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.

backgroundMultiple 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.

objectiveTo systematically document the cultural adaptation process of the 4Rs and 2Ss MFGT intervention for adolescents living with HIV (ALHIV) and caregivers in Ghana.

methodsThis 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.

resultsThe 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.

conclusionAll 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. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT06701942).