RESILIENCE AND DEPRESSION AMONG OPD IN HEALTH CENTRE

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RESILIENCE AND DEPRESSION AMONG PATIENTS ATTENDING OUT-
PATIENT DEPARTMENT AT DOKOLO HEALTH CENTRE IV, DOKOLO TOWN
COUNCIL, DOKOLO DISTRICT, NORTHERN UGANDA.
BY
OKELLO DENIS DANIEL
16/U/0138/LCP/PS
A RESEARCH PROPOSAL SUBMITTED TO THE FACULTY OF HEALTH
SCIENCES, LIRA UNIVERSITY IN PARTIAL FULFILLMENT FOR THE AWARD
OF THE DEGREE OF A BACHELOR OF SCIENCE IN COMMUNITY
PYSCHOLOGY AND PSYCHOTHERAPHY OF LIRA UNIVERSITY
MARCH 2019
SUPERVISOR’S NAME: DR. AMIR KABUNGA

i
Declaration
This is to declare that this research proposal is my own work and has never been presented
anywhere to any academic institution for any award other than the one for which it is now
being submitted for.
Date………………………………………….

ii
Supervisor’s Approval
I DR.AMIR KABUNGA, the supervisor of DANIEL do hereby certify that this research
proposal was developed under my supervision and is ready for submission.
Sign…………………………………………………..
Date…………………………………………………

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LIST OF ACRONYMS
AOR Adjusted Odds Ratio
CI Confidence Interval
H/C Health Centre
HRZ Hazard Risk Zone
IPI Intestinal Parasite Infection
NGO Non-Governmental Organization
OR Odds Ratio
PR Prevalence Ratio
SD Standard Deviation
STH Soil Transmitted Helminthes
WASH Water Sanitation And Hygiene
WHO World Health Organization
HIV Human Immuno Deficiency Virus
PLWHIV People Living With HIV
AIDS Acquired Immuno Deficiency Virus
HIVpp Human Immuno Deficiency Virus Positive People
DSM-IV Diagnostic and Statistical Manual Of Mental Disorder.
ICD International Classification of Disease.
MD Mental Disease
χ² Chi Square
p Probability Value
CD4 Cluster of Differentiation 4
MDE Major Depressive Episode

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HAART Highly Active Antiretroviral Therapy
ART Antiretroviral Therapy
STSS Silencing The Self Scale
CES-D Center of Epidemiological Studies Depression

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TABLE OF CONTENTS
Declaration..................................................................................................................................i
Supervisor‟s Approval ...............................................................................................................ii
LIST OF ACRONYMS ........................................................................................................... iii
CHAPTER ONE........................................................................................................................8
INTRODUCTION .....................................................................................................................8
1.0 Introduction......................................................................................................................8
1.1 Background of the Study..................................................................................................8
1.2 Problem statement..........................................................................................................11
1.3 Study objectives .............................................................................................................11
1.3.1 General objective.........................................................................................................11
1.3.2 Specific objectives.......................................................................................................11
1.4 Research questions.........................................................................................................12
1.5 Justification of the study ................................................................................................12
1.6 Significance of the Study ...............................................................................................12
1.7 Scope of the Study..........................................................................................................13
1.7.1 Geographical Scope.....................................................................................................13
1.7.2 Content Scope .............................................................................................................13
1.7.3 Time Scope..................................................................................................................13
1.8 Conceptual framework...................................................................................................14
CHAPTER TWO .....................................................................................................................15
LITERATURE REVIEW ........................................................................................................15
2.0 Introduction....................................................................................................................15
This chapter deals with related literature in line with three specific objectives namely:.....15
2.1 The prevalence of depression among HIV patients. ......................................................15
2.2 The factors associated with depression among HIV patients.........................................18
CHAPTER THREE .................................................................................................................23

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METHODOLOGY ..................................................................................................................23
3.0 Introduction....................................................................................................................23
3.1 Study Design ..................................................................................................................23
3.2 Study Setting ..................................................................................................................23
3.3 Study Population ............................................................................................................23
3.4. Eligibility criteria ..........................................................................................................24
3.4.1 Inclusion criteria......................................................................................................24
3.4.2 Exclusion Criteria........................................................................................................24
3.5 Sample size calculation..................................................................................................24
3.6 Sampling procedures......................................................................................................24
3.7 Data collection techniques/methods...............................................................................24
3.8 Data collection tools.......................................................................................................25
3.9 Quality control techniques .............................................................................................25
3.10 Measures.......................................................................................................................26
3.11 Demographic and clinical characteristics.....................................................................26
3.12 Depression....................................................................................................................26
3.13 Resilience .....................................................................................................................26
4.0 Data analysis plan...........................................................................................................27
4.1 Ethical considerations ....................................................................................................27
4.1.1 Permission to Conduct Research .............................................................................27
4.1.2 Voluntary Participation............................................................................................27
4.1.3 Informed Consent ....................................................................................................28
4.1.4 Confidentiality & Anonymity..................................................................................28
REFERENCES ........................................................................................................................28
APPENDIX I; CONSENT.......................................................................................................32
APPENDIX II: QUESTIONNAIRE........................................................................................33
APPENDIX III; WORKPLAN................................................................................................40

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APPENDIX 1V; BUDGET OF THE STUDY ........................................................................41
APPENDIX IV; MAP OF DOKOLO DISTRICT...................................................................42
APPENDIX V; MAP OF DOKOLO HEALTH CENTER IV DISTRICT .............................43
APPENDIX VI; PICTURE OF DOKOLO HEALTH CENTER IV.......................................44

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CHAPTER ONE
INTRODUCTION
1.0 Introduction
This chapter introduces us to the background of the study, research questions, objectives,
significance of the study and organization of chapters and other pertinent issues related to the
study.
1.1 Background of the Study
Resilience and depression share many psychobiological pathways and may share common
affective, somatic and cognitive symptoms. For instance, aspects of resilience, such as beliefs
related to one‟s perceived capacity to man- age stressors, appear to be particularly influential
in predicting depression(Toukhsati, Jovanovic, Dehghani, Tran, & Tran, 2017). Depression is
the most common psychiatric problem associated with HIV disease, depression rates for
HIV- positive people are about 60%; but half of all PLWHIV with depression go
underdiagnosed and untreated(Amare, Getinet, Shumet, & Asrat, 2018). In physics the term
resilience is “a property by which the energy stored in a deformed body is released when
elastic deformation ceases” Other fields, including psychopathology, also use the term to
refer to the heterogeneity of coping responses utilized by individuals in face of major life
stressors such as disease, socioeconomic difficulties, parental psychopathology and ruptures
in the family unit, whereby one succumbs to such experiences, escapes unharmed or becomes
stronger(Fontes & Neri, 2016).
In the context of HIV/AIDS, depression is an often overlooked but potentially dangerous
condition that can influence not only quality of life, relationships, employment, and
adherence to medical care, but also perhaps survival. Depression is associated with isolated
lives, the absence of pleasure, and social and vocational impairment. Depression is also
associated with failure to maintain a proper diet and exercise regimen and to adhere to
medical care. Other than substance use disorders, depression is the most prevalent
psychiatric disorder among HIV-positive (HIV+) adults(Rabkin, 2008).
Many people living with HIV have depression. About 90% of people who die by suicide have
at least one psychiatric diagnosis; of these, depressive disorders are the most commonly
associated with suicidal behavior. Undetected mental health problems such as depression,
personality disorders, cognitive disorders, and cooccurring conditions such as substance-

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related disorders can affect drug adherence, clinic attendance, and quality of life and can
influence the outcome of disease and high-risk behaviors that increase risk of HIV
transmission(Richter, 2016). Globally, by 2030, depression will be the leading cause of
disease burden. In low- and middle- income countries, about 76% and 85% of people with
severe mental disorders do not get treatment for their mental health problem, the prevalence
of mental problems in HIV-infected individuals is significantly higher than that in the general
population(Richter, 2016).
Worldwide, depression is a substantial contributor to the global burden of disease and affects
people in all communities across the globe. Nowadays, depression is estimated to affect 350
million people. The World Mental Health Survey conducted in seventeen countries found that
about 1 in 20 people reported having an episode of depression in the preceding year. Many
people living with HIV have depression. About 90% of people who die by suicide have at
least one psychiatric diagnosis; of these, depressive disorders are the most commonly
associated with suicidal behavior(Eloff et al., 2014). In India, the prevalence of depression
among the HIV/AIDS patients was 40%, psychiatric complications of HIV/AIDS signify a
significant additional burden for mental health services and professionals in less affluent
countries with high HIV prevalence rates(Amare et al., 2018). When there is a variation in
HIV prevalence, there is also a variation of depression prevalence. In Africa, the systematic
review showed that factors that associated with depression among PLWHIV were receiving
poor-quality health services, being female, and lack of emotional support from friends and
family. In Uganda, age above 50 years and being female were associated factors for
depression(Amare et al., 2018).
In South Africa, evidence from a study has revealed that foster parents continue to play a
significant role in enhancing resilience amongst children living with HIV and placed in foster
care. The key research question that guided the study was: How do children living with HIV
and in dire poverty as well as who are placed in foster care develop resilience Inspired by
resilience theory, this study highlighted that there were three main protective factors that the
children used to cope despite living in a high-risk environment: intra-personal traits, family
and community influences, and state social grants. Consistent with other empirical evidence,
this confirms gaps in ongoing psycho-social and support networks required by foster parents
caring for children living with HIV(Gomo, Raniga, & Motloung, 2017).

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Kenya has one of the world‟s worst HIV and AIDS epidemics. In 2011, an estimated 1.6
million people were living with HIV and nearly 62,000 people died from AIDS-related
illnesses including Korogocho, the worst slum area with 14% HIV prevalence. Even though
awareness of HIV and AIDS in Kenya is high, many people living with the virus still face
stigma and discrimination. Studies have shown that although people are aware of the basic
facts about HIV and AIDS, many do not have the more in-depth knowledge that address
issues of stigma. Especially social stigma of HIV to women is an urgent issue in Kenya.
Especially women with HIV suffered from stigma and discrimination to break themselves
down. Their severe depression and psychological trauma is the most significant cause of their
deprived quality of life. Kenya women have been exposed to intense and ongoing trauma and
depression since diagnosis of HIV/AIDS. The women living with HIV showed resilience
with determination to live in spite of the tangible threats of a well-known chronic disease.
Perceived or self-stigma added to the impact. Psychological and social support is necessary to
address the impact of the disease
Another study in Uganda found that approximately 50% of HIV-positive adolescents reported
significant psychological distress , and 18% of the participants reported a suicide attempt
within the last year. HIV-positive adolescents are at heightened risk for post-traumatic stress
following a range of potentially traumatic events including acute or prolonged domestic
violence, sexual abuse, caregiver abandonment, and receiving a diagnosis of HIV(Ramaiya et
al., 2016). Because the coping process involves constant interaction between individuals and
their ecological contexts, resilience is distributed across interacting dynamic systems at
different levels, including both external and individual levels(Huang, Zhang, & Yu, 2019). In
Dokolo district, HIV prevalence was reportedly higher among women i.e. 7.5% as compared
to their male counterpart at 7.2% and the national prevalence is 6%(Dokolo, 2017).

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1.2 Problem statement
The World Health Organization report on HIV/AIDS and mental illness (WHO, 2008) has
indicated that while low and middle- income countries carry more than 90% of the burden of
HIV/AIDS, there is very little information about the interaction between HIV/AIDS and
mental health in these countries(Huang et al., 2019).
Depression is one of the most common mental health disorders among people with
HIV/AIDS. It causes more disability and greater decrements in health than most other chronic
illnesses. Psychiatric complications of HIV/AIDS signify a significant additional burden for
mental health services and professionals in less affluent countries with high HIV prevalence
rates(Richter, 2016). Depression and problems with adherence to treatment regimens have
been noted for a variety of other medical conditions, including hypertension, coronary artery
disease; diabetes mellitus and kidney failure. Adherence is also thought to be a significant
problem for people with HIV/AIDS, and may mediate the relationship between HIV/AIDS
and mortality(Kibret & Salilih, 2015).
The understanding of pathways leading to resilience in PLWHA in Dokolo district may
inform intervention strategies to facilitate better adaptation to contextual adversities in this
population. Resilience
1.3 Study objectives
1.3.1 General objective
To assess the relationship between depressive symptomatology and resilience among HIV
patients attending out-patient department at Dokolo Health centre IV.
1.3.2 Specific objectives
1. To establish the prevalence of depression among HIV patients attending out-patient
department at Dokolo Health centre IV.
2. To determine the factors associated with depression among HIV patients attending
out-patient department at Dokolo Health centre IV.
3. To assess the relationship between depressive symptomatology and resilience among
HIV patients attending out-patient department at Dokolo Health centre IV.

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1.4 Research questions
1. What is the prevalence of depression among HIV patients attending out-patient
2. What are the factors associated with depression among HIV patients attending out-
patient department at Dokolo Health centre IV.
3. What is the relationship between depressive symptomatology and resilience among
1.5 Justification of the study
The findings of this study will add to the limited body of knowledge about the prevalence rate
of depression among HIV/ AIDS infected patients in Uganda. It will also serve as a clinical
reference to HIV care providers who may use the findings to offer comprehensive care to
their patients. Since little is known about the prevalence of depression and the factors
associated with Depression in a population of PLWHA in Uganda, this study might serve as a
foundation for future public health and Mental Health research in the area, thus deepening
understanding of the issue. It is therefore anticipated that the findings of this study will
contribute to the development of local knowledge about mental illness and HIV/AIDS and
used to inform Mental Health education curricula for both community and mental Health
should be incorporated. The findings of this study might also help in influencing the
development of appropriate policies, plans and intervention programs for the management of
psychiatric illnesses in HIV/AIDS care settings. This in turn, might improve the quality of
life for HIV/AIDS patients who are also suffering from Depression.
1.6 Significance of the Study
 The study will help identify the relationship between depressive symptomatology and
resilience and factors associated with depression among HIV patients attending out-
patient department at Dokolo Health centre IV. This will help in providing
appropriate recommendation to the policy makers and community health workers
towards improving health services delivery in Dokolo District, Northern Uganda.
 The research will be of great importance to the whole Uganda aimed at helping the
government in policy making and achieving projected coverage treating HIV and
depression in Dokolo District, Northern Uganda. As this will greatly reduce the
burden of diseases in Uganda

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 The research will be of great importance to the researcher as its part of the
requirements for him to acquire Bachelor science in psychology and psychotherapy.
 The research will also be relevant as a reference for research institutes, hospital, NGO
etc in drawing out their map out works and target groups when delivering HIV and
mental health services.
1.7 Scope of the Study
1.7.1 Geographical Scope
Dokolo District is located in northern Uganda between longitudes 320 51‟ East and 340 15‟
East and latitudes 1021‟ North and 2042‟ North. Of the 1352 Km2, 77.8 Km2 is open water,
protected forests 46.1Km2 and 516.02 Km2 is under cultivation.
The district is characterized by Tropical climate with two seasons; dry and wet seasons.
There is also a bimodal rainfall pattern with one peak during April-May and the other in
September-October. The hottest months of the year are December, January and February.
1.7.2 Content Scope
This study will involve prevalence of depression, associated factors and resilience among
HIV patients attending out patient department at Dokolo health center IV.
1.7.3 Time Scope
The time scope of the study will be within the months of April 2019 to August 2019. This is
an academic research that will be carried out as per Lira University regulations in partial
fulfillment of the requirement for the award of Bachelor of science in Psychology.

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1.8 Conceptual framework
Independent Variable Independent Variable
Dependent Variable
Socio-demographic Factors
 Age of the patient
 Gender of the patient
 Education level of the patient
 Area of residence of the patient
 Employment status
 Age of patient at diagnosis
 Religion of the patient
Other Factors
 Monthly Income of the patient
 Living condition of the patient
 Stigma and discrimination
 Health Status
 HIV Staging
Presence of Depression
1. I was bothered by things that usually don‟t bother me.
2. I did not feel like eating; my appetite was poor.
3. I felt that I could not shake off the blues even with help from my family or
friends.
4. I felt I was just as good as other people.
5. I had trouble keeping my mind on what I was doing.
Resilience
 Able to adapt to change
 Close and secure relationships
 Sometimes fate or God can help
 Can deal with whatever comes
 Past success gives confidence for new challenge
 See the humorous side of things
 Coping with stress strengthens
 Tend to bounce back after illness or hardship

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CHAPTER TWO
LITERATURE REVIEW
2.0 Introduction
This chapter deals with related literature in line with three specific objectives namely:
1. To establish the prevalence of depression among HIV patients attending out-patient
2. To determine the factors associated with depression among HIV patients attending
out-patient department at Dokolo Health centre IV.
3. To assess the relationship between depressive symptomatology and resilience among
2.1 The prevalence of depression among HIV patients.
Major depression is the most common psychiatric manifestation associated with HIV
infection. The estimation of depression prevalence is particularly difficult because it is
necessary to take into account (i) demographic data (gender, age); (ii) whether the depressive
disorder is caused by the infection itself or is a complication (primary or secondary); and (iii)
whether there is an overlap between HIV symptoms and depression(Article, 2014).
Globally, depression is a substantial contributor to the global burden of disease and affects
people in all communities across the globe. Nowadays, depression is estimated to affect 350
million people. The World Mental Health Survey conducted in seventeen countries found that
about 1 in 20 people reported having an episode of depression in the preceding year. Many
people living with HIV have depression. About 90% of people who die by suicide have at
least one psychiatric diagnosis; of these, depressive disorders are the most commonly
associated with suicidal behavior(Eloff et al., 2014).
Studies conducted in sub-Saharan Africa settings have demonstrated that depression is a
commonly-occurring disorder among PLWH. A systematic review by Nakimuli Mpungu et
al (2011) put the prevalence of depressive disorders at 31% and that of major depression at
18% across HIV clinics in sub-Saharan Africa. The prevalence of depressive disorders among
PLWH in Kenya has been reported to be as high as 42% (Eloff et al., 2014)Studies conducted
in western Kenya setting have reported similar trends with results showing that as high as

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between 13% and 25% of PLWH in this region are presenting with major depression(Eloff et
al., 2014).
In Nigeria, studies carried out in different regions of the country also reported varying
prevalence rates for depression in PLWHA. One study in three hospitals in Enugu, South East
Nigeria reported that 33.3% of the participants had depressive disorder, in North Central
Nigeria prevalence rates as high as 56.7% has been reported9 while in Benin, South-South,
Nigeria 29.3% was reported with 14.7% of the cases having mild depression, 12% and 1.3%
having moderate and severely depression respectively(Aguocha et al., 2015). Overall,
depressed women were shown to have a greater severity of depression compared to males but
generally, both genders were similar in the distribution of symptoms. The closest was in the
frequency of fatigue in which the prevalence in both genders was almost identical. The only
significant difference was in difficulty with concentration which was reported more often by
the female participants(Aguocha et al., 2015).
Compared with the general population, HIVpp are 2–7-fold more likely to meet the
diagnostic criteria for MD in accordance with international classification systems (DSM-IV
or ICD-10), while MD prevalence rates range from 18% to 81%, depending on the subjects.
Most studies, however, have not used strict diagnostic criteria, according to DSM-IV or ICD-
10, but have relied on physician reporting or structured screening surveys. Prevalence rates
based on DSM-IV diagnostic criteria may be lower than those based on screening
instruments. The variation in MD prevalence rate may be due to differences in methodology
and subject characteristics(Article, 2014)
In a study carried out to determine the prevalence and Socio-demographic Determinants of
Depression among Patients Attending HIV/AIDS Clinic in a Teaching Hospital in Imo State,
Nigeria, a total of 106 (39.1%) of the participants were identified as depressed. Out of these,
26 (24.5%) were mildly depressed, 53 (50.0%) moderately depressed while 27 (25.4%) were
severely depressed. Of those that were depressed, 28.3% were males while 71.7% were
females. About 11.1% of the total male participants were identified as depressed compared to
28.0% of the females. (χ2=0.21, p=0.65). There was increased severity of depression among
the females but this was not significant (χ²=0.87, p=0.83)(Aguocha et al., 2015).
In a study done about the prevalence of depression and associated factors among HIV/AIDS
patients attending ART Clinic at Debrebirhan Referral Hospital, North Showa, Amhara
Region, Ethiopia, the prevalence of depression was found to be 38.94%. Multiple logistic

17
regressions were used to minimize the risk of confounder for factors like sociodemographic
status, Substance use, and Perceived stigma. The association between these factors and
depression were tested and from socio demographic characteristics, being female
(AOR=2.071(1.077, 3.985) was associated with depression. This study showed that there is
high prevalence of depression among HIV/AIDS at Debrebirhan Referral Hospital when we
compare the result with the general population. A cross-sectional study conducted by at three
hospitals in Ethiopia on 269 HIV patients showed that prevalence of depression was 43.9%
which was higher when we compare it with the finding in this research(Eshetu, Meseret, &
Gizachew, 2015).
In another study to find Prevalence and Associated Factors of Depression among HIV
Infected Patients in Debre Markos Town Northwest Ethiopia Getiye, the prevalence of
depression among the study participants was 48(11.7%). This finding is lower than previous
study in Northern Ethiopia which was 43.9%. The difference might due to the social
composition and support. The finding is also in approach with a finding from Nigerian
University teaching hospital among HIV- infected participants(Kibret & Salilih, 2015).
Another study from Yaoundé, Cameroon among HIV infected patients showed that 63% of
the study population had depressive symptoms, most of them having symptoms
corresponding to moderate depression (46% of the entire sample, and 73% of the depressed
ones). The overall prevalence of depressive symptoms was 63%, the majority having
symptoms corresponding to moderate depression. Probably depressed patients were more
likely than those who were not depressed to have had experience of alcohol abuse and a 100
CD4 cells/mm3 fewer was associated with a 2.9 times increase of the odds of probable
depression(Town, Kibret, & Salilih, 2015).
A study from Canadian National Population Health Survey showed that low education level
and financial strain were associated with an increased risk of MDE in participants who
worked in the past 12 months. In those who did not work in the past 12 months, participants
with low education were at a lower risk of MDE compared with those with higher education.
Working men who reported low household income (12.9%) and participants who did not
work and reported low personal income (5.4%) had a higher incidence of MDE than
others(Town et al., 2015).
A study done in Northern Ethiopia showed that among 269 participants 43.9% were
depressed. In this research depression was associated with urban dwellers, with lower socio-

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economic class, unemployed and government employees. Overall, 73% of participants had
good adherence to HAART and 63.6% of participants with depressive disorder had poor
adherence to HAART compared to 21.1% of participants without depressive disorder(Town
et al., 2015).
2.2 The factors associated with depression among HIV patients
The combination of old age and HIV infection increases the risk of neuropsychiatric
symptoms, among the depressive ones. Hinkin et al., in a study of 131 HIVpp, of whom 25%
were over the age of 50, found that there was a higher rate of current depressive disorder in
the older patients (20%) compared with the younger ones (12%). Grov et al. studied 914
HIVpp men and women over the age of 50 and noted that 39.1% of participants exhibited
symptoms of MD(Article, 2014).
Loneliness was also shown to be significantly associated with depression in older HIV-
infected adults (Brennan & Karpiak, 2010). Other psychosocial issues that have been
identified with this population include stigma and discrimination(Emlet, Tozay, & Raveis,
2010).
Another investigated socio-demographic correlates of major depression in rural Ethiopia,
based on a door-to-door survey of 70,000 residents, with older age and status as formerly
married associated with risk for depression. These programs show that such research is
feasible, even in difficult field situations with a dearth of clinicians trained in psychiatry and
in respondents unfamiliar with psychiatric concepts. Although they do not easily lend
themselves to summary, these studies illustrate that Western diagnostic measures in
translation appear to be valid, and that depression is present in meaningful proportions in
most HIV+ populations globally, even if treatment options are not(Rabkin, 2008).
In a study carried out in Debre Markos Town Northwest Ethiopia Getiye, majority (51%) of
respondents were at HIV stage of T1. Fifty seven (13.8%) of the respondents were with less
than 200 CD4 count. About 383 (93%) of the total respondents had started ART and the most
common regimen they were taking was 1e/Tdf-3tc- Nvp. Among those on ART about 233
(56.6%) had experienced drug side effects. About thirty five percent of the respondents had
started ART before five years of data collection time and the remaining 65% were on ART
for one to- five years duration(Kibret & Salilih, 2015). Regarding ART adherence, majority
(87.1%) of respondent‟s adherence status was good and the remaining 3.2% and 9.7% adhere
fairly and poorly respectively. Majority of patients 332(80.6%) had disclosed their HIV status

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and their disclosures were for families (64%), spouses (7.3%), friends (3.4%), neighbors
(3%) and media (2.7%) respectively(Kibret & Salilih, 2015).
In a study done at Debrebirhan Referral Hospital, North Showa, Amhara Region, Ethiopia,
multiple logistic regressions were used to minimize the risk of confounder for factors like
socio-demographic status, Substance use, and Perceived stigma. The association between
these factors and depression were tested and from socio demographic characteristics, being
female (AOR=2.071(1.077, 3.985) was associated with depression. Male to female ratio of
depression was found to be 2.071:1 Age category between 30-39 years (AOR =2.761(1.165,
6.540)) was associated with depression, those with age category between 30-39years
2.761times more likely to develop depression than the age category between 20-29 years.
Age between 40-49 years (AOR=3.847(1.489, 9.942)) was associated with depression, those
with age between 40-49 years 3.847times more likely to develop depression than the age
category between 20-29 years. Age between 60-69 years (AOR=19.645(4.020, 95.991)) was
associated with depression, those with age between 60-69 years were 19.645times more
likely to develop depression than the age category between 20-29 years(Eshetu et al., 2015).
A study done among patients attending HIV/AIDS clinic in a Teaching Hospital in Imo State,
Nigeria Chinyere revealed that there was increased severity of depression among the females
but this was not significant (χ²=0.87, p=0.83). Depressive disorder was significantly
associated with younger age of diagnosis (χ²=15.6, p=0.001), while gender (χ²=0.21, p=0.65),
marital status (χ²=0.011, p=0.92), level of education (χ²=0.63, p=0.43) and employment status
(χ²=2.34, p=0.12) were not significantly associated with depression(Aguocha et al., 2015).
Among those that were depressed, dysphoria, difficulty sleeping, psychomotor retardation
and suicidal ideation were more frequent among the males with depression while anhedonia,
poor appetite, trouble concentrating and negative self-assessment were commoner among the
females. The rate of fatigue was almost the same in both genders. The rate (χ²=4.14, p=0.04)
and severity (χ2=8.64, df=3, p=0.04) of depression were significantly higher in females
compared to males. Feeling bad about one‟s self was significantly associated with severity of
depressive symptoms (χ2 =95.45, p=0.0001). No male reported anhedonia(Aguocha et al.,
2015).

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2.3 The relationship between depressive and resilience among HIV patients
Resilience refers to a person‟s capacity to cope with changes and challenges and bounce back
during difficult times or in the face of adversity, resilience emerges out of the concept that
despite a person having several risk factors, being resilience enabled them to adapt or
response well to life stressors and not develop mental health problems. Understanding what
protective factors contribute to this resilience against developing mental health problems and
an understanding of how to cultivate or foster these protective factors may aid in developing
targeted preventive mental health interventions(Maatouk et al., 2018). There are two basic
underlying conditions of the concept of resilience as patterns of adaptation in the context of
situations of risk or adversity: exposure to significant risk, and evidence of positive
adaptation to threats to development, positive adaptation refers to successful development
despite the risks: ability to deal with stress, including the capacity to minimise the effects of
the stressful event; capacity for a rapid recovery from a trauma; and, in the long term, ability
to contain negative responses and capacity to promote positive consequences and behaviours
that enable the individual to overcome adversity(Fontes & Neri, 2016). Further studies related
to resilience and depression/anxiety support that personality type and resilient behaviors
provide protection from the experiences of depression and anxiety and that resilience
increases the odds of not being depressed or stressed(Edward & Edward, 2015).
A study conducted in Australia examined the needs of children whose parents had mental
illness. This study found that the core features of resilience in this group involved the
exposure to risk and successful adaptation. They concluded that the experience of resilience
did not result from avoidance of risk; rather, it stemmed from exposure to risk and the
consequent successful negotiation through successful problem-solving skills(Edward &
Edward, 2015). This is supported by another Australian study undertaken by Edward (2005)
examining resilience as experienced by crisis care mental health clinicians. The findings of
her study suggest that resilience was expe rienced as a result of the caring environment in
addition to having a sense of self, faith and hope, having in- sight, and self-care(Edward &
Edward, 2015). In a study, Eight participants (36%) expressed feeling comfortable with
themselves and who they are at this stage of their life. They acknowledged that self-
acceptance was central to overcoming the negative effects of HIV/AIDS and the complexities
of aging with such a stigmatizing disease. This is illustrated by a comment from Taleef (age
56): “You got to love yourself, you got to want to do what you need to do for yourself.”
Similarly, Louis (age 64) showed self-acceptance in stating: “I just try to like myself. I‟m ok

21
with being me.” Bob (age 52) emphasized the utility of acceptance when confronting aging:
“It‟s been fine for me because I just accept growing older. I don‟t wanna act like or think that
I‟m still 25 or some- thing.” Paul (age 53) compared being older to a bottle of wine: “The
older you get, the better, the more refined it is(Emlet et al., 2010).
A cross-sectional study on depression and resilience in women with HIV and early life stress
revealed that there was a significant negative correlation between depressive symptomatology
and resilience (p=<0.01). PLS path analysis revealed a significant direct effect between
depression and resilience. On the Sobel test for mediation, distal (childhood trauma) and
proximal traumatic events did not significantly mediate this association (p=> 0.05). However,
post-traumatic stress symptomatology significantly mediated the relationship between
depression and resilience in trauma-exposed women living with HIV(Spies & Seedat, 2014).
The unadjusted findings of a study about resilience in perinatal HIV+ adolescents in South
Africa, suggested that lower level of depression in children was associated with higher care-
giver education (β =−0.412, p = .010), lower household density (β = 0.092, p = .041), and
greater food security (i.e., less reported hunger in the past month) (β = 0.254, p = .029).
Social regulation factors were also associated with depression in children. Lower levels of
youth-reported supervision by caregiver (β =−1.667, p < .001) and less likelihood of youth
seeking social support (β =−0.429, p = .003) were associated with higher levels of youth
depression. Within self-regulation factors, higher self-concept scores (β =−0.076, p < .001)
and lower levels of internal stigma (β = 0.655, p = .027) were associated with lower levels of
youth depression, while the use of social withdrawal (β = 1.297, p = .022) and resignation (β
= 1.156, p = .036) as coping methods were associated with higher levels of depression(Bhana
et al., 2016).
In a cross sectional study carried out in Germany, multivariate ordered logistic regression
analysis showed that the odds for higher depression severity were significantly lowered for
individuals with a high level of resilience compared with the individuals with a low level of
resilience (OR 0.11; p<0.001). Individuals with moderate level of resilience showed a trend
towards significance with lowered odds for higher depression severity (OR 0.51;
p=0.06)(Maatouk et al., 2018).
Another study about resilience among asylum seekers living with HIV showed that there
were three main stressors that threatened participants‟ resilience. First, migration caused them
to leave behind many resources (including social support). Second, stigmatising attitudes led

22
their HIV diagnosis to be a taboo subject furthering their isolation. Third, they found
themselves trapped in the asylum system, unable to influence the outcome of their case and
reliant on HIV treatment to stay alive. Participants were, however, very resourceful in dealing
with these experiences. Resilience processes included: staying busy, drawing on personal
faith, and the support received through HIV care providers and voluntary organisations. Even
so, their isolated existence meant participants had limited access to social resources, and their
treatment in the asylum system had a profound impact on perceived health and
wellbeing(Orton, Griffiths, Green, & Waterman, 2012).
A phenomenological study of women's experiences on testing HIV positive in pregnancy
showed that the emergent phenomenon was transition and transformation of „being,‟ as
women accepted HIV as part of their lives. Paired themes support the phenomenon: shock
and disbelief; anger and turmoil; stigma and confidentiality issues; acceptance and resilience.
Women had extreme reactions to their positive HIV diagnosis, compounded by the cultural
belief that they would die. Initial disbelief of the unexpected result developed into sadness at
the loss of their old self. Turmoil was evident, as women considered termination of
pregnancy, self-harm and suicide. Women felt isolated from others and relationship
breakdowns often occurred. Most reported the pervasiveness of stigma, and how this was
managed alongside living with HIV. Coping strategies included keeping HIV „secret‟ and
making their child(ren) the prime focus of life. Growing resilience was apparent with
time(Lingen-stallard, Furber, Lecturer, & Lavender, 2016).
The results of a study about resilience among women with HIV: Impact of silencing the self
and socioeconomic factors showed that the sample consisted of 85 women with HIV, diverse
ethnic/racial groups, aged 24 – 65 enrolled at the Chicago site of the Women‟s Interagency
HIV Study in the mid western region of the United States. Measures included the Connor-
Davidson Resilience Scale -10 item and the Silencing the Self Scale (STSS). Participants
showed high levels of resilience. Women with lower scores on the STSS (lower self-
silencing) reported significantly higher resilience compared to women with higher STSS
scores. Although employment significantly related to higher resilience, silencing the self
tended to predict resilience over and above the contributions of employment, income, and
education. Results suggest that intervention and prevention efforts aimed at decreasing
silencing the self and increasing employment opportunities may improve
resilience(Manuscript, 2015).

23
CHAPTER THREE
METHODOLOGY
3.0 Introduction
This chapter presents the methodology that will be used in the study; it includes the research
design, study population, sample size, sampling techniques, data collection methods, data
collection tools, quality control techniques, data management and analysis, and ethical
consideration
3.1 Study Design
A cross-sectional study design will be used to conduct this study using interview
questionnaire to determine the prevalence of depression, factors associated with depression
and the relationship between depressive symptomatology and resilience among HIV patients
attending out-patient department at Dokolo Health centre IV.
3.2 Study Setting
The health center IV is located in Dokolo district, Northern Uganda. The population is mainly
Lango with trading and farming being their major occupation. The health center has an
Antiretroviral Treatment (ART) designated clinic activated in 2008. The HIV clinic has a
total enrollment of 4769 patients out of whom 3565 are on ART. A total of 3330 of those on
ART are aged above 18years. ART drugs and investigations in the center are free of charge.
This study is a hospital based cross sectional descriptive study carried out on two hundred
and seventy one patients aged eighteen years and above receiving HAART between January
and March 2019.
3.3 Study Population
The study will be targeting all the HIV positive patients attending the ART clinic at Dokolo
HC/IV

24
3.4. Eligibility criteria
3.4.1 Inclusion criteria
Patients who will have received ART at the HIV clinic for at least 6 months, patients who
will be at least 18 years old and who will have consented to be part of the study will be
included in the study.
3.4.2 Exclusion Criteria
Those who will be too physically ill to participate, those whose medical records will indicate
that they have severe mental disorder and those not receiving ART will be excluded from the
study.
3.5 Sample size calculation
On each clinic day, patients were recruited by the study staff during the process of getting
their vital signs measured. The sample frame consisted of patients with HIV/AIDS aged
eighteen years and above receiving ART who attended clinic on a particular day. Using
systematic random sampling method, we recruited an average of five participants every day.
3.6 Sampling procedures
Interviewers will trained be conduct the survey using a pre-tested standardized questionnaire
about depression and resilience. For patients who understand English, the instruments will be
self-administered. For those who cannot read, the questionnaires will be administered by two
trained research assistants who are staff of the HIV Clinic and their responses scored as
appropriate.
3.7 Data collection techniques/methods
Appointments will be scheduled with the selected patients and the instruments will be
administered at their convenient time. The Center for Epidemiologic Studies on Depression
scale (CES-D) is a short self-report scale designed to measure the current level of depressive
symptomatology in the general population. It contains 20 items about symptoms that
occurred in the week prior to the interview with response options from 0 to 3 that refer to the
frequency of the symptoms. The score ranges between 0 (best possible) to 60 (worst) and the
cut off point that has been typically recommended is 16 for possible depression and 23 for
probable depression . Individuals with a score of 16 or more must have had either at least 6 to
20 symptoms on the scale for shorter periods of time. CES-D literacy level has been defined

25
as easy and it takes between 2 and 5 minutes to complete. It will be used to make diagnosis
and also rate the severity of depression. The participants‟ severity of depression will be
classified according to their CES-D score as mild (16-30), moderate (31-45) and severe (46-
60). Those with scores ranging between 0-15 will be regarded as not depressed. Among those
suffering HIV, the CES-D has a sensitivity of 78.7% and specificity of 83.4%.
3.8 Data collection tools
A structured questionnaire will be used to collect data on socio- demographic characteristics
(age, sex, ethnicity, religion, education, occupation, and marital status). CES-D (Center for
Epidemiologic Studies Depression) will be used to measure the depression level of
HIV/AIDS patient. The CES-D has demonstrated acceptable reliability, validity, sensitivity,
and specificity (CES-D score has a sensitivity of 88% and a specificity of 88% for major
depression). A questionnaire format will be used to collect CD4 count, stage of HIV, duration
on HIV status to be now, perceived stigma and social support. The questionnaires will be
close-ended items for ticking of yes or no, and making of choices among a number of
possible alternatives and fill in items. The researcher will recruit qualified nurses to collect
the data. They will be oriented on how to fill the questionnaire, the ethical principles,
confidentiality and data management prior to their involvement for data collection. The
completed questionnaires after being administered will be collected by the principal
investigator from each research assistants in order not to encourage change of information.
3.9 Quality control techniques
There will be measures put in place to ensure quality control and validity of data and findings
of the study. Questionnaires will evaluated by data collectors to keep its standard in small
numbers. The data consistency will be checked at the site. Data quality control issues will be
insured by conducting pre-test among 5% total samples obtained from patients attending
ART clinic at Dokolo Health Centre IV, one of the health centres located in the town which
gives care and treatment for patients with HIV/ AIDS. Training will be given to data
collectors on the data collection tool and sampling techniques. Supervision will be held
regularly during data collection period. The collected data will be checked on daily basis for
completeness and Consistency. The questionnaire will be translated to Lango and back to
English using backward forward translation method and feedback will be obtained from two
psychiatrist who have worked on depression most of their lives.

26
Furthermore, all completed forms from the field will be reviewed daily and on-the-spot
feedback provided with follow-up/callback undertaken, where needed. Data collection
instruments will be coded with unique ID numbers to make them traceable. The researcher
will verify how data has been coded and entered into the computer.
3.10 Measures
3.11 Demographic and clinical characteristics
Age, gender, marital status, ethnicity, years of education and employment status will be
captured. A comprehensive history will be obtained from, and a general physical examination
will be conducted in, all patients. Virological markers of disease progression (CD4
lymphocyte count and viral loads) will be obtained from blood samples.
3.12 Depression
Participants will be assessed for depressive symptomatology using the Center for
Epidemiologic Studies Depression Scale (CES-D).33 The CES-D is a 20-item widely used
self-report instrument designed to measure depressive symptomatology. The scale is
specifically designed to measure depressive symptomatology in the general population,
unlike previous depression scales that were predominantly used in clinical populations. The
CES-D emphasizes the affective component of depressive symptomatology, namely
depressed mood. Each item comprises a Likert scale ranging from 0 to 3. A total score for the
20 items is obtained, with the lowest possible score being 0 and the highest possible score
being 60. Higher scores are indicative of more severe depression.
3.13 Resilience
Resilience will be assessed using the Connor Davidson Resilience Scale (CD-RISC). The
CD-RISC is a self- report measure of resilience consisting of 25 items. The content of the
scale reflects hardiness, control, commitment, personal or collective goals, change or stress
viewed as a challenge/opportunity, strengthening effect of stress, past successes, recognition
of limits to control, engaging the support of others, self-efficacy, optimism, action
orientation, self-esteem/confidence, adaptability, tolerance of negative affect, problem-
solving skills, humour in the face of stress, patience, faith and secure bonds to others.
Examples of items include „I am able to adapt when changes occur‟, „I have at least one close
and secure relationship which helps me when I am stressed‟, „when there are no clear
solutions to my problems, sometimes fate or God can help‟, „under pressure I stay focused

27
and think clearly‟, „I try to see the humorous side of things when I am faced with problems.‟
The scale rates participants over the past month with a total score of the CD-RISC varying
from 0 to 100. The items are scored on a five-point Likert scale, with higher scores reflecting
higher resilience.
4.0 Data analysis plan
The coded data will be checked, cleaned and entered once into a computer using EpiData
software and then exported into STATA 12.0 for analysis. Descriptive summary using
frequencies, proportions, graphs and cross tabs will be used to present results of the study.
Bivariate analysis will be done to determine each of these factors and how they are associated
with the dependent variable. Only factors that have been found to be significantly associated
with depression among HIV/AIDS during bivariate analysis will be entered into the
multivariate analysis. P value <0.05 will be taken as statistically significant. Chi-square will
be used to test associations between independent variables and dependent variable (main
outcome).
4.1 Ethical considerations
Prior to the commencement of the study approval letter will be obtained from research ethics
committee at Lira University. Permission will also be obtained from Dokolo district officials
and authority of the health center where the study will be conducted. Informed verbal consent
will be obtained from the patients. The patients‟ privacy during the interview will be
maintained and the data obtained from them will be strictly kept confidential. Finally, the
study participants who will be found to be depressed, will be offered counselling and
guidance services for free by local health professionals.
4.1.1 Permission to Conduct Research
The researcher will obtained permission to conduct study research ethics committee at Lira
University. Authority to conduct research in Dokolo district will be also obtained from the
District Authorities before commencement of data collection.
4.1.2 Voluntary Participation
The right of the participants to participate in the research or not, as they choose, will be
respected. All participants will participate freely after receiving information on the study and

28
their right to answer questions or not, right to avoid being made uncomfortable and the right
to withdraw at any time during the interview process will be emphasized.
4.1.3 Informed Consent
Participants will be provided with adequate information on the research before the interview
and due to the low level of literacy, the consent obtained from most participants will be
verbal (oral).
4.1.4 Confidentiality & Anonymity
The right of participants to anonymity and confidentiality will be ensured by reporting
research findings in a way that would not relate to participants.

29
REFERENCES
Aguocha, C. M., Uwakwe, R. U., Duru, C. B., Diwe, K. C., Aguocha, J. K., Enwere, O. O., &
Olose, E. O. (2015). Prevalence and Socio-demographic Determinants of Depression among
Patients Attending HIV / AIDS Clinic in a Teaching Hospital in Imo State , Nigeria, 3(6),
106–112. https://doi.org/10.12691/ajmsm-3-6-4
Amare, T., Getinet, W., Shumet, S., & Asrat, B. (2018). Prevalence and Associated Factors of
Depression among PLHIV in Ethiopia : Systematic Review and Meta-Analysis , 2017, 2018.
Article, R. (2014). HIV infection and depression, (July 2013), 96–109.
https://doi.org/10.1111/pcn.12097
Bhana, A., Mellins, C. A., Small, L., Nestadt, D. F., Leu, C., & Petersen, I. (2016). Resilience
in perinatal HIV + adolescents in South Africa, 28, 49–59.
Box, P. O. (n.d.). HIGHER LOCAL GOVERNMENT STATISTICAL ABSTRACT
DOKOLO DISTRICT, (June 2009).
Edward, K., & Edward, K. (2015). Resilience : A Protector to Depression, (August 2005).
https://doi.org/10.1177/1078390305281177
Eloff, I., Finestone, M., Makin, J. D., Boeving-allen, A., Visser, M., Eberso, L., … Forsyth,
B. W. C. (2014). A randomized clinical trial of an intervention to promote resilience in young
children of HIV-positive mothers in South Africa, (May).
https://doi.org/10.1097/QAD.0000000000000335
Emlet, C. A., Tozay, S., & Raveis, V. H. (2010). “ I ‟ m Not Going to Die from the AIDS ”:
Resilience in Aging with HIV Disease, 51(1), 101–111.
https://doi.org/10.1093/geront/gnq060
Eshetu, D. A., Meseret, S., & Gizachew, K. D. (2015). iMedPub Journals Prevalence of
Depression and Associated Factors among HIV / AIDS Patients Attending ART Clinic at
Debrebirhan Referral Hospital , North Showa , Amhara Region , Ethiopia, 1(1), 1–7.
Fontes, A. P., & Neri, A. L. (n.d.). Resilience in aging : literature review, 1475–1496.
https://doi.org/10.1590/1413-81232015205.00502014

30
Gomo, P., Raniga, T., & Motloung, S. (2017). RESILIENCE AMONGST CHILDREN
LIVING WITH HIV : VOICES OF FOSTER PARENTS RESIDING IN BHAMBAYI ,
KWAZULU- NATAL , SOUTH AFRICA Paida Gomo , Tanusha Raniga , Siphiwe
Motloung, 53(2).
Huang, J., Zhang, J., & Yu, N. X. (2019). Close relationships , individual resilience resources
, and well-being among people living with HIV / AIDS in rural China. AIDS Care, 0(0), 1–9.
https://doi.org/10.1080/09540121.2018.1496222
Kibret, G. D., & Salilih, S. Z. (2015). Prevalence and Associated Factors of Depression
among HIV Infected Patients in Debre Markos Town Northwest Ethiopia, 17(4), 714–716.
Lingen-stallard, A., Furber, C., Lecturer, S., & Lavender, T. (2016). Testing HIV positive in
pregnancy : A phenomenological study of women â€TM
s experiences. Midwifery, 35, 31–38.
https://doi.org/10.1016/j.midw.2016.02.008
Maatouk, I., He, S., Becker, N., Hummel, M., Hemmer, S., Hillengass, M., … Hillengass, J.
(2018). Association of resilience with health- related quality of life and depression in multiple
myeloma and its precursors : results of a German cross-sectional study, 1–8.
https://doi.org/10.1136/bmjopen-2017-021376
Manuscript, A. (2015). NIH Public Access, 70, 221–231. https://doi.org/10.1007/s11199-014-
0348-x.Resilience
Orton, L., Griffiths, J., Green, M., & Waterman, H. (2012). Resilience among asylum seekers
living with HIV. BMC Public Health, 12(1), 1. https://doi.org/10.1186/1471-2458-12-926
Rabkin, J. G. (2008). HIV and Depression : 2008 Review and Update.
Ramaiya, M. K., Sullivan, K. A., Donnell, K. O., Cunningham, K., Shayo, A. M., Mmbaga,
B. T., & Dow, D. E. (2016). A Qualitative Exploration of the Mental Health and Psychosocial
Contexts of HIV-Positive Adolescents in Tanzania, 1–13.
https://doi.org/10.1371/journal.pone.0165936
Richter, L. (n.d.). THE IMPACT OF HIV / AIDS ON THE DEVELOPMENT OF
CHILDREN.
Spies, G., & Seedat, S. (2014). Depression and resilience in women with HIV and early life
stress : does trauma play a mediating role ? A cross-sectional study, 1–7.
https://doi.org/10.1136/bmjopen-2013-004200

31
Toukhsati, S. R., Jovanovic, A., Dehghani, S., Tran, T., & Tran, A. (2017). Low
psychological resilience is associated with depression in patients with cardiovascular disease.
https://doi.org/10.1177/1474515116640412
Town, M., Kibret, G. D., & Salilih, S. Z. (2015). Prevalence and Associated Factors of
Depression among HIV Infected Patients Prevalence and Associated Factors of Depression
among HIV Infected Patients in Debre Markos Town Northwest Ethiopia, 1(1), 10–13.
https://doi.org/10.4172/1522-4821.1000297

32
APPENDIX I; CONSENT
Project Title: DEPRESSION AND RESILIENCE AMONG PATIENTS ATTENDING
OUT-PATIENT DEPARTMENT AT DOKOLO HEALTH CENTRE IV, DOKOLO
DISTRICT, NORTHERN UGANDA.
Purpose of this Research/Project
This research is aimed at determining the prevalence of depression, factors associated with
depression and the relationship between depressive symptomatology and resilience among
HIV patients attending out-patient department at Dokolo Health centre IV. The results of this
study will be given to Dokolo District local government and administrators of Dokolo Health
center IV who will take the necessary actions depending on the outcomes. The study will
therefore be of benefit to the participants and the community as a whole.
Procedures
The study will involve random recruitment of study respondents from the patients attending
the ART clinic of Dokolo health centre IV.
Extent of Anonymity and Confidentiality
Information regarding you and your family will be kept anonymous and confidential and
results obtained will be made available to the health sector only if you agree for it to be
shared.
Subject's Permission
I have been fully informed about the study and conditions of this study. I have been given the
opportunity to ask questions and they have been answered to my satisfaction. I hereby
acknowledge the above and give my voluntary consent:
Signature: ________________________ Date: ________________
If I have any pertinent questions about this research, its conduct, participants rights, and
whom to contact in the event of a research-related inquiry to the subject, I may contact:
Investigator(s) Name: OKELLO DENIS DANIEL
Investigator‟s Contact: 0775267388

33
APPENDIX II: QUESTIONNAIRE
Date of Interview ……………………………......
Study Number ………………………………..
SECTION A: BIODATA
Tick the number that is applicable to you.
1. Age of the respondent
1. 18 - 25
2. 26 - 35
3. 36 - 45
4. 46 - 55
5. 56 - 65
2. Gender of the respondent
1. Male
2. Female
3. What is the highest level of formal education you have attained?
1. None
2. Primary
3. Secondary
4. Diploma and Above
4. Area of Residence
1. Rural
2. Urban
5. Employment Status.
1. Peasant
2. Government Employee
3. Private Employee
4. Business
5. Unemployed
6. Other

34
7. Marital Status
1. Single
2. Married
3. Divorced
4. Widowed
8. Presence of opportunistic infections
1. Yes
2. No
9. Age of the respondent
1. 18 - 25
2. 26 - 35
3. 36 - 45
4. 46 - 55
5. 56 – 65
10. Religion
1. Catholic
2. Anglican
3. Muslim
4. SDA
5. Other
11. Body mass index………………………….
12. CD4+ Cell Counts………………………

35
Section B; Prevalence of Depression
Center for Epidemiologic Studies Depression Scale (CES-D), NIMH
Below is a list of the ways you might have felt or behaved. Please tell me how often you have
felt this way during the past week.
During the Past Week
Rarely or none
of the time
(less than 1
day )
Some or a
little of the
time (1-2
days)
Occasionally or a
moderate amount of
time (3-4 days)
Most or all
of the time
(5-7 days)
1. I was bothered by things
that usually don‟t bother me.
2. I did not feel like eating;
my appetite was poor.
3. I felt that I could not shake
off the blues even with help
from my family or friends.
4. I felt I was just as good as
other people.
5. I had trouble keeping my
mind on what I was doing.
6. I felt depressed.
7. I felt that everything I did
was an effort.

36
8. I felt hopeful about the
future.
9. I thought my life had been
a failure.
10. I felt fearful.
11. My sleep was restless.
12. I was happy.
13. I talked less than usual.
14. I felt lonely.
15. People were unfriendly.
16. I enjoyed life.
17. I had crying spells.
18. I felt sad.
19. I felt that people dislike
me.
20. I could not get “going.”
SCORING: zero for answers in the first column, 1 for answers in the second column, 2 for
answers in the third column, 3 for answers in the fourth column. The scoring of positive
items is reversed. Possible range of scores is zero to 60, with the higher scores indicating the
presence of more symptomatology.

37
Section C; Other factors associated with depression
16. What is your monthly income?
1. No income
2. <Ushs 50,000
3. Ushs 50,000 – 250,000
4. Ushs 250,000 – 500,000
5. Ushs 500,000 – 1,000,000
6. >Ushs 1,000,000
17. What is your Living Condition?
1. Alone
2. Nuclear Family
3. Extended Family
18. How do you rate social support given to you?
1. Very good
2. Fair
3. Poor
19. Are you stigmatized and discriminated based on your HIV status?
1. Yes
2. No
20. What is your health status?
1. Very good
2. Fair
3. Poor
21. Were you hospitalized in the past one month?
1. Yes
2. No

38
22. HIV stage
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
23. Have you disclosed your HIV status?
1. Yes
2. No
24 To whom have you disclosed your HIV status?
1. Family
2. Spouse
3. Friends
4. Neighbours
Section C; Resilience of patients
Connor-Davidson Resilience Scale CD-RISC
S/N ITEM
RESPONSE
Not True at
all for me
Neutral
True
Sometimes
True nearly
all the time
1 Able to adapt to change
2 Close and secure
relationships
3 Sometimes fate or God can
help
4 Can deal with whatever
comes
5 Past success gives
confidence for new
challenge
6 See the humorous side of
things
7 Coping with stress
strengthens

39
8 Tend to bounce back after
illness or hardship
9 Things happen for a reason
10 Best effort no matter what
11 You can achieve your goals
12 When things look hopeless,
I don‟t give up
13 Know where to turn for help
14 Under pressure, focus and
think clearly
15 Prefer to take the lead in
problem solving
16 Not easily discouraged by
failure
17 Think of self as strong
person
18 Make unpopular or difficult
decisions
19 Can handle unpleasant
feelings
20 Have to act on a hunch
21 Strong sense of purpose
22 In control of your life
23 I like challenges
24 You work to attain your
goals
25 Pride in your achievements
THE END
THANK YOU FOR PARTICIPATING IN THE STUDY

40
APPENDIX III; WORKPLAN
months
Activity
Feb
2019
Mar
2019
Apr
2019
May
2019
Jun
2019
Jul
2019
Aug
2019
Sept
2019
Oct
2019
Pre-reading
Tool Design
Proposal writing
Data collection
Data Analysis
Draft report writing
Corrections
Report submission

41
APPENDIX 1V; BUDGET OF THE STUDY
Serial
number
ITEM QTY UNIT COST TOTAL COST
( SHILLINGS)
1 Stationary
(Ream of paper)
2 22,000 44,000
2 Proposal development 1 50,000 50,000
3 Development of research tools
80,0000
4 Local transport 40,000 40,000
5 Data analysis 1 150,000 150,000
6 Typing of report 1 30,000 30,000
7 Printing and binding of report
3 70,000 70,000
TOTAL 464,000

42
APPENDIX IV; MAP OF DOKOLO DISTRICT

43
APPENDIX V; MAP OF DOKOLO HEALTH CENTER IV DISTRICT

44
APPENDIX VI; PICTURE OF DOKOLO HEALTH CENTER IV

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