Multiple family group therapy (MFGT) based on the 4Rs and 2Ss framework (rules, responsibility, relationships, respectful communication, stress management and social support) has shown effectiveness addressing mental health and behavioural problems in high-income settings. However, family structures, traditional healing practices and community support systems in sub-Saharan Africa differ substantially from Western therapeutic models. The authors framed the need to adapt MFGT to Ghanaian cultural contexts to ensure relevance and acceptability for adolescents living with HIV (ALHIV) and their families.
The primary objective reported here was to systematically document the cultural adaptation process of the 4Rs and 2Ss MFGT for ALHIV and caregivers in Ghana. This work represents the adaptation phase of a larger three-phase randomized controlled trial registered as ClinicalTrials.gov NCT06701942. The adaptation study was qualitative and participatory in design, with emphasis on preserving intervention fidelity while integrating local cultural practices.
A four-phase stakeholder engagement process was used. Thirty-four stakeholders participated across the four phases; these included ALHIV, parents, extended family members and healthcare providers. The adaptation employed community-based participatory research principles to ensure culturally authentic integration and local ownership of the intervention while maintaining core therapeutic elements.
The adaptation process was guided by three conceptual frameworks: the Theory of Triadic Influence, Social Action Theory and the Stirman adaptation framework. The Stirman framework was used specifically to categorise and document modifications as content, contextual or implementation changes. These frameworks supported systematic decision-making about what to adapt and what to retain to preserve effectiveness.
All modifications made during the adaptation were systematically documented and classified using Stirman’s established taxonomy. Modifications were grouped as content changes (what is delivered), contextual changes (how and where it is delivered), and implementation changes (who delivers and how the program is organized). The study emphasizes transparent documentation to enable replication in other West African contexts.
The adapted intervention was given the local name Abusuafoo Apomuden and preserved all six core therapeutic goals of the original MFGT. Content-level adaptations included integration of traditional proverbs as a basis for therapeutic dialogue and incorporation of spiritual practices where appropriate. Interactive activities were adapted to include culturally familiar elements such as drumming, storytelling and traditional games to engage participants while maintaining focus on mental health targets including depression, anxiety and antiretroviral therapy adherence.
Contextual changes included enlarging group size to better reflect communal participation, with reported groups of 10–20 families. Facilitation was adapted to be trilingual to match local language needs. Implementation adaptations involved task-shifting: sessions could be led by existing health professionals and peer mothers rather than exclusively by specialist therapists. The study reports that these changes were made while aiming to preserve the therapeutic integrity of MFGT.
Despite the cultural integrations and delivery modifications, the adaptation retained the original intervention’s core components and goals. The authors highlight that all six core objectives were preserved in the Abusuafoo Apomuden model, and that the culturally grounded additions were designed to enhance acceptability without undermining the therapy’s focus on mental health and antiretroviral adherence.
This report details the adaptation phase and documentation process; it does not report clinical effectiveness outcomes or long-term feasibility data. Specific quantitative results, measures of fidelity post-adaptation, and participant-level outcome data were not provided in this adaptation report and will be addressed in the forthcoming randomized controlled trial referenced by the registration number.
The documented, theory-informed cultural adaptation offers a replicable model for implementing family-based MFGT in West African settings. By describing content, contextual and implementation changes systematically, the study provides practical guidance for programs aiming to integrate traditional practices, extended family networks and community-based support structures. Clinical effectiveness and scalability will be evaluated in the subsequent trial phase (ClinicalTrials.gov NCT06701942).