Ingredients for success: Factors associated with successful integration of depression care into non-communicable disease clinics in Malawi: A mixed-methods analysis

Depression is a leading cause of disability worldwide that disproportionately impacts low- and middle-income countries (LMICs). Evidence-based depression care options are often limited in LMICs and poorly integrated into existing healthcare systems. Improving such integration is crucial to improving patient outcomes and reducing disability. In Malawi, a cluster-randomized trial of implementation strategies to integrate depression care into non-communicable disease clinics was conducted at 10 healthcare facilities from 2019 to 2021. Some clinics were highly successful in integrating depression care while others were less successful in both arms. This post-hoc mixed-methods analysis (01/10/2023 and 31/05/2024) combined quantitative clinic performance indicators with qualitative endline key informant interview data to identify factors other than the tested implementation strategies that differentiated clinics that effectively integrated depression treatment from those that did not. Most participants reported several implementation barriers that were present across nearly all clinics. These pervasive barriers included access to resources, provider attitudes, and provider turnover. Differentiating factors, which when present allowed successful clinics to overcome pervasive barriers and when absent made the barriers difficult to overcome, included clinic coordinator engagement, management engagement, clinic ownership, and adequate training. Differentiating factors that facilitated implementation of depression care integration, even in the presence of commonly identified barriers, should be prioritized as targets for future implementation efforts.