Power and medical knowledge: a qualitative study of attitudes regarding co-occurring depression and chronic diseases in Malawi

Background : Globally, depression is a leading cause of morbidity and mortality particularly in Low and Middle-Income Countries (LMICs). The burden of non-communicable diseases (NCDs) are also increasing in LMICs, the conditions frequently co-occur and exacerbate NCD outcomes. Depression interventions alone are not effective at improving NCD outcomes resulting in wide-reaching calls for integrated services. Integrated services are in a nascent phase in LMICs in general and in Malawi in particular. This manuscript serves to clarify Malawian patients’ and providers’ attitudes towards depression integration into routine NCD services. Methods : Ten District Hospitals were selected for data collection. Thirty-nine participants were interviewed. An iterative approach to concept-driven coding was applied to facilitate the formation of similarities, differences, and connections between codes. Results : While patients infrequently described moderate depression as a medical condition, and held various attitudes regarding treatments, they agreed on the appropriateness of integrated services. Patients’ respect for their providers led them to support integration. Patients discussed how medical knowledge is highly regarded, revealing a power dynamic with their providers. Both patients and providers further acknowledged the power of a provider’s communication in shaping a patient’s feelings about depression. Conclusions : Training and interventions that facilitate providers abilities to effectively transfer their medical knowledge, use strategies to channel their power, and engage patients in a collaborative relationship will be key to successfully integrating depression treatment into Malawian NCD clinics and other integrative care settings in the region. Trial Registration : This work served as part of formative data collection for National Institute of Mental Health (NIMH) Trail NCT03711786 registered on 10 th October, 2018