Cultural adaptation of an evidence-based psychosocial screening tool for adolescents living with HIV/AIDS in adolescents’ antiretroviral therapy program in Zomba, Malawi
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Date
7-07-21
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Kamuzu University of Health Sciencies
Abstract
Executive Summary
D. Title of the study: Cultural adaptation of an evidence-based psychosocial screening tool for adolescents living
with HIV/AIDS in adolescents’ antiretroviral therapy program in Malawi
Problem Statement: In Malawi, a study on depression among adolescents living with HIV (ALHIV) revealed a
prevalence rate of 18.9%3. Despite the high prevalence and impact of depression on ALHIV health outcomes, lack
of awareness and stigma around mental health services leave ALHIV with depression undetected and there are few
culturally, sensitive, standardized, and validated instruments available for depression screening in the African
region1,6. The Home, Education, Activities, Drugs, Sexuality, Suicide/Depression (HEADSS) psychosocial screening
tool, is an efficacious evidence-based intervention (EBI)8-10 to improve identification of psychosocial issues, such as
depression screening and risky behavior. This tool was recommended for use in the adolescent antiretroviral therapy
(ART) program called Teen Club (TC) in Malawi in an attempt to identify the above-mentioned challenges. However,
its introduction has had poor uptake. Our previous formative study on “Implementation barriers of the HEADSS
screening tool in Teen Club Program in two districts in Malawi” found that HEADSS was too long, time consuming
and not culturally appropriate to the Malawi setting and some of the suggestions included modification of this tool in
order to be culturally acceptable for use in Malawi. Therefore, this current study builds upon our previous findings.
Main objective of the study: The long-term goal of this study is to culturally adapt the HEADSS psychosocial
screening tool based on our formative work, identify the barriers and facilitators to implementing the modified
HEADSS, and identify implementation strategies to address identified barriers to improve the mental health
outcomes among ALHIV in Malawi.
Specific Objectives are to:
1) Review prior formative study findings and conduct systematic modifications process of the existing HEADSS
psychosocial screening tool.
2) Identify the barriers and facilitators to the implementation of the adapted HEADSS among the HCPs in Teen
Club program and ALHIV in order to understand the usability and acceptability of the adapted HEADSS
screening tool.
3) Based on the findings in objective 2, identify implementation strategies to address the identified barriers to
improve the mental health outcomes among ALHIV in Malawi.
Methodology: This will be a cross-sectional descriptive qualitative study design and it will take place in Zomba
district (Zomba Central Hospital and 1 health center). A purposive sampling approach will be used to select the
participants. In-depth interviews (IDIs) using a semi-structured questionnaire will be conducted with key informants
(KIs) and health care providers (HCPs) then FGDs with adolescents living with HIV (ALHIV) between 12 and 18
years old. The sample will comprise of 1 clinical psychologist, 1 psychosocial counsellor, 1 Adolescent Coordinators
from the NGOs, 1 District Nursing Officer as key informants and 4 HCPs from the Health center and 2 from Zomba
Central Hospital Teen Club Program (Lighthouse). A similar proportion of male and female ALHIV will be included
in the FGDs from each site, totalling to 20 ALHIV in the 2 sites. An estimated total of 30 research participants will be
included in this study.
Potential constraints: Not many ALHIV might feel comfortable to speak up, however, our formative study showed
that the ALHIV were open and expressed themselves without any problem. The training will be provided to the
Research Assistant prior to commencement of data collection, and this will deliver specialized communication skills
to enable ALHIV to feel free and speak out on their experiences. Support will be provided to those ALHIV who need
to be referred to specialized mental health services and the research team will be trained to ensure that a correct
support and referral system is in place before the start of data collection. Some participants may also experience
discomfort to respond to the questions, however, they will be informed during the consenting process that they have
the right to refuse to answer any question that makes them uncomfortable and to stop the interview at any time. In
addition, while the research is aiming to reach an equal number of females and males, it may not be possible be get
a gender balanced participation. However, we will communicate these limitations clearly during feedback,
recommendation and dissemination activities. Additionally, due to the Covid pandemic, it might be a challenge to
get the number of ALHIV on the appointed date as there is limited number of staff and ALHIV assigned for each day.
We might even have to do face-to face interviews instead of FGDs depending on how the situation will be during