Table 3. Summary of themes from the experience of Community Health Officers (CHO) and Community Health Extension Workers (CHEW) who provided care for older people with depression in primary care settings.

THEMES	SOME ILLUSTRATIVE QUOTES
Views about Depression Characterised by mood, behavioural and cognitive symptoms which made clinical assessment difficult. Symptoms and clinical presentation overlapped with those seen in people with dementia. Bodily symptoms as a gateway to accessing primary health care clinics Personal economic challenges and lack of social support as key triggers of depression.	‘You know, someone who presented with physiological health problems won’t give a lot of trouble compared to those with depression or other mental health problems. People with mental health challenges pose a lot of trouble. Sometimes, they could be irritable, angry, thinking someone is being rude to them.’ (Interview 49 years old CHO) ‘In a depressive (depressed) elderly, they usually have low mood, mood swings and withdraw (al) from daily activities. So, the one with depression is withdrawn and experiences low mood…, none depressed person don’t show these symptoms.’ (Focus group 39 years old CHEW) ‘I actually realize that most of the elderly, they have issues of their belief system. No matter what you try to tell them, they have a concept of what is wrong with them. They have this mindset of what is wrong with them which they want to tell you and they want u to believe it too. So, you need to find a way of trying to convince them to change their orientation about that thing that they believe. Sometimes they believe that it’s spiritual. Yes, “the awon aye” (A curse or bewitchment)..maybe from their families. (Interview 38 years old CHO) ‘Hope you are not thinking of commuting suicide? that is the question they react to most of the time. It is always irritating to them, most of them will be like God forbid.’ (Interview 37 years old CHEW) ‘…she doesn’t talk well, if asked a question, she derails completely from the answer.’ (Interview 38 years old CHO) ‘Sometimes, you (Heath worker) may tell them something and they won’t hear because they were absent minded…Then, if you (Health worker) remind them that you (Health worker) initially asked if they have headache or insomnia, they’ll deny hearing the question….then you’ll know that the individual is challenged.’ (Interview 49 years old CHO) ‘There is also the peculiarity of dementia among them. So, they need someone to remind them if they have taken their drugs, including the clinicians.’ (Interview, 56 years old CHO) ‘When someone gets old, they forget things. This is called senile dementia. But if someone does not have the knowledge of depression, he might mistake or misdiagnose it as depression.’ (Interview 51 years old CHO) ‘He wasn’t violent, but he withdrew and was not eating. He has been on this for more than 2 months. But they didn’t know until he came to the clinic presenting a physical problem that it was detected that he had depression.’ (Interview, 56 years old CHO) ‘They (Patients) might say they have arthritis or body pain. If one isn’t thorough, he might not know that the patient is depressed.’ (Interview 46 years old CHEW) ‘The difference I know is that when you ask them about their children, they would tell you that they are alone. That would tell us that she has depression in the sense that there is no one to care for her and if she sees her children it would give her joy.’ (Interview 41 years old CHEW) ‘There was a woman who suffered economic reversals in her business. She could no longer care for her children, so this made her depressed.’ (Interview, 48 years old CHO)
Treatment of depression in primary care Counselling in the form of basic psychoeducation and advice Adjunctive use of sedatives and vitamins Involving patients’ family in their care Positive perception of treatment engagement	‘Most of the time, this requires counselling. There are some who do not require or need drugs; they only need counselling. That is talking therapy. That way we know the extent of how they are affected. For such ones we schedule visits for them. We like to have a discussion with them.’ (Interview, 48 years old CHEW) ‘The first thing is their belief system. Sometimes they believe that it’s spiritual. Yes, ‘the awon aye’ (Spirit agents) trying to get them, maybe from their families. The only challenge for me is trying to bring them out of that belief system to the reality of what is happening to them.’ (Interview, 38 years old CHO) ‘She then told me that since the other children are not taking care of her, she thinks death is the best option. I told her death is not an option, and that d other children would take care of her, if they’re being told that it is their responsibility. I later called on the children that accompanied her, then told them what mama said n they promised to take care of her. They also asked her what she wanted. She told them what her late child does for her and they promised to do it. Mama told them she’ll be fine if they fulfil their promise.’ (Interview, 49 years old CHO) ‘On knowing that, I invited one of the children. I also invited the man and counseled him and let him know that what has happened has happened and that he should put his mind at rest. His daughter whom I invited was also counselled, that she shouldn’t leave her father alone, that you should be there to take care of him and to make sure that he takes whatever drug was given to him.’ (Interview, 56 years old CHO) ‘But for an elderly patient with depression, like the woman I just mentioned, I did not use anything for her. I only asked her to used paracetamol for headaches and I told her to get diazepam to correct her sleeping patterns. That was what I used for her until she got okay.’ (Interview, 38 years old CHO) ‘I gave her some homework and amitriptyline because of lack of sleep.’ (Interview, 37 years old CHEW) Some of the challenges include them expecting you to give them medications. Some think psychoeducation is just an ordinary discussion. They believe everything wrong with them can only be sorted out with medications, whereas psychoeducation works better than drugs most times if they can adhere to it.’ (Interview, 49 years old CHO) ‘So, I realize that she’s having some symptoms of depression, and I tried to book her for counselling sessions. She said she’s having pain instead and that I needed to give her some mild analgesics to at least be fine.’(Interview, 38 years old CHO) ‘We would tell them that due to their age there is need for them to be coming for checkup, and of course, they comply, because most of them are less busy now, they don’t have so much doing, they come, in fact, they find it interesting. They have somebody to go and talk to, In fact, most of them, staying at home, they feel lonely. So, they believe when they come to hospital, they have someone to rub minds with.’ (Interview, 38 years old CHO) ‘Though they are cooperative, there are times when the children might take them away to another place. Like the example I cited earlier, the woman used to live alone. But when the children saw that she was getting better, they took her to another state (County)’ (Interview, 46 years old CHEW).
Community outreach Expected practice, but currently limited to infectious diseases immunization. No incentives to implement for older peoples’ mental health conditions in current practice. Mobile technology may circumvent current barriers to implementation in future practice.	‘Normally, going for home visit is part of our work, it is inside the standing order that we have with us.’ (Interview, 41 years old CHO) ‘We have done outreach about measles and other immunizations, and also (Mosquito) nets distribution’. (Focus group, 31 years old CHEW) ‘But because of their age and mobility, they may not be able to leave the house is to seek medical care at the clinics. But if they are visited at home by medical personnel, they would be elated such that they will tell everyone who cares to listen that they were visited by health care professionals. They will be very happy and count themselves as part of the community.’ (Interview, 48 years old CHO). ‘What I can say that is hindering us to take care of them, is the transportation means to get to their homes, even the communication gap (means of communication). So if we have those things, it will make it easier for us to take care of them.’ (Interview, 41 years old CHEW) I feel that if going to visit will be difficult, calling would serve as a solution to that to some extent. Though, it is not a full solution; we will still need to visit. (Interview, 56 years old CHO) I treated an elderly patient under remote consultation. When we have some with chronic diseases and they would like to be treated on the mobile (over the phone, I guess), we accept such. (Interview, 51 years old CHO) ‘Maybe phones should be provided for the health workers and an application that would guide them in the treatment and care of the elderly patient be installed on the phones’ (Interview, 51 years old CHO) ‘If it’s possible for the app to have something like a voice note, where u can play to them, in a language like in Yoruba. If it’s possible the app is in a way that if it can speak out to them. Any instruction you want to give them, maybe app first reads it out and do a level of reinforcement on it. This might be attractive to the elderly.’ (Interview, 51 years old CHO)