Sample characteristics
The study sample consisted of eight health care workers. All were NCD care providers; one female and seven males (See Table 1). Professionally, all participants were clinical officers and three were specialized in mental health. Two were NCD coordinators and six were general NCD care providers.
Table 1: Sample description of NCD care providers (n=8)
Demographic
|
Number
|
Age – 21 – 30
31 – 40
41 – 50
|
1
3
4
|
Sex
Female
Male
|
1
7
|
Occupation
General Clinical Officer
Mental Health Clinical Officer
|
5
3
|
Years of work experience
1-10
11-20
21-30
|
5
1
2
|
Years of NCD care experience
1-5
6-10
|
4
4
|
Main Findings
Six major themes were identified from the in-depth interviews: (1) the relationship between depression and NCDs; (2) feasibility and experiences of screening; (3) acceptability of using the screening tool (PHQ-9); (4) challenges of using the PHQ-9; (5) patients’ reactions to screening and treatment for depression; and (6) recommendations for integration. The data are presented in a narrative format following the themes with supporting quotes.
Relationship between depression and NCDs
Almost all NCD care providers recognised the relationship between depression and NCDs. The respondents reported that having NCDs and taking medicine for life causes “thinking a lot” (the literal translation of the most commonly used term for depression in Chichewa, the local language), depression causes patients not to adhere to healthy lifestyle advice as well as not to take medicine as prescribed, and depression causes poor outcomes for NCD patients.
“Sometimes because of depression, the patient cannot comply with lifestyle changes. If you advise the patient to have strict diet observation sometimes they cannot do those observations in diet because of depression. So it can have a huge impact on the improvement of non-communicable disease”. (NCD care provider # 1, Kasungu)
“The clinical impact of depression on the clients with NCDs, usually the treatment outcome is not good because those patients with depression are on long time treatment, they lose interest in doing social things or taking treatment so usually we find out that those who are depressed their symptoms may not be resolving because possibly they are not taking their medication as routinely or they stop medication as well, so usually the outcome is bad for those who are depressed as well as on NCD treatment”. (NCD care provider # 3, Kasungu)
“Because non-communicable diseases are chronic diseases, so people with these chronic diseases will tend to have so many worries as to why they are having conditions. They worry much because of the medication they are taking it’s just so long. So the conditions themselves will put someone at risk of having depression”. (NCD Coordinator #2)
Feasibility of and experiences of screening for depression
The feasibility of integrating depression screening and management into diabetes care was evaluated from the perspectives of NCD care providers by identifying potential factors that would either facilitate or hinder the integration. Some of the respondents reported improving patient management as one of the issues that was not being addressed before but was now highlighted by the PHQ-9.
“I remember one time I was administering the questions to one of our fellow health worker who works in a remote health centre and I was not expecting that she was having depression but after administering that questionnaire to her I extracted responses which indicated that she is depressed and also she had suicide ideation. So for me I regarded it as a positive situation where if I was not going to administer that tool, I could not even think that she has depression or she is having suicide ideas. So because of that tool, it assisted me a lot”. (NCD care provider # 1, Kasungu)
“Previously the clinic was already running except for the PHQ-9 tool so it’s not difficult in incorporating it because the system is already there now it’s just introducing the tool to depict some of the psychosocial problems”. (NCD care provider # 2, Kasungu)
“Now we are able to look at the patient from a broader prospective. Usually previously we were missing some of these components like when the patient is depressed but we are concentrating on the disease that we are treating at that moment without thinking that there are other conditions or things that have an effect on the treatment that we are giving so we have an improvement”. (NCD care provider # 3, Kasungu)
“So now there is this new component we are screening depression in those patients with non-communicable diseases. So the role is to screen in as far as depression is concerned looking how they are adhering to their drugs as well as looking if the treatment we are giving them is working or if there is need to do any other interventions”. (NCD care provider # 1, Salima)
“Looking at the PHQ-9, that tool has made screening of depression very easy. In the past it was quite difficult, with the PHQ-9 it has simplified everything as far as depression is concerned because there are steps which we are supposed to follow so for such you can’t miss a patient with depression”. (NCD care provider # 1, Salima)
The NCD care providers perceived the PHQ-9 as a useful tool to have, despite increased workload and described the time required to screen for depression using the PHQ-9.
“Mostly it is about planning ourselves and just dedicating ourselves to see each and every one to be screened, so we make sure on our daily clinics to be as a routine that each one should be screened for depression no matter how busy we may be or how many patients they may be that day”. (NCD Coordinator #2)
“If the patient has responded negatively on the first two questions, it may take 2 to 3 minutes; but if the patient has responded yes to the first two questions it takes may be 5 to 7 minutes to administer the whole PHQ-9 questions”. (NCD care provider # 1, Kasungu)
“Sometimes it depends on the patient in terms of the understanding but 5 minutes it’s enough to screen on average”. (NCD care provider # 1, Salima)
Acceptability of using the screening tool (PHQ-9)
Providers also reported that they perceived the PHQ-9 to be a useful tool, easy to use even for non-clinicians. The providers also reported that use of the PHQ-9 supported comprehensive treatment in NCD care. The selected quotes demonstrate the acceptability for NCD providers of integrating depression care into NCD care and how they perceived the importance of screening for depression. The providers indicated that screening allows clinicians to get a current diagnosis of depression and to understand why some patients had poor NCD outcomes, as well as to help improve the patients’ NCD outcomes.
“Now we are able to look at the patient from a broader prospective. Usually previously we were missing some of these components like when the patient is depressed but we are concentrating on the disease that we are treating at that moment without thinking that there are other conditions or things that have an effect on the treatment that we are giving so we have an improvement”. (NCD care provider # 3, Kasungu)
“Like I said the time we were having sessions on depression, it looked not that easy to do it but with the PHQ-9 doing it over and again, I think now it’s easier”. (NCD care provider # 1, Salima)
“My clinical practice has changed because am actually able to see these patients and make a decision”. (NCD care provider # 4, Kasungu)
Challenges of using PHQ-9
Although NCD care providers expressed that the PHQ-9 is easy to use, our study also found that most NCD care providers had experienced some challenges in using the PHQ-9. The NCD care providers indicated challenges in relation to patients as well as NCD care providers.
In relation to patients, the providers stated that some of the patients could not understand the questions while others were responding quickly to questions from the PHQ-9 to get done with the consultation.
“I remember on two occasions there were two clients, when you ask the questions which are on the PHQ-9 tool, they responded to almost all questions. They were responding positively but after probing more it showed that they were just responding positively because they just wanted to answer in that way but they were not having depression neither did they have suicide ideation but they just wanted to answer everything yes yes yes”. (NCD care provider # 4, Kasungu)
“On the recipient of care, when we are administering the PHQ-9 they also try to bring in things which are not related to the PHQ-9. So it’s like they interrupt unknowingly but mostly it does work well”. (NCD care provider # 1, Salima)
In relation to health care workers, they reported that administering the PHQ-9 adds extra time to the consultation (an extra task). They described that this is made worse by the fact that there is high workload due to limited staffing and many patients that attend the clinic; as such, some clinicians do not administer the PHQ-9 or they do it with haste.
The following quote emphasizes how shortage of staff impacts the administration of the PHQ-9;
“As a district usually in our clinics we have very long queues and as I said earlier on that we have patient who possibly come before we open the clinic around 6 o’clock they are already at the hospital so they stay long and we have a long queue so to go through the master card, to go through the PHQ-9 possibly sometimes it takes a bit of time so the only challenge is time consuming though we just ask the first two questions when its less than zero we proceed but at times when we have long queues it’s a challenge in our institution.” (NCD care provider # 4, Kasungu)
Patients’ reactions to screening and treatment for depression
NCD providers reported on patients’ reactions to screening and treatment for depression in a mixed way. The NCD care providers described the reactions as mostly positive, with a perception that the screening is helpful. However, some patients perceive that it entails spending more time at the clinic. For some patients, it increases the burden as it may entail more medicines as well as appointments at the hospital. The following quotes from the NCD care providers illustrate the patients’ reactions towards screening and treatment for depression in NCD clinics.
“Most of the patients, we don’t have problems with our patients in terms of administering that tool because most of the times they accept”. (NCD care provider # 2, Kasungu)
“Most of the patients may be because they know, usually they take whatever we do at the hospital as the true gospel so we haven’t seen much resistance, and they are always comfortable”. (NCD care provider # 3, Kasungu)
“It was twofold, first there was a resistance as people could see we were taking much time screening them but after telling them the goodness of it people realized that we were really managing them well and they are proud of it”. (NCD Coordinator # 2)
“As I have already said that some patients say it’s tiresome and complain about the long time they spend at the NCD clinic before they get the medications. Some patients feel that it’s not useful”. (NCD care provider # 1, Mchinji)
Recommendations for integration
The respondents also suggested possible solutions that could be used to address identified challenges to integration. The NCD care providers suggested that due to the relationship between depression and NCDs, all patients should be screened for depression. Furthermore they proposed training of HCWs in health centres as well as in other districts. Another suggestion was that of increasing the number of staff in the facilities so that screening is done appropriately or alternatively to consider that screening should be done by other health care workers such as clerks while taking vitals rather than by clinicians. They further described that when using the PHQ-9, there is a need to observe how patients are responding and probe accordingly, and that the providers should be conducting quarterly meetings to evaluate screening.
The following quotes emphasize the proposed solutions to facilitate the integration of depression into NCD care:
“Manage them as a whole” (NCD Coordinator 2)
“So I observed that the in administering the PHQ-9 questions you have to be very observant with how the client is responding and also his position, his gestures, if really what he is responding is really what is showing you and also you have to probe more to identify what is really deep in his or her heart”. (NCD care provider # 1, Kasungu)
“The integration is a good idea, as we are starting this I felt like there should be a time where we should be able to evaluate it together to see how we are faring for example on quarterly basis we can meet and see what we are doing so that we can be making improvements in due course. Issues of integration have come to stay”. (NCD care provider # 5, Kasungu)
“The challenges like I have already told you will be like another task added on. So if we are to say the way our hospital setup is, talk about the human resource so it means we will need someone to be screening so that there should be an easy of workload”. (NCD care provider # 1, Salima)
“The screening can be done by anyone who has undergone the training or may be has undergone the orientation in as far as screening is concerned because PHQ-9 is just a tool. So those who are oriented or trained on the PHQ-9 then those ones can screen, can be involved in screening not necessarily only the nurse or the clinician. But like may be the patient attendants who have been trained and we feel that they are conversant with PHQ-9. Those ones can screen as well”. (NCD care provider # 1, Salima)