From implementation to sustainability? A 5-year follow-up on a physical activity counseling program in Uganda for people with HIV and mental health conditions

Abstract

Physical activity (PA) interventions benefit people living with HIV and co-morbid mental health conditions, but sustaining them in low-resource settings remains difficult. This study explored the long-term sustainability of a multi-stakeholder PA counseling program in a rural Ugandan fishing community, five years post-implementation. The program integrated a PA counseling into routine HIV care, combining motivational interviewing and self-determination theory. It began with sessions led by health care providers and later transitioned to lay-led group sessions that focused on goal-setting, identifying barriers, and fostering community support. Using a context–mechanism–outcome (CMO) framework and Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis, a focus group (n = 10) involving patients, lay health workers, and staff identified key influencing factors. Although the program ended, PA awareness and some brief counseling persisted. Lay health workers remained partially active despite unpaid roles and limited supervision. Early success was supported by family involvement, and stakeholder enthusiasm, while long-term delivery was hindered by funding gaps and persistent stigma. Sustainability was supported by co-creation, community engagement, and task-shifting, but depended on material support and health system integration. Future efforts should prioritize early financial planning, integration into existing systems, and strengthening of lay roles through stable funding and supportive policy.