Common mental disorders (CMD) which primarily include depression, anxiety
disorders and mixed anxiety depression are leading causes of disability in subSaharan
Africa. They are particularly common in people living with HIV (PLWH) and
may hasten HIV disease progression.
This thesis consists of 5 articles which have been submitted for publication and
provide evidence on the requirements for developing a psychological intervention to
be delivered by lay health workers (LHW) and a strategy for scaling up this
intervention to over 50 primary health care clinics in Harare, Zimbabwe. The thesis
formed part of formative research leading to a cluster randomized controlled trial
(RCT) of a psychological intervention and provides supplementary research to the
RCT to support the scale up of the intervention.
The first chapter describes the magnitude of the problem and the lack of resources
to reduce the treatment gap for CMD. It highlights the growing evidence of using Lay
Health Workers (LHW) to reduce this treatment gap.
Chapter two describes the results of a systematic literature review of psychological
interventions carried out in low and middle-income countries (LMIC) for CMD among
PLWH. Key findings of the review include the lack of evidence-based interventions in
this field with only 5 studies identified. Of the 5 eligible studies, four did not meet the
Consolidated Standards of Reporting Trials (CONSORT) guidelines, highlighting the
need for well-designed interventions in this area.
Chapter three describes a cross-sectional study that examines the prevalence and
correlates of CMD in a high HIV prevalence setting in Zimbabwe. Of the 264
participants, 165 (62.5%) were PLWH, and 152 (92%) of these were on Highly Active
Anti-Retroviral Therapy (HAART). The prevalence of CMD as measured by the
Shona Symptom Questionnaire (SSQ14>=9) and depression according to the
Patient Health Questionnaire (PHQ9>=11) were higher among people living with HIV
than among those without HIV (67.9% and 64.9% (p=0.02) vs 51.4% and 44.4%(p=0.003) respectively). The study further shows that CMD in PLWH is associated
with negative life events and female gender.

The fourth chapter describes the results of a qualitative study that examined the
experience of LHWs in delivering a psychological intervention based on problem
solving therapy for PLWH. This study reveals that over a 4-year period LHWs
themselves developed three key concepts to navigate delivery of the problem solving
therapy based intervention. These included opening the mind (kuvhura pfungwa),
uplifting (kusimudzira) and strengthening (kusimbisa). Through these concepts,
which they developed through knowledge sharing, it was possible to adapt a western
developed therapy to address local mental health needs of Zimbabweans.
The fifth chapter describes a series of workshops conducted using the theory of
change model (ToC) as a way of building consensus and defining the overall
objective of the trial with an emphasis on integrating a package of care for PLWH
with CMD. The ToC workshops led to development of a ToC map describing the
causal pathway for the initiative with interventions, indicators, barriers, and rationale
outlined for each point along the pathway to impact.
In the sixth chapter the thesis focuses on the development of a strategy for scaling
up the intervention to over 50 primary health care clinics in Harare. This chapter
focuses on the core competencies of LHWs, putting in place a supervision strategy,
bringing on board key stakeholders and accessing funding for the scale up.
The final chapter provides a summary of key findings and recommendations for
future research, which include looking into the use of mobile phone technology to
provide supervision, and expanding the use of LHWs for other mental, neurological
and substance use disorders.