Themes
Factors that affected the perceived acceptability and feasibility of the CoCM in HIV clinics spanned the five CFIR domains, as shown in Table 3.
Table 3
Themes | Feasibility | Acceptability |
Barriers | Facilitator |
Intervention Characteristics | Adaptability (screening, monitoring, care team) |
Cost | | |
| | Design Quality |
| | Evidence based |
Outer Settings | | Patient Needs |
| Collaborations | |
Policies |
| | Stigma |
Inner Settings | Available Resources | |
Leader Engagement | | |
| Tension for Change |
Structural characteristics |
Characteristics of Individuals | | | Belief in intervention |
Individual capacity | |
| Individual identification with Organization |
| Other personal attributes |
Process | | Planning |
| Executing |
Evaluation and monitoring | |
Intervention Characteristics (design quality, evidence based, adaptability, cost)
Most participants welcomed the idea of the CoCM, as it manages both physical and mental health in the same setting and uses a care team, provided that the team members’ roles and responsibilities are defined. According to an HIV physician, the CoCM can be a good model for less severe cases if HIV providers can assess mental health concerns using screening tools that have been validated among Filipinos and translated in the local language and use evidence-based strategies for care.
In a good program, I agree that a psychiatrist or psychologist should be the one to monitor (mental health)… but then let’s go back to the reality that there is inadequate (mental health providers)… I believe psychologists and psychiatrists are expensive. They are not easy to access. So let’s go back to reality, that I agree… if the HIV counsellor or physician can already resolve (mental health concerns), that can be (done), I agree! – PLHIV
The inadequate number of psychiatrists in the country compounded by their unequal distribution in rural and urban areas (most are in urban centers) were mentioned as barriers for constructing the CoCM care team. Additionally, more data on the local prevalence of mental health disorders among PLHIV may be needed to get better support in having psychiatrists in HIV clinics, according to policy makers and mental health providers.
We have limitations in the number of psychiatrists. Even if it is recommended as a part of the HIV/AIDS core team, not all can comply.- HIV policy maker
The cost for a psychiatrist, additional staff and psychotropic medications were also mentioned as potential barriers in implementing the CoCM. Some participants suggested having at least one psychiatrist in the city or province and utilizing teleconsultations to access psychiatrists. In addition, available and affordable psychotropic medications, if possible through the Department of Health or the Philippine Health Insurance, would help implementation according to patients.
Some participants shared that factors that may support implementing the CoCM include already having a psychiatrist in HIV clinics, HIV counsellors’ previous experiences with mental health screening tools, and a registry and monitoring process in place where mental health monitoring outcomes can be added. HIV counsellors and patients raised potential concerns by with the mental health screening and monitoring processes that included patients’ time and willingness to participate and a potential breach of confidentiality in registries or during monitoring. Participants recommended incorporating mental health screening in follow-up visits or during times when medications are being refilled and improving patient registries for security and efficiency.
One is patient confidentiality and data security….We use open source materials, Microsoft excel, Gmail. So, if we have a tracker or registry, we have to make sure that the access is limited. - HIV physician
Outer Setting(patient needs, stigma, policies, collaborations)
The CoCM can meet patients’ needs through normalization of mental health consultation and providing more holistic care. Patients may feel better cared for if their HIV providers can manage their mental health concerns.
We tried to refer to an outside psychiatrist but […] the client's real concern is "I'm already here at your facility, why would I transfer to someone else?" […] "Why do someone else needs to know about my (HIV) status”. This (CoCM) will really help because we need to enhance our psychosocial services. […] we don't just focus on the virus….- HIV physician
Different stakeholders also mentioned that reduced financial concerns, shortened duration of referral to mental health providers, which may sometimes cause loss to follow-up, and the potential to address stigma on both mental health and HIV faced when consulting a psychiatrist were benefits of the CoCM.
Actually, it’s the stigma attached to consulting a psychiatrist, that you are really mentally sick… that’s on top of the stigma attached to the HIV diagnosis so the discouragement that a patient would feel to see a psych doctor, just because of that stigma, that’s actually one big factor why it’s very difficult to refer patients to psychiatrists.. - HIV clinic head
Participants highlighted several policies that could benefit or challenge implementation. The current Universal Health Care Law and Mental Health Law have already started integrating mental health services in community-based clinics by training primary care physicians using the World Health Organization Mental Health Gap Action Programme (mhGAP) and hiring community psychiatrists. These policies can support the CoCM, according to a mental health provider and policy maker.
They’re already training for primary health care physicians (on mental health) because the process is really primary care - primary health care or the universal health care… there’s already a training being done with the mhGap. So I don’t think it's going to be a problem. I think we just need to look what is existing and what can be done.-MH provider
However, mental health providers thought that the Counselling Law in the Philippines could be a possible barrier if the policy does not allow HIV counsellors to provide low intensity therapies or administer mental health screening tools. On the other hand, participants stated that the Philippine Health Insurance policy, which includes the Outpatient HIV/AIDS Treatment Package, can support implementation of the CoCM if costs for psychiatrists and psychotropics can be covered.
Some participants suggested collaborations, such as within and across hospitals or rehabilitation centers, schools with mental health services, or with volunteer or privately practicing psychiastrists, to have better access to mental health providers. Collaborations between HIV clinics and “access sites” (where the Department of Health distributes psychotropics under the mental health program), and other government agencies that may provide assistance for psychotropic medications were also mentioned. In addition, a policymaker pointed out that collaboration between the governmental HIV and mental health programs is important in planning for the HIV-mental health integrated services.
Inner Setting (tension for change, available resources, structural characteristics, leadership)
Participants perceived the current mental health services and referral systems – which include support groups, mental health seminars, and referral to HIV counsellors or mental health providers – as inadequate and unclear. They noted that mental health services in HIV clinics need to be strengthened. Patients and HIV providers perceived mental health assessment as inadequate and described assessment as only being done if patients exhibit severe mental health symptoms.
Our only measurement is ourselves, the service providers. We don’t have objective [tools], like a checklist when do we refer. If we think we cannot manage anymore, like after 2 or 3 visits, the [patient] is still not okay, then we give up and we refer them. –HIV physician
Despite having psychiatrists in some HIV clinics, some HIV and mental health providers believed that training primary care physicians for mental health management would be helpful as psychiatrists are overburdened, resulting in delays in mental health management. The CoCM may help psychiatrists focus more on severe cases. However, most participants also raised concerns about inadequate numbers of HIV clinic doctors and staff, affected by employment status, turnover rate, and redistribution of roles for the COVID-19 response, resulting in higher caseloads and less time per patient as possible barriers in the CoCM. Thus, the CoCM may be more feasible in smaller HIV clinics with lower caseloads. Participants suggested hiring additional staff, strengthening capacity and incentivizing current clinic staff, and improving clinic and documentation processes to be more efficient to address workload. Other identified barriers were a lack of private space for mental health screening and management, which participants deemed important for confidentiality and patients’ comfort, and availability of computers for the patient registry in some HIV clinics.
Participants, especially HIV clinic heads and physicians, mentioned lack of leadership support and changes in leadership in HIV and mental health programs as a potential concern, as this may affect allocation of funds and resources, sustainability of programs, or even employee turnover.
The mayor is not supportive of the HIV program ---- because of our politics here, ma'am. So it seems that their thoughts about HIV are not stable. – HIV counsellor
Characteristics of Individuals (belief in the intervention, individual identification and capacity, passion)
Most participants believed that the CoCM can potentially provide more holistic care that may help in early detection of mental health disorders and improve retention to care, treatment adherence, quality of life and patient empowerment. However, some participants thought that the CoCM would only be helpful if sustained. Some patients and HIV providers also expressed preference for a separate mental health program with healthcare providers specific for mental health care.
Most providers recognized that HIV counsellors are commonly the first contact of patients in the clinic making them the practical and acceptable option for doing mental health assessment and referral. HIV physicians are sometimes treated as family physicians and long term carers for any medical or psychosocial concerns, giving them the opportunity to do mental health assessment and management. Most participants believed that patients may already have trust, comfort and rapport with their HIV providers which may help with their mental health management.
HIV providers expressed a passion for helping patients and a willingness to be trained on mental health and participate in the CoCM for the benefit of patients despite heavy workloads.
I already knew that their (HIV counsellors’) passion is really for the patients…. even if this is an additional task, they will really take that additional task wholeheartedly…there is the satisfaction they can get, to a certain degree they helped their patient, I mean with their holistic health. -HIV counsellor
However, according to HIV counsellors and physicians, HIV providers need to be prepared for their role in the CoCM, which includes not only the responsibilities, but their own mental health as well to avoid burnout. Some mental health providers also expressed their willingness to be a part of the CoCM and believed other psychiatrists may be also willing. However, an HIV physician and mental health provider still felt that identifying willing psychiatrists could be a challenge.
Several participants believed that HIV counsellors’ trainings and capacity for HIV counselling and experience in using screening tools would be helpful for the role of care manager in the CoCM. HIV physicians were thought to already possess basic knowledge about mental health disorders. However, some pointed out that HIV counsellors have diverse training backgrounds, educational levels, knowledge and skills for providing mental health care. Some HIV physicians shared having low confidence, inadequate knowledge and formal training in mental health assessment and management, especially with pharmacotherapy.
That’s a good idea. But maybe we still need a lot of training because maybe we’re not doing it habitually. Maybe it’s not our forte anymore, but we are willing to learn. -HIV physician
A few HIV providers also mentioned that psychiatrists’ knowledge of HIV concerns and needs may be inadequate, and they may need to learn more about the unique struggles of PLHIV.
Process(planning, executing, evaluation and monitoring)
Most participants emphasized the need for training both HIV providers and psychiatrists to implement the CoCM. With differences in individual capacity, participants suggested that different levels of mental health training, and HIV training for psychiatrists, would be needed for various providers. Several suggested ways to bolster mental health training included utilizing the World Health Organization mhGAP, incorporating mental health trainings more intensively in HIV trainings, holding separate trainings specifically for mental health issues of PLHIV, or providing mentoring in HIV clinics that have access to a psychiatrist. Ideally, these activities would be free and can be done synchronously or asynchronously for the whole care team to be able to participate. A policymaker expressed that social workers and HIV nurses can also be care managers in the CoCM and other staff with interactions with PLHIV should be considerd for participation in mental health training.
Utilizing our (HIV) case manager is a good idea. However, we need to make sure they are properly trained… I don’t think there’s adequate sessions or training for mental health diagnosis and management (in HIV counselling training), so it should be part of the program before. And then there should also be a tool to assess whether they are indeed capable of assessing and managing mental health issues of patients..” – HIV clinic head
HIV providers, clinic directors, and policymakers highlighted the need to have a clear protocol, service delivery integration, and proper evaluation and monitoring for the CoCM to be acceptable and feasible. Pilot testing was thought to be important, with some already willing to pilot with their current available resources. Others expressed the need for the CoCM to be piloted in different HIV clinics in the country to assess feasibility and effectiveness and seek funding before they integrate mental health in their HIV clinic.
It's just like, formalizing or adapting it. At least like you have an ideal set up, then you have in a resource limited setting, you can start with what is available and then you just improve to reach the ideal.– HIV counselor
Other recommendations in planning for the CoCM included adding suicidal risk and substance use assessment, scales for spirituality due to its effect on mental health in the Filipino culture, and incorporating mental health screening as early as HIV testing. A mental health provider suggested that planning should involve consultation with local mental health professionals in the Philippines and other experts, such as anthropologists, sociologists, local tribe leaders, and PLHIVs, accustomed to the local culture.