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Introduction: Depression is the most common mental disorder among people living with HIV/AIDS and has a negative impact on HIV treatment outcomes. Training lay HIV counselors to identify and manage depression may contribute to improved patient access and adherence to treatment, and reduce stigma and discrimination among lay health workers toward both HIV and depression. The purpose of this study was to assess the current knowledge and attitudes of lay HIV counselors toward managing depression in primary care in Mozambique. Methods: We conducted a mixed-methods cross-sectional study to assess depression-related knowledge and attitudes among lay HIV counselors in 13 primary healthcare facilities in Mozambique. We used the quantitative Depression Attitude Questionnaire (DAQ) scale, followed by open-ended questions to further explore three key DAQ domains: the nature of depression, treatment preferences, and professional attitudes or reactions. Results: The sample included 107 participants (77.6% female, mean age: 32.3 years, sd = 7.4). Most (82.2%) had less than a high/technical school education. Findings suggested that some HIV counselors had knowledge of depression and described it as a cluster of psychological symptoms (e.g., deep sadness, anguish, apathy, isolation, and low self-esteem) sometimes leading to suicidal thoughts, or as a consequence of life stressors such as loss of a loved one, abuse, unemployment or physical illness, including being diagnosed with HIV infection. HIV counselors identified talking to trusted people about their problems, including family and/or counseling with a psychotherapist, as the best way for patients to deal with depression. While acknowledging challenges, counselors found working with patients with depression to be rewarding. Conclusion: Lay health counselors identified HIV and psychosocial issues as key risk factors for depression. They believed that the treatment approach should focus on social support and psychotherapy.
This study was a mixed-methods cross-sectional study investigating knowledge and attitudes among lay HIV counselors in Mozambique toward depression. Between April and November 2019, we randomly selected 13 primary health care centers from two provinces: six in Maputo Province and seven in Maputo city, and invited all HIV counselors to participate. This yielded a convenience sample of 107 providers (93.04% response rate). We considered the following eligibility criteria: currently working as a lay HIV counselor at primary care health centers (HIV, TB, Maternal and Child Health), having been a lay HIV counselor for more than 3 months, and providing written informed consent to participate in the study. Participants provided basic information about their clinical background as well as sociodemographic information, including age, sex, education, marital status, type of counselor, years of counseling experience, and whether they had prior training in managing mental health problems. A research assistant administered the Depression Attitudes Questionnaire (DAQ) (43). We chose the DAQ because it was relevant to the research question, available in Portuguese, and culturally adaptable to Mozambique context. The DAQ includes 20 statements with 5-point Likert Scale response options ranging from strongly agree to strongly disagree. For the analysis, we collapsed the 5-point Likert scale responses to 3 points “disagree”; “neutral” and “agree.” The 20 statements/questions are grouped into three domains. The three domains include: nature of depression (nine items: Q1, Q2, Q4, Q5, Q6, Q7, Q8, Q10 and Q11); treatment of depression (eight items: Q3, Q12, Q14, Q16, Q17, Q18, Q19, and Q20), and professional attitudes (three items: Q9, Q13 and Q15). The domain “nature of depression” corresponded to depression risk factors and clinical features (44). The “treatment of depression” domain describes the treatment orientation and confidence in types of treatment, and the “professional reaction” domain is the professional confidence and ease in managing the needs of depressed patients (45). After completing the DAQ, each participant was asked a brief set of open-ended qualitative questions to further explore participants knowledge about diagnosis, symptoms, related risk factors, management and prevention of depression. These follow up questions were structured around the three domains of the DAQ, in order to further elucidate the participants’ perspectives on these topics. For the first domain, “nature of depression,” after administering the series of structured questions from the DAQ, we asked providers to use their own words to define depression, the common symptoms, and the perceived risk factors. We also asked specifically whether they considered HIV and AIDS to be a risk factor for depression, as well as to identify barriers to mental health treatment among people with HIV. For the second domain, “treatment of depression,” after asking their agreement to various statements about treatment alternatives for depression from the DAQ, we asked participants to use their own words to describe the types of depression treatment available locally, and where the services were provided. For the third domain, “professional attitudes,” we asked counselors to describe in their own words how they help patients with depression, and if they knew of any strategies to prevent depression in people with and without HIV. The qualitative interviews were recorded and then transcribed by the research assistants. The researcher revised each transcript to verify the accuracy of the data. After transcription of the interview, the voice records were stored on a password-protected computer, only accessed by the researcher. The average duration of each interview was 25 to 30 minutes. All interviews were conducted in Portuguese. All study procedures were reviewed and approved by the two Ethics Committees (from Federal University of São Paulo in Brazil and Eduardo Mondlane University in Mozambique). We used an explanatory QUANT = >QUAL sequential mixed-methods approach to data collection and analysis whereby the quantitative questions were asked first, and the qualitative questions were used to further explain and expand upon each domain (46, 47). For the quantitative data, we used frequency statistics to describe the distribution of demographic characteristics, training, and clinical experience in the sample for the quantitative data. We used Stata, Version 17 for the quantitative analysis. We also calculated the internal consistency of the three DAQ subscales using Cronbach’s alpha. For the qualitative data, we used software NVIVO version 10 to file and organize verbatim transcriptions of the interviews. We utilized a directed content analytic approach wherein we began analysis examining the three sub-domains of the DAQ and then broadened our analysis to include additional pre-defined topics (47). We thereafter quantified all qualitative data by coding, thematic analysis and describing patterns that emerged in the data (48, 49). All qualitative data were coded according to predominant themes identified by FM and LFG independently. The raters worked collaboratively to develop a taxonomy of the initial themes that emerged from the data. MCG and ACS supervised the coding and re-coding at different steps of this process to verify that findings were grounded in the data. Finally, we compared the qualitative responses by domain to the quantitative findings to help interpret those observations. When there was overall agreement in the sentiment of the qualitative statements and the quantitative findings, we had more confidence that questions were being understood in the correct way. When apparent contradictions emerged between the qualitative and quantitative data, we looked to the qualitative data to try to understand if those differences were real or if another explanation–such as the misunderstanding of one or more questions–could better explain the observations.
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