NR 603 Week 1 Case Study Discussions Overview Of Behavioral Health And Cultural Diversity Issues In Primary Care

NR 603 Week 1 Case Study Discussions Overview Of Behavioral Health And Cultural Diversity Issues In Primary Care Recent

NR 603 Week 1 Overview Of Behavioral Health And Cultural Diversity Issues In Primary Care

Week 1 Case Study Discussions – Behavioral Health and Cultural Diversity in Primary Care
Part 1, Part 2 & Part 3 (Summary in SOAP Format)

Key Findings

  • Integrating care for chronic diseases, including mental health conditions, is a critical yet challenging element of universal health coverage goals, especially in low- and middle-income countries. The simple intervention for depression and anxiety, based on behavioral methodologies, supports people living with HIV and/or TB with comorbid depression or anxiety.
  • This pilot service evaluation presents real-life findings, with a focus on acceptability and feasibility, demonstrating issues around feasibility and the capacity of nonspecialist nursing staff to undertake additional mental health counseling without explicit support and resources, including time. It demonstrates acceptability among staff and patients.

Key Implications

  • Policymakers, health systems leaders, and health service staff should recognize the importance of integrated care, especially neglected mental health care, and advocate for dedicated resources, time, and capacity of health workers to take on this additional role.
  • Meaningful consultation with the health workforce is a critical element of service development.



Depression associated with chronic illnesses is common in Southern Africa, yet there are major treatment gaps. This study assesses the feasibility and acceptability of the Healthy Activity Program intervention for depression among people with HIV and/or TB. The intervention involves training nonspecialist nurses in depression, including identification, counseling based on behavioral activation theory, and structured referral.


This is a mixed methods evaluation of a pilot counseling service integrated within routine HIV and TB care from 2018 to 2019. Participants included people living with HIV and/or patients with TB in rural Eswatini.

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A total of 324 people living with HIV and/or TB were screened for depression, with 19% (62/324) screening positive. The median number of sessions attended was 3 (interquartile range: 1–5), with 16/60 (26%) attending the minimum 5 sessions. Qualitative results indicated acceptability, but there were concerns about feasibility.


The Healthy Activity Program is a promising option to manage the treatment gap for depression in people with HIV and/or TB. However, task-shifting to nonspecialist health care professionals without increasing staff capacity is a barrier to implementation. Realistic and pragmatic assessments of capacity and workforce are essential.


Depression is the most common mental health condition worldwide, including in sub-Saharan Africa (SSA).1 Estimated prevalence of mental disorders in low- and middle-income countries is high, yet data are scant, and mental health systems are limited and underresourced.24 The World Health Organization’s Mental Health Gap Action Program outlines that the majority of people living with mental health conditions in low- and middle-income countries cannot access psychological care.5 Providing basic care for depression in nonspecialist primary care is a global priority.6,7 Evidence from Africa about how best to provide this is scarce.8

HIV and TB have a profound impact on health in SSA. Approximately 800,000 new HIV infections were diagnosed in 2017 in Eastern/Southern Africa, bringing the total number of people living with HIV (PLHIV) in this region to an estimated 20.6 million.9 In 2021, TB incidence in the World Health Organization Africa Region was 2.4 million.10 In 2020, 73% of global HIV-associated TB infections occurred there.11

HIV and TB are risk factors for depression and anxiety.12,13 It is estimated that more than one-third of PLHIV in SSA experience depression.13,14 Stigma and discrimination, family life, and financial impacts intersect with sequelae of disease and treatment, posing substantial risks to mental health.13,15 These mental health conditions are poorly recognized and vastly undertreated.12,13,16,17

Treatment adherence, which is vital to good HIV and TB outcomes, involves complex and multidimensional factors and is highly linked to social pressures and mental health. Successive systematic reviews have found lower adherence to antiretroviral medication in those living with depression.1820 It is clear that providing holistic care for people living with HIV and TB must include mental health support. Integrating high-quality, culturally sensitive care within routine health care systems has the potential to improve both mental health outcomes and HIV and TB treatment adherence.21,22 Integration of HIV, TB, and mental health into primary care is critical to improving access to this holistic care.23,24

Treatment adherence is vital to good HIV and TB outcomes and is highly linked to mental health. Adequate care for people living with HIV and/or TB must include mental health support.

Eswatini is a small country in southern Africa with a population of around 1 million.25 The Lubombo region is predominately rural and poverty is prevalent. Despite middle-income status, Eswatini is an economically unequal country, with more than 60% of the population living below the national poverty line.26,27 It has one of the highest HIV rates in the world at 27.4% of adults, with the highest rates in Lubombo.28,29 TB rates are high, with more than 4,200 new cases reported nationally in 2017, an estimated 70% in PLHIV.30 Public mental health care is centralized in Eswatini, with 1 psychiatrist and (at the time of this study) 2 psychologists working in 1 public National Psychiatric Referral Hospital, which is too far and too expensive to travel for many people, especially from rural Lubombo. The gap in basic mental health care nationally, while not recorded, is significant.

This study aims to assess whether the Healthy Activity Program (HAP), a psychological intervention developed in India,31,32 can be feasibly delivered to PLHIV and people with TB with depression within the existing primary health care system in Lubombo. It seeks to explore acceptability among health care workers and patients. This study contributes to filling the gap in knowledge of mental health intervention delivery in resource-limited settings.


This study used a modified version of HAP, a brief psychological treatment for depression that was developed in India by Sangath, that showed a positive effect when evaluated through a randomized controlled trial.31,32 The intervention involves training nonspecialist primary health care staff in the identification and causes of depression and, for those identified as having depression, using structured counseling based on behavioral activation theory with or without a referral to a doctor for further care.

Counseling consisted of 30–60 minutes sessions between individual participants and nurse counselors in the clinic with activity “homework” for participants between sessions. Key modifications from the original study were to (1) reduce the counselor’s manual size, (2) omit the patient manual (replacing vital content with handouts), (3) modify Indian-specific content, and (4) change counseling intervals from weekly to fortnightly. Modifications were made in recognition of the capacity of nurse counselors and patients, including limited literacy in the latter group, and were reviewed by individuals involved in the original study. Table 1 provides additional details about the intervention, including participants, setting, and process

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