Bishop Stuart University
Department of Public Health and Biomedical Sciences
10/05/2025
Shivani Kalaskar
Editor
BMC Psychology
Dear Madam/Sir
Re: Point by Point to reviewers' comments on the manuscript “Counseling and Depressive
Symptoms in Older Adults with HIV/AIDS in Mbarara, Uganda”
Thank you for allowing us to resubmit our manuscript. The review comments are highly appreciated,
and they have been utilized to improve the manuscript. Below, kindly receive the point-by-point
responses to the reviewers’ comments
Sn Comment Authors Response
Reviewer 4
1 Writing Quality: While the Some sentences have been shortened, and other
manuscript is generally well- sentences paraphrased
written, some sentences are overly
long and complex, which may
reduce readability. For example, in
the Introduction: "Since
depression has been connected to
worse psychological and medical
outcomes in PLWH, such as a
higher risk of mortality, an
elevated viral load, and a lower
perceived quality of life,
depression in PLWH is a serious
public health problem." I suggest
breaking such sentences into
shorter, clearer ones.
2 Additionally, inconsistent use of PLWH has been used throughout the manuscript
terms like "PLWH" and
"PLWHA" should be standardized
(e.g., use "PLWH" throughout).
3 References: Reference #40 is Reference #40 has been updated.
marked as "INVALID
CITATION" and must be
corrected.
4 Additionally, some claims lack Reference (18) supports the claim. - Mpondo BC. HIV
precise citations, such as "The Infection in the Elderly: Arising Challenges. J Aging
number of older people living with Res. 2016;2016:2404857.
HIV is rising worldwide, having
increased by nearly 17% in the last
ten years" (Reference 19 does not
support this claim). Please ensure
all claims are backed by
appropriate references.
5 Statistical Analysis: The logistic This has been added in the discussion: The identified
regression model’s Pseudo R² is predictors, such as home visits, frequent counseling
relatively low (0.26), indicating remain clinically actionable. The modest variance
that the model explains only 26% explanation underscores the complexity of depression
of the variance. This limitation etiology in PLWH and aligns with existing literature
should be acknowledged in the highlighting multifactorial influences stigma, social
Discussion section. isolation, medication side effects (17, 43, 46).
Interventions should adopt a holistic approach,
combining psychosocial support with medical care to
address unmet needs.
6 Additionally, the exclusion of Factors like gender or marital status had a p-value
variables like gender or marital greater than 0.05. Factors significant at p<0.1 at
status from the multivariate bivariate logistic regression were considered for
analysis (Table 4) should be inclusion in a multivariable level analysis. Factors
briefly justified in the text or a with a p value < 0.05 were kept in the final
footnote. multivariable model and all effect measures were
presented with a significance level of 5% with a
95%CI.
Confounding Variables: Potential The following was added in the limitations: The study
confounders (e.g., education level, did not account for potential confounders such as
socioeconomic status, or HIV education level, socioeconomic status, or HIV disease
disease severity) were not severity, which may influence both depression and the
controlled for in the analysis. This effectiveness of counseling. Future studies should
should be noted as a limitation, include these variables in their design and analysis to
and future studies could address better isolate the impact of counseling on depressive
these factors. symptoms.
Results Presentation: In Table 3, This has been addressed in the manuscript.
the column heading "Depression
(n=22, .3%)" appears to have a
typographical error; it should
likely be "8.3%" as per the text.
Please correct this.
Additionally, non-significant This has been addressed in the manuscript: The lack of
results (e.g., gender, p=0.487 in significance may reflect the homogeneity of the
Table 1) could benefit from a brief sample, like similar socioeconomic challenges across
explanation in the text to guide the participants or the protective role of counseling in
reader. mitigating demographic disparities.
Recommendations: The Recommendations have been revised as follows; It is
recommendations are practical but recommended that healthcare providers integrate the
could be more specific. For PHQ-9 or other validated tools into routine HIV care
instance, instead of "Regular visits to systematically screen for depression and track
monitoring and evaluation of these symptom changes over time.
services should be conducted,"
consider specifying the type of To further reduce the risk of depression, it is
monitoring (e.g., using recommended to prioritize home visits for high-risk
standardized mental health groups such as those with limited mobility, low social
screening tools) or evaluation support, or prior depressive symptoms and measure
metrics (e.g., patient satisfaction outcomes through pre- and post-visit PHQ-9
or adherence rates). assessments.
Train counselors to involve family members during
sessions, leveraging tools like the Family Support
Scale to quantify improvements in household
dynamics and emotional support.
Establish peer-led support groups for older PLWH,
with biannual evaluations of participation rates and
mental health outcomes like depression prevalence,
self-efficacy scores.
Discussion: Some claims in the References have been added in the manuscript:
Discussion are overly generalized, Mugisha JO, Ssebunnya J, Kigozi F, Ndyanabangi S.
such as "home-based counseling Comparative effectiveness of clinic-based versus
for older adults living with home-based counseling among HIV-positive
HIV/AIDS can be understood individuals in urban Uganda: A randomized trial. .
through the lens of person- BMC Health Services Research. 2019
centered and culturally sensitive 19:514.
care models." This statement 46. Giusti A, Nkhoma K, Petrus R, Petersen I,
would benefit from a supporting Gwyther L, Farrant L, et al. The empirical evidence
reference or further elaboration. underpinning the concept and practice of person-
centred care for serious illness: a systematic review.
BMJ Glob Health. 2020;5(12).
47. Lofgren SM, Tsui S, Atuyambe L, Ankunda
L, Komuhendo R, Wamala N, et al. Barriers to HIV
care in Uganda and implications for universal test-
and-treat: a qualitative study. AIDS Care.
2022;34(5):597-605.
48. Nakimuli-Mpungu E, Musisi S, Smith CM,
Von Isenburg M, Akimana B, Shakarishvili A, et al.
Mental health interventions for persons living with
HIV in low- and middle-income countries: a
systematic review. J Int AIDS Soc. 2021;24 Suppl
2(Suppl 2):e25722.
Additional Suggestions:
Shorten the title for better The title has been shortened from: Role of
readability, e.g., "Counseling and Counselling in Reducing Depressive Symptoms
Depressive Symptoms in Older among Older Persons Living with HIV/AIDS in
Adults with HIV/AIDS in Mbarara City, South-Western Uganda
Mbarara, Uganda." To Counseling and Depressive Symptoms in Older
Adults with HIV/AIDS in Mbarara, Uganda
In the Limitations section, The limitation has been added; The study did not
consider mentioning the potential explicitly account for how cultural beliefs and
impact of cultural differences on practices in southwestern Uganda may influence
responses to counseling, as this perceptions of counseling effectiveness. For instance,
could vary across populations. preferences for spiritual or communal support systems
(e.g., traditional healers, family-led interventions)
might shape engagement with formal counseling. This
cultural nuance could limit the generalizability of
findings to other regions or populations with distinct
sociocultural contexts.
For future studies, the authors The variables that would strengthen this suggestion
might explore longitudinal or (explore longitudinal or quasi-experimental designs to
quasi-experimental designs to establish causality) are: home visits and depression
establish causality, as noted in the
manuscript. Specifying which
variables (e.g., social support or
stigma) to focus on in such studies
would strengthen this suggestion.
My Final Recommendation: This is great. The comments identified were addressed
This manuscript makes a valuable and hopefully, it will be accepted.
contribution to the literature on
mental health interventions for
older adults with HIV/AIDS in
low-resource settings. The study is
scientifically sound, with minor
revisions needed to enhance
clarity, precision, and depth. I
recommend acceptance after
addressing the points above.
Reviewer 2
Reviewer Comments to the
Authors
1. Although the introduction The theoretical framework has been included;
provides a solid rationale for the The Stress-Buffering Model (33) provides a robust
study, the manuscript lacks a clear theoretical foundation for understanding the
theoretical framework to guide the relationship between counseling and depressive
study’s hypotheses and variable symptoms in this study. This model posits that social
selection. Consider incorporating support mitigates the adverse psychological effects of
relevant psychological or stressors by enhancing coping mechanisms, fostering
behavioral theories (e.g., the resilience, and reducing perceived isolation. For older
Stress-Buffering Model, Socio- adults living with HIV/AIDS, stressors such as stigma,
Ecological Model, or Person- chronic illness management, and social isolation
Centered Counseling Theory) to exacerbate depression. As a form of structured social
frame the association between support, counseling may buffer these stressors by
counseling and depression. providing emotional validation, practical problem-
solving strategies, and a sense of empowerment.
2.The manuscript states that
stratified sampling was used Within each stratum, participants were selected
across health centers, but it also proportionally based on the total number of clients at
mentions sequential enrollment, each facility. However, patients were enrolled
raising questions about consecutively (one after another) as they accessed
randomization and services, rather than through random selection. This
representativeness. Please clearly sequential enrollment method was likely chosen for
articulate how patients were practicality, ensuring the target sample size per
selected within each stratum. stratum was met.
Were they enrolled consecutively,
randomly, or based on
availability?
3. Although the Yamane formula The effect size for the power calculation was informed
and a power estimate are provided, by prior studies on counseling interventions in similar
the effect size and key populations, which reported an odds ratio (OR) of
assumptions are not clearly ≥2.0 for the association between counseling frequency
defined. Include a brief and reduced depression (17, 24). Using G*Power 3.1,
description of the assumed effect a post-hoc power analysis was conducted for logistic
size and rationale behind selecting regression with a two-tailed test, α=0.05, and a sample
a power of 87% for logistic size of 265. The analysis assumed a medium effect
regression. Mention the software size (Cohen’s f² = 0.15), consistent with psychosocial
used (e.g., G*Power). intervention studies in PLWH (42). This yielded a
power of 87%, which exceeds the conventional 80%
threshold, ensuring sufficient capacity to detect
clinically meaningful associations. The rationale for
accepting 87% power was its alignment with resource
constraints and feasibility, while maintaining
robustness against Type II errors.
4.The number of eligible All the eligible participants were approached and the
participants approached and the response rate was 100%, there was no any refusal or
actual participation rate are not drop out.
mentioned. Report the response
rate and clarify whether any
refusals or dropouts occurred, as
this affects generalizability and the
potential for response bias.
5. The operationalization of The study operationalized counseling using single-
“counseling” (e.g., frequency, item, researcher-developed measures: frequency of
mode, family involvement) interaction (e.g., “How often do you talk to your
appears multi-faceted but lacks counsellor?”), home visits (yes/no), family
psychometric structure. Please involvement (yes/no), and perceived benefits
elaborate on how each counseling (checklist of outcomes like reduced stigma). No
dimension was measured. Was a validated scales were used for counseling dimensions,
formal scale used or were these though content validity (CVI=0.92) and reliability
single-item measures developed (Cronbach’s α >0.81) were reported for the broader
for this study? Has a pilot questionnaire. A pilot study was not mentioned. While
application been made? depression was assessed via the validated PHQ-9,
counseling variables relied on non-standardized items,
limiting psychometric rigor and generalizability. This
approach prioritized context-specific practicality over
structured measurement of counseling’s multifaceted
aspects.
6. The stepwise logistic regression The stepwise logistic regression approach is
approach is described but lacks described;
justification. It may lead to Stepwise logistic regression was employed to identify
overfitting or exclusion of key predictors of depression in this exploratory study,
theoretically important variables. justified by resource constraints and the need to
Justify the use of stepwise prioritize variables in a setting with limited prior local
methods and ensure that evidence. While stepwise methods risk overfitting,
theoretical rationale—not just variable inclusion was guided by both statistical
statistical significance—guides significance (p < 0.05 for entry, p < 0.10 for retention)
model inclusion. Consider testing and theoretical relevance—such as home visits and
for multicollinearity and reporting counseling frequency, which align with literature
VIF values. linking social support to reduced depression in
PLWH. Multicollinearity was assessed using Variance
Inflation Factor (VIF) values, all < 2.0, confirming
model stability. The final model explained 26% of
variance (Pseudo R² = 0.26), underscoring residual
variance likely attributable to unmeasured
confounders (e.g., socioeconomic status, viral load),
emphasizing the need for holistic interventions beyond
counseling alone.
7.Several odds ratios (e.g., AOR = The significant associations between lack of home
2.54 for lack of home visit) are visits (AOR=2.54) and infrequent counseling
statistically significant but their (AOR=1.24) with depression underscore actionable
clinical relevance and contextual strategies for health services. Home visits address
interpretation are not fully barriers like mobility limitations and stigma, enabling
explored. Expand the discussion to tailored psychosocial support and family engagement,
address the practical significance critical in low-resource settings. Integrating home-
of these findings. What do they based counseling into HIV care through task-shifting
mean for health service planning? such as training community health workers could
expand reach, while optimizing contact frequency via
telehealth or group sessions enhances accessibility.
Policymakers should prioritize funding for counselor
training, transportation, and culturally adapted
interventions, potentially partnering with traditional
healers. These steps, coupled with routine depression
screening, may improve ART adherence, reduce
healthcare costs, and mitigate mental health burdens,
though resource constraints and sustainability require
longitudinal evaluation.
8.There are a number of language The language was reviewed and errors minimized.
and syntax issues throughout the
manuscript (e.g., “clients were
counselled in presence of family
members” → “clients were
counseled in the presence of
family members”). A language
review by a native English speaker
or professional editor is
recommended.
9.Tables 1–4 could be improved in For Table 1: Values presented as mean ± SD or n (%)
layout. Consider aligning For Table 2: Multiple responses allowed; percentages
decimals. Table 2’s multiple- sum to >100%
response structure should be more All values in Tables 1-4 have been aligned right.
clearly explained in the footnote.
10.The limitations are only The study was limitations self-report bias, lack of
partially addressed. Important longitudinal data, and selection bias have been
concerns such as self-report bias, explicitly discussed
lack of longitudinal data, and
selection bias should be discussed
more explicitly.
11. Provide more insight into the In Uganda, cultural beliefs and stigma profoundly
cultural relevance of counseling shape engagement with counseling services. HIV-
within the Ugandan context. For related stigma remains pervasive, driven by
example, how do local beliefs or misconceptions about transmission and moral
stigma influence engagement with judgments, which often isolate individuals and deter
counseling services? Consider them from seeking formal mental health support.
discussing how the study's Many older Ugandans prioritize familial and
findings might inform policy communal support systems, relying on traditional
development, including the healers or spiritual leaders for psychosocial needs, as
potential integration of home- these align with deeply rooted cultural norms. This
based psychosocial services into preference may limit uptake of clinic-based
HIV care programs. counseling, perceived as impersonal or stigmatizing
due to fears of disclosure. Home visits circumvent
stigma by offering privacy and familiarity, while
involving family members during sessions resonates
with Uganda’s collectivist culture, where communal
decision-making is valued. These findings suggest that
integrating home-based services into national HIV
care programs, leveraging community health workers
(CHWs) or trained peers who understand local dialects
and traditions, could enhance accessibility and
acceptability.
To further reduce the risk of depression, it is
recommended to prioritize home visits for high-risk
groups such as those with limited mobility, low social
support, or prior depressive symptoms. These visits
should involve collaboration with traditional healers
and spiritual leaders to co-deliver counseling,
fostering trust and bridging gaps between biomedical
and cultural health systems.
Additionally, community-led anti-stigma campaigns
should be developed to dispel HIV myths,
emphasizing counseling as a tool for empowerment
rather than a marker of weakness. Training
community health workers in cultural competence,
including strategies to address spiritual concerns or
familial dynamics, could further align services with
local norms.
