost- Funding efectiveness analysis. In this formative study, our focus This study is funded through Senior Wellcome Fellowship to Eugene Kinyanda, reference number 205069/Z/16/Z. was on technical and operational feasibility. Formative cost efectiveness studies including the local validation of Availability of data and materials health economics study tools were later undertaken and The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. will be reported in a separate paper.

Conclusion Declarations Integrating the management of depression into routine Ethics approval and consent to participate HIV care in Uganda is acceptable among key stakehold- Ethical approval for this study was obtained from the Uganda Virus Research Institute Research Ethics Committee, the Science and Ethical Committee ers (patients and clinicians), but the feasibility of this of the London School of Hygiene and Tropical Medicine and the Uganda innovation would require some changes at the organisa- National Council for Science and Technology. tional and patient levels. We have shown in the paper that Consent for publication stakeholders, most importantly service users (patients), Not applicable – no images or other details identifable to any particular attribute a number of benefts to integration, including individual were reported within the manuscript. improvement of ART adherence, overcoming sleepless- Competing interests ness and suicidal ideation, and regaining a sense of self- All authors report no competing interests. efcacy. We have also highlighted stakeholders’ concerns about the various challenges to integration, broadly cate- Author details 1 MRC/UVRI & LSHTM Uganda Research Unit & Senior Wellcome Trust Fellow- gorised as organisational and patient-level factors, as well ship, Mental Health Section, 50‑59 Nakiwogo Street, Entebbe, Uganda. 2 Buta- as their recommendations on how best to integrate. One bika National Referral Mental Hospital, Old Port Bell Road, Kampala, Uganda. 3 4 key observation from our fndings was that stakeholders Kyambogo University, Kampala, Uganda. STD/AIDS Control Program, Ministry of Health, Ministry of Health, Kampala, Uganda. 5 Mental Health Divi- who spoke most to the acceptability of integration were sion, Ministry of Health, Kampala, Uganda. 6 Director of the MRC/UVRI & LSHTM patients and clinicians. Acceptability among the patients Uganda Research Unit, Kampala, Uganda. 7 Department of Global Health 8 was evident in the wide array of benefts they attributed and Social Medicine, Harvard Medical School, Boston, MA, USA. Department of Psychiatry, Makerere University, Kampala, Uganda. to the HIV + D intervention in which they had a chance to experience integrated (depression and HIV) care. Sim- Received: 19 November 2020 Accepted: 16 June 2021 ilarly, we have noted that some clinicians demonstrated acceptability by supporting integration in spite of the extra workload it engendered. We consider the perspec- tives of these stakeholders an important indication of References 1. UNAIDS. Communities at the centre. Geneva: UNAIDS; 2019. Report No.: future uptake of integration considering that they are the UNAIDS/JC2956. most directly impacted and their cooperation arguably is 2. Levitt NS, Steyn K, Dave J, Bradshaw D. Chronic noncommunicable critical for the success of integration. Given the paucity of diseases and HIV-AIDS on a collision course: relevance for health care delivery, particularly in low-resource settings—insights from South Africa. research on service integration in sub-Sahara Africa [36] Am J Clin Nutr. 2011;94(6):1690S-S1696. our fndings will feed into the much needed knowledge 3. Douaihy A, Singh N. Factors afecting quality of life in patients with HIV base for the development of evidence-based and contex- infection. The AIDS Reader. 2001;11(9):450–4, 60–1, 75. 4. Ciesla JA, Roberts JE. Meta-analysis of the relationship between tually grounded models of integration. HIV infection and risk for depressive disorders. Am J Psychiatry. 2001;158(5):725–30. 5. Kinyanda E, Hoskins S, Nakku J, Nawaz S, Patel V. Prevalence and risk Abbreviations factors of major depressive disorder in HIV/AIDS as seen in semi-urban HIV/AIDS: Human immune defciency virus/Acquired immune defciency syn- Entebbe district. Uganda BMC Psychiatry. 2011;11(1):1–9. drome or acquired immunodefciency syndrome; ART​: Antiretroviral therapy; 6. Olley BO, Seedat S, Stein DJ. Persistence of psychiatric disorders in a PLWHA: Persons living with HIV and AIDS; STD: Sexually transmitted disease; cohort of HIV/AIDS patients in South Africa: a 6-month follow-up study. J HIV D: Integrating the management of depression into routine HIV care in Psychosom Res. 2006;61(4):479–84. Uganda.+ Rutakumwa et al. Int J Ment Health Syst (2021) 15:63 Page 14 of 14

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