Facilitators, barriers and potential solutions to the integration of depression and non-communicable diseases (NCDs) care in Malawi: a qualitative study with service providers

(2021) 15:59 Zimba et al. Int J Ment Health Syst https://doi.org/10.1186/s13033-021-00480-0 International Journal of Mental Health Systems Open Access RESEARCH Facilitators, barriers and potential solutions to the integration of depression and non‑communicable diseases (NCDs) care in Malawi: a qualitative study with service providers Chifundo Colleta Zimba1* , Christopher F. Akiba2, Maureen Matewere, Annie Thom3, Michael Udedi3, Jones Kaponda Masiye3, Kazione Kulisewa4, Vivian Fei‑ling Go3, Mina C. Hosseinipour3, Bradley Neil Gaynes3 and Brian Wells Pence3 Abstract Background: Integration of depression services into infectious disease care is feasible, acceptable, and effective in sub-Saharan African settings. However, while the region shifts focus to include chronic diseases, additional informa‑ tion is required to integrate depression services into chronic disease settings. We assessed service providers’ views on the concept of integrating depression care into non-communicable diseases’ (NCD) clinics in Malawi. The aim of this analysis was to better understand barriers, facilitators, and solutions to integrating depression into NCD services. Methods: Between June and August 2018, we conducted nineteen in-depth interviews with providers. Provid‑ ers were recruited from 10 public hospitals located within the central region of Malawi (i.e., 2 per clinic, with the exception of one clinic where only one provider was interviewed because of scheduling challenges). Using a semi structured interview guide, we asked participants questions related to their understanding of depression and its management at their clinic. We used thematic analysis allowing for both inductive and deductive approach. Themes that emerged related to facilitators, barriers and suggested solutions to integrate depression assessment and care into NCD clinics. We used CFIR constructs to categorize the facilitators and barriers. Results: Almost all providers knew what depression is and its associated signs and symptoms. Almost all facilities had an NCD-dedicated room and reported that integrating depression into NCD care was feasible. Facilitators of service integration included readiness to integrate services by the NCD providers, availability of antidepressants at the clinic. Barriers to service integration included limited knowledge and lack of training regarding depression care, inadequacy of both human and material resources, high workload experienced by the providers and lack of physical space for some depression services especially counseling. Suggested solutions were training of NCD staff on depression assessment and care, engaging hospital leaders to create an NCD and depression care integration policy, integrating depression information into existing documents, increasing staff, and reorganizing clinic flow. *Correspondence: 1 University of North Carolina Project, Lilongwe, Malawi 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://creativeco mmons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/ zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Zimba et al. Int J Ment Health Syst (2021) 15:59 Page 2 of 12 Conclusion: Findings of this study suggest a need for innovative implementation science solutions such as reorgan‑ izing clinic flow to increase the quality and duration of the patient-provider interaction, as well as ongoing trainings and supervisions to increase clinical knowledge. Trial registration This study reports finding of part of the formative phase of “The Sub-Saharan Africa Regional Partner‑ ship (SHARP) for Mental Health Capacity Building—A Clinic-Randomized Trial of Strategies to Integrate Depression Care in Malawi” registered as NCT03711786 Keywords: Integration, Depression, NCD, Qualitative, Providers Background Mental health disorders are a leading cause of death and disability worldwide. As the fifth-leading cause of disability-adjusted life years, mental illness accounts for nearly a third of years lived with disability [1]. This problem is especially high in low and middle-income countries (LMICs), which account for approximately three-quarters of this burden [2] and where depression is the most commonly presenting mental illness [1, 3]. Nevertheless, access to mental health treatment is strikingly low, with over three-quarters of those living with mental illness in LMICs not receiving any treatment, and an even smaller proportion receiving adequate treatment [4]. The main factors contributing to lack of access to mental health services in LMICs include a lack of scale-up of mental health services, inadequate mental health providers (i.e., less than two overall mental health providers and less than one psychiatrist per 100,000 population) in low income countries, and the absence of any overall policy agenda to address mental health issues all contribute to difficulties in scaling up of mental health services [5]. In Malawi, scale up is further challenged by the way mental health treatment is managed in relation to levels of the country’s healthcare delivery system [6]. In some parts of the country, mental health care has been integrated into primary and secondary care [7], however most patients with mental health problems are only able to access care at just three central hospitals where services are focused on treating the most severe mental health disorders. Reserving mental health resources for the only most severely affected creates a gap in service across lower levels of the healthcare system, potentially leaving many individuals with less severe cases of depression undiagnosed and untreated. The mental health treatment landscape in Malawi remains similar to that of many LMICs, and calls to integrate mental health services into NCD, maternal and child healthcare, and HIV care have increased in recent years to address respective treatment gaps [8–10]. Such calls for mental health treatment integration often rely on “task-shifting,” an evidence-based implementation strategy where primary clinicians, n (...truncated)