Culturally adapting a mindfulness and acceptance-based intervention to support the mental health of adolescents on antiretroviral therapy in Uganda

Abstract

The dual burden of living with HIV and negotiating life stage changes has been identified as a contributing factor to lapsed adherence among adolescents with HIV in sub-Saharan Africa. While psychosocial support can promote medication adherence, most interventions in use with adolescents were originally developed for the general population creating a gap in appropriate support. Life-stage-appropriate, evidence-based psychosocial support interventions have been used with young people in high-income contexts, prompting interest in their use in low-income contexts. However, many interventions are less effective when implemented outside of their original settings, hence the need for modifications before implementation. We aimed to culturally adapt an evidence-based psychosocial support intervention designed to improve the mental health of young people for use among adolescents with HIV in a sub-Saharan African context and to explore the acceptability of the adapted intervention among adolescents. We engaged thirty stakeholders (n = 30) in Kampala, Uganda including psychologists, psychiatrists, social workers, HIV counselors, religious leaders and adolescent peers from December 2021 to April 2022 to modify an evidence-based intervention for adolescents. Key adaptations included simplifying the language, adding local practices, integrating locally relevant slang and stories into therapy, introducing racially-congruent visuals and cards representing emotions, and adjusting therapy materials for use in resource-constrained settings. We then tested the acceptability of the intervention in a small sample of service users using a qualitative approach. We recruited nine adolescents with HIV from a participating clinic in Kampala, delivered six 90-minute sessions of the adapted intervention across three weeks and conducted in-depth interviews to assess the acceptability of the intervention. We used thematic analysis to analyze the qualitative data. The adapted intervention was perceived as acceptable among adolescents with HIV, with many stating that it helped them overcome fears, increased their self-acceptance, and gave them the confidence to make careful health-enhancing decisions.

The Effect of a Group-Based Mindfulness and Acceptance Training on Psychological Flexibility and Adherence to Antiretroviral Therapy Among Adolescents in Uganda: An Open-Label Randomized Trial

“…43 – 45 Moreover, the results concur with studies that found improved levels of psychological flexibility among adolescents who were exposed to DNA-v training. 42 , 67 By improving psychological flexibility among AWH, our results confirm that MABIs are transdiagnostic and can address a range of emotional and behavioral challenges across conditions. 70 …”

“…Mindfulness and acceptance-based interventions (MABIs) have the potential to promote self-regulation, resilience, and self-acceptance among young people 41 , 42 through a mechanism called psychological flexibility, the ability to live consciously aware of life challenges but deliberately making choices that are personally meaningful. 43 – 45 MABIs, through targeting psychological flexibility, address cognitive fusion (a state where individual behaviors are dominated by particular thoughts) and experiential avoidance (obsessing about suppressing negative thoughts), 41 , 46 processes that can impact adherence to medication among young people.…”

Effectiveness of a mindfulness and acceptance-based intervention for improving the mental health of adolescents with HIV in Uganda: An open-label trial

“…To implement these adaptations, sessions one and two (Introduction and Discoverer) were merged into a single session and the same was done for sessions five and six (Values and Self as context). To reduce session time with the adapted schedule, we replaced lengthy narratives from the DNA-V manual with shorter plays and games carrying the same messages [31]. This adaptation was reviewed and approved by the developers of the DNA-V.…”

“…The DNA-V intervention is a flexible mental health support program that targets to promote psychological flexibility among young people and can be delivered by lay providers such as counsellors and adolescent peers with minimal experience in facilitating group psychotherapy and working with adolescents. The providers are trained in using the DNA-V manual, practicing mindfulness, creating present moment awareness, values clarification and facilitating experiential exercises [30,31] and adherence to the guides of the manual ensures fidelity. In this study, group sessions of the DNA-V were delivered to AWH as life skills training responding to the developmental needs of young people [29].…”

“…In an earlier related study, we engaged thirty stakeholders involved in HIV care and mental health support in Uganda to review the DNA-V manual, gauge the appropriateness of the intervention for use in Uganda and suggest adjustments to improve its social validity. Key adjustments made included; simplifying the language of the Discoverer-Noticer-Advisor-values model DNA-V manual, incorporating local stories and plays in therapy, using racially congruent visuals, adjusting therapy sessions from six to four to minimize clinic visits and adding cards that depict different emotion expression [31].…”