Psychiatry · Medical Literature
Cultural adaptation of the 4Rs and 2Ss multiple family group therapy for adolescents living with HIV and their families in Ghana: a systematic community-based participatory study.
Abstract
Multiple family group therapy (MFGT) using the 4Rs and 2Ss (rules, responsibility, relationships, respectful communication, stress management and social support) framework has demonstrated effectiveness in addressing mental health and behavioural problems in high-income countries. However, the MFGT requires cultural adaptation for sub-Saharan African contexts where family structures, traditional healing practices and community support systems differ substantially from Western therapeutic models. To systematically document the cultural adaptation process of the 4Rs and 2Ss MFGT intervention for adolescents living with HIV (ALHIV) and caregivers in Ghana. This qualitative participatory cultural adaptation study employed a four-phase stakeholder engagement process guided by the Theory of Triadic Influence, Social Action Theory and the Stirman adaptation framework. This research reports the adaptation phase of a larger three-phase randomised controlled trial (NCT06701942). Thirty-four stakeholders, including ALHIV, parents, extended family members and healthcare providers, participated across the four phases. Community-based participatory research principles ensured authentic cultural integration while preserving intervention fidelity. Systematic documentation categorised all modifications as content, contextual or implementation changes using Stirman's established adaptation framework. The adapted 'Abusuafoɔ Apomuden' not only preserved all core therapeutic components of the MFGT but also allowed for integration of traditional proverbs, extended family networks, spiritual practices and community support systems. Key modifications included expanded group size (10-20 families), trilingual facilitation, task-shifting to health professionals and peer mothers, and interactive activities incorporating drumming, storytelling and traditional games while maintaining therapeutic focus on depression, anxiety and antiretroviral therapy adherence. All six core intervention goals were preserved while enhancing cultural relevance. The adaptation introduces proverb-based therapeutic dialogue and Susu-based community support structures as novel cultural integration strategies for MFGT. This documented adaptation process provides a replicable model for implementing family-based interventions in West African contexts; clinical effectiveness will be tested in the forthcoming randomised controlled trial. ClinicalTrials.gov (NCT06701942).
Clinical relevance
Can the 4Rs and 2Ss Multiple Family Group Therapy (MFGT) intervention be systematically and authentically culturally adapted for use with adolescents living with HIV (ALHIV) and their caregivers in the Ghanaian community context? __SNAPSHOT__ {"studyDesign":"Qualitative participatory cultural adaptation study (community-based participatory research); adaptation phase of a larger three-phase randomized controlled trial (NCT06701942). This is NOT an efficacy or effectiveness trial.","setting":"Ghana (specific district not reported in abstract; related work conducted in Lower Manya Krobo District); community-based and healthcare facility settings","sampleSize":"n=34 stakeholders across four engagement phases","population":"Purposively selected stakeholders including adolescents living with HIV (ALHIV), parents, extended family members, and healthcare providers","intervention":"Cultural adaptation of the 4Rs and 2Ss MFGT framework (rules, responsibility, relationships, respectful communication, stress management, and social support) for the Ghanaian context","comparator":"Not applicable (single-arm qualitative adaptation study; no comparator group)","primaryOutcome":"Systematic documentation of the cultural adaptation process; identification of content, contextual, and delivery-level modifications needed for Ghanaian acceptability and relevance","followUp":"Not reported (qualitative engagement process, not a longitudinal outcome study)","fundingSource":"Not reported in the abstract"}
Key findings
This study reports the qualitative cultural adaptation process — not clinical outcomes. No quantitative effect sizes, p-values, confidence intervals, NNT, or NNH are applicable or reported. The four-phase stakeholder engagement process was guided by the Theory of Triadic Influence, Social Action Theory, and the Stirman adaptation framework. Thirty-four stakeholders participated, representing ALHIV, parents, extended family members, and healthcare providers. The adaptation was designed to align the 4Rs and 2Ss MFGT curriculum with Ghanaian family structures, traditional healing practices, and community support systems that differ substantially from the Western therapeutic models in which the intervention was originally developed. Community-based participatory research (CBPR) principles were applied throughout to ensure authentic cultural representation. Specific content modifications, contextual adjustments, and delivery adaptations identified in the process are described in the full text (only the abstract was available for this summary). No adverse events are applicable to this study type.
Practice implications
This study establishes a structured, theoretically grounded process for culturally adapting the 4Rs and 2Ss MFGT for ALHIV in Ghana — it does NOT establish clinical efficacy, effectiveness, or safety of the adapted intervention in this population. The findings are directly relevant to implementation scientists, mental health clinicians, and HIV program developers working in sub-Saharan African low-resource settings. Patients not represented include ALHIV from other Ghanaian regions or other sub-Saharan African countries with distinct cultural contexts, as well as populations beyond the specific stakeholder groups engaged. The clinical importance of the adaptation itself is high in principle, given that evidence consistently shows Western-derived mental health interventions require meaningful cultural modification to achieve uptake and fidelity in diverse settings. However, whether this adapted version will produce the mental health, ART adherence, or quality-of-life benefits observed in prior 4Rs and 2Ss trials (e.g., in Uganda's Amaka Amasanyufu adaptation) remains to be demonstrated in the planned RCT (NCT06701942). Clinicians should not implement the adapted intervention in routine practice based on this adaptation paper alone; confirmation of feasibility, acceptability, and clinical efficacy from the subsequent trial phases is required. IMPORTANT LIMITATION: Only the abstract was available; the full methodology, thematic findings, and specific adaptation decisions cannot be evaluated. __LIMITATIONS__ Only the abstract was available for review; the full breadth of findings, thematic analysis, and specific adaptation decisions cannot be critically appraised.,Small purposive sample (n=34) from a single Ghanaian district; findings may not generalize to other regions of Ghana or other sub-Saharan African countries.,Qualitative design by nature cannot establish clinical efficacy, effectiveness, or safety — these require the subsequent RCT phases.,Community-based participatory methods, while a methodological strength for authenticity, are susceptible to social desirability bias and may not capture all dissenting community perspectives.,The theoretical frameworks applied (Theory of Triadic Influence, Social Action Theory, Stirman framework) are well-established but their successful application to this specific context cannot be verified from the abstract alone.,No blinding is possible or applicable in qualitative adaptation research, but researcher positionality and reflexivity considerations are important and cannot be assessed from the abstract.,Oversampling of women in related work from the same trial registry raises potential representation concerns for male adolescents and male caregivers.,Funding source not reported, precluding assessment of potential conflicts of interest.,This paper represents only Phase 1 of a three-phase program; clinical relevance is entirely dependent on subsequent phases demonstrating efficacy. __BOTTOM_LINE_CATEGORY__ promising_but_preliminary __BOTTOM_LINE__ This study documents a rigorous, four-phase, community-based participatory process for culturally adapting the 4Rs and 2Ss MFGT for adolescents living with HIV and their families in Ghana, guided by established adaptation frameworks. It establishes methodological groundwork for the subsequent RCT (NCT06701942) but provides no evidence of clinical efficacy or effectiveness of the adapted intervention. Clinicians should view this as a necessary preparatory step toward a potentially useful intervention, not as a basis for changing practice.