Multiple-Family Group Intervention Programming to Improve Mental Health of Adolescents Living With HIV/AIDS in Ghana: An Implementation Science Study Protocol.

Globally, 38.4 million people are living with HIV, of which 1.7 million are children aged 0-14 years (UNAIDS, 2022). Sub-Saharan Africa contributes substantially to the HIV burden, reflected in the high HIV prevalence, mortality and morbidity (Kharsany & Karim, 2016). Relating to Ghana, about 1.7% of population is living with HIV, with adolescents aged 15-19 years contributing to 0.7% of the HIV burden (Agyemang et al., 2020). The diagnosis of HIV potentiates a cascade of mental health problems that impact all aspect of HIV prevention, treatment/management. This vulnerability is significantly elevated in adolescents who have heightened risk for mental health problems owing to their developmental stage (Wright et al., 2021). In a recent global meta-analytic study, the prevalence of depression among ALHIV was 26.07%, with females (32.15%) and older adolescents aged 15-19 years (37.09%) recording the highest rate than males (25.07%) and younger adolescents aged 10-14 years (29.82%), respectively (Ayano et al., 2021).

Focusing on SSA, a recent systematic review found that 25% ALHIV screened positive for any psychiatric disorder, whereas 30-50% presented with emotional, behavioral difficulties or significant psychological distress (Dessauvagie et al., 2020). Despite the paucity of epidemiological studies in Ghana, existing evidence suggests that ALHIV suffer from discrimination and rejection, ushering them into profound psychological distress such as suicidal thoughts and hopelessness (Doat et al., 2021) that often culminate into poorer psychosocial adjustment (Doku, 2010). Unaddressed mental health problems in ALHIV not only contribute to mental health burden but also negatively impact on treatment adherence, prevention of HIV through adoption of safe sexual practices and behaviors, school attendance and academic achievement (Remien et al., 2019).

In view of the above, analysts have called for a proactive response to the mental health issues in ALHIV(Bhana et al., 2021). In particular, the healthcare systems has been admonished to provide integrated healthcare to ALHIV that includes mental health (Dessauvagie et al., 2020; Vreeman et al., 2017). Doing so would not only strengthen HIV prevention and care outcomes, but it would additionally improve global access to mental healthcare (Remien et al., 2019). Indeed, living with HIV as an adolescent raises the exigency for effective support and guidance, including addressing mental health issues, to ensure they traverse through this developmental stage (Hodgson et al., 2012). However, the literature is replete with the general neglect of mental health problems in ALHIV, particularly in low resource settings where investment in and delivery of mental health are notably poor and disorganized (Essien & Asamoah, 2020). Significant advances have been made in the prevention and treatment of HIV. For example, adolescents diagnosed with HIV can expect a near normal life span given access and adherence to combination anti-retroviral therapy (cART)(Mills et al., 2011; Teeraananchai et al., 2017). Ghana, like other countries have subscribed to the Joint United Nations Programme on HIV/AIDs goal of 95-95-95 call for 95% of people living with HIV (PLWH) to be diagnosed, with 95% of them initiating cART, and 95% of those on cART to achieve and sustain viral suppression through adherence to the treatment. However, these gains will not be achieved without addressing the significant mental and substance use problems among ALHIV(Remien et al., 2019). The lack of research and support for mental health needs in Ghana and other resource-limited settings presents an enormous burden for which cost-effective solutions are urgently needed (Vreeman et al., 2017).

The Multiple Family Group Therapy (MFGT) is an extremely cost-effective interventions that has the tendency to address psychosocial burden holistically among ALHIV and their significant others simultaneously. Listed on the national Registry of evidence-based programs in the US, the MFGT uses relatively minimal resources to achieve positive mental health outcomes for different participants. It was originally developed to target children with disruptive behavior disorders, their parents and service providers but has since been applied to address a range of psychopathological behaviors such as depression, anxiety in different population, including individuals living with HIV(Sensoy Bahar et al., 2020). As a structured program and a hybrid of group and family interventions, the MFGT is focused on improving skills and family processes referred to as 4Rs (Rules, Responsibility, Relationship and Respectful communication) and 2Ss (Stress and Social support). The key therapeutic aim of MFGT is to foster mutual support and learning between families who face similar difficulties and are united by a common goal of improving mental health and behavioral outcomes (Loh et al., 2021). It aims to support engagement with healthcare service, treatment adherence, symptoms reduction, relapse prevention, and quality of life. The MFGT is a Western-based model with strong theoretical underpinning, been a derivative of multiple theories such as family systems, structural family, and social learning theories. It is also anchored in psychoeducation and social group work. The MFGT is attractive in low resource settings such as Ghana given that it has been successfully facilitated by lay counsellors, community health workers, village health team and/or parent peers(McKay et al., 2004; Mellins et al., 2014). This is consistent with the task shifting strategy proposed by the WHO to address mental health problems by empowering non-mental health professionals to provide essential and basic mental health support(Adjorlolo et al., 2019).

The major caveats in relation to the application of the MFGT in Ghana are two-fold. First, the MFGT is formulated based on predominantly individualistic, western family principles, processes and practices that starkly contrast family systems in predominantly collective societies, including Ghana. This questions the application of the MFGT in Ghana without recourse to Ghanaian family systems and practices(Asampong et al., 2021; Sensoy Bahar et al., 2020); an observation that necessitates the adaption of the MFGT to increase its sensitivity to the local settings and family systems in Ghana. Although some versions of the MFGT have been incorporated into a family-based HIV prevention intervention (i.e., CHAMP program) in South Africa (McKay et al., 2004; Mellins et al., 2014) and family focused economic strengthening intervention (SUUBI program) in Uganda(Ssewamala et al., 2014), this is the first attempt to wholly adapt the MFGT to address mental health and psychosocial issues in ALHIV in SSA, focusing on Ghana. Previous effort to adapt the MFGT in Uganda has centered on adolescents with disruptive behaviors disorders in educational settings; a population that is functionally and psychological distinct from ALHIV, including family structures and functioning. Besides, none of the previous efforts were aimed at healthcare system strengthening to deliver integrated health services that include mental health support. Owing to the limited human resource, finance and logistics, the healthcare system in Ghana, just like other countries in SSA, is fragmented mostly at the primary level. Mental health services are barely integrated into the primary healthcare for ALHIV. Most of the psychiatric units of the Ghanaian hospitals are poorly resourced, making referrals of ALHIV in need of mental support to psychiatric hospitals the most viable option. However, financial problems and geographic barriers and others limit the utilization of the referral system, leaving the mental health of ALHIV unaddressed. This demands the integration of mental health support system into the primary care for ALHIV; the MFGT holds significant prospects in this regard.