“Just trying to make it work:” A qualitative exploration of healthcare provider implementation considerations for integrating mental health and HIV care in central Uganda

BACKGROUND: There is a growing push to integrate mental health services within HIV care in Uganda. Given the limited mental healthcare infrastructure in the country and growing burden of mental health issues among the HIV positive patients, there is a critical need to understand 1) What are the current practices, routines, barriers, and facilitators that influence providers' ability to address their patients' mental health needs? 2) How do providers navigate this environment to provide mental healthcare? METHODS: Semi-structured qualitative interviews were conducted with 16 healthcare providers at two HIV clinics to understand current practices, routines, barriers, and facilitators to implementing mental health care services within HIV care. Abductive thematic analysis, drawing from Consolidated Framework for Implementation Research (CFIR) and Theoretical Domains Framework (TDF) frameworks, was used in conjunction with inductive analytical approaches to explore this research question. Both frameworks guided the development of the interview guide and the creation of the codebook. The CFIR was used to elucidate and understand systemic and institutional barriers and facilitators to mental health service integration and the TDF was used to determine provider level processes that impact the uptake of mental health protocols in practice. FINDINGS: In lieu of formalized integrated mental health services, HIV care providers navigate a complicated implementation climate and experience tension with both the clinic they work for and the patients they serve. They overcome these complications with a range of adaptive processes, collectively summarized as "making it work." CONCLUSIONS: These findings highlight the hidden mechanisms HIV care providers engage in to cater for patients' mental health needs and demonstrate the impact of this work on their own wellbeing as well.