Psychosocial Assessments for HIV+ African Adolescents: Establishing Construct Validity and Exploring Under-Appreciated Correlates of Adherence

Abstract

Study ObjectivesPsychosocial factors such as outcome expectancy, perceived stigma, socio-emotional support, consideration of future consequences, and psychological reactance likely influence adolescent adherence to antiretroviral treatments. Culturally-adapted and validated tools for measuring these factors in African adolescents are lacking. We aimed to identify culturally-specific factors of importance to establishing local construct validity in Botswana.MethodsUsing in-depth interviews of 34 HIV+ adolescents, we explored how the psychosocial factors listed above are perceived in this cultural context. We evaluated six scales that have been validated in other contexts. We also probed for additional factors that the adolescents considered important to their HIV medication adherence. Analyses were conducted with an analytic framework approach using NVivo9 software.ResultsWhile the construct validity of some Western-derived assessment tools was confirmed, other tools were poorly representative of their constructs in this cultural context. Tools chosen to evaluate HIV-related outcome expectancy and perceived stigma were well-understood and relevant to the adolescents. Feedback from the adolescents suggested that tools to measure all other constructs need major modifications to obtain construct validity in Botswana. The scale regarding future consequences was poorly understood and contained several items that lacked relevance for the Batswana adolescents. They thought psychological reactance played an important role in adherence, but did not relate well to many components of the reactance scale. Measurement of socio-emotional support needs to focus on the adolescent-parent relationship, rather than peer-support in this cultural context. Denial of being HIV-infected was an unexpectedly common theme. Ambivalence about taking medicines was also expressed.DiscussionIn-depth interviews of Batswana adolescents confirmed the construct validity of some Western-developed psychosocial assessment tools, but demonstrated limitations in others. Previously underappreciated factors related to HIV medication adherence, such as denial and ambivalence, should be further explored.

Scaling a waterfall: a meta‐ethnography of adolescent progression through the stages of HIV care in sub‐Saharan Africa

“…This was reinforced by experiences with external stigma at other levels including: family neglect or ostracism from peers [39,40,43,[47][48][49][50], community gossip [41][42][43]46], discrimination in school [49,[51][52][53][54] or lack of empathy from health care workers (HCW) [45,50,[55][56][57]. Such social conditions reinforced barriers to HIV care linkage, retention in HIV services and adherence; with ALHIV often choosing to prioritize secrecy around their disease status over unintended disclosure [48,[51][52][53][54][55][57][58][59][60]. This choice frequently accounted for missed ART doses when social conditions were unfavourable, such as having minimal privacy in the home [49,51,53,57] or at school [49,52].…”

“…Fear surrounding the ability to manage the consequences of a positive diagnosis frequently created a barrier to testing [39,40,42,43,47]. Such diminished self-efficacy similarly affected ALHIVs' capacity to maintain new health behaviours over time, such as the ART adherence necessary to achieve viral suppression, due to frustration surrounding the ongoing nature of treatment or side effects [48][49][50][51][52][53]57,58,60,61]. Lack of self-efficacy was often associated with an absence of empathetic support to adolescents offered within HIV services regarding how to integrate these required new behaviours into their lifestyles [45,[49][50][51][52][53]57,58,60].…”

“…Such diminished self-efficacy similarly affected ALHIVs' capacity to maintain new health behaviours over time, such as the ART adherence necessary to achieve viral suppression, due to frustration surrounding the ongoing nature of treatment or side effects [48][49][50][51][52][53]57,58,60,61]. Lack of self-efficacy was often associated with an absence of empathetic support to adolescents offered within HIV services regarding how to integrate these required new behaviours into their lifestyles [45,[49][50][51][52][53]57,58,60]. Selfefficacy was restored through acts or interventions that operated at other levels of the SEM including support from family members, participation in community support groups or support from treatment buddies [48][49][50][51][52]54,[57][58][59].…”

“…Lack of self-efficacy was often associated with an absence of empathetic support to adolescents offered within HIV services regarding how to integrate these required new behaviours into their lifestyles [45,[49][50][51][52][53]57,58,60]. Selfefficacy was restored through acts or interventions that operated at other levels of the SEM including support from family members, participation in community support groups or support from treatment buddies [48][49][50][51][52]54,[57][58][59].…”

CNS Impact of Perinatal HIV Infection and Early Treatment: the Need for Behavioral Rehabilitative Interventions Along with Medical Treatment and Care

“…Such neurobehavioral biomarkers can allow for early intervention using primary and secondary behavioral prevention and treatment strategies [84–86]. This is so that psychological support and treatment services can be developed in low-resource settings with a high prevalence of adolescents with HIV.…”