Abstract
BackgroundSafety protocols are an essential component of studies addressing violence and mental health but are rarely described in the published literature from Sub-Saharan Africa. We designed and implemented a safety protocol within Project YES! (Youth Engaging for Success), which enrolled 276 youth living with HIV (ages 15–24 years) in a randomized controlled trial of a peer-mentoring intervention across four HIV clinics in Ndola, Zambia.MethodsYouth who reported severe violence and/or suicidal thoughts on research surveys or during meetings with youth peer mentors (YPM) were referred to designated healthcare providers (HCP). We explored experiences with the safety protocol using: a) monitoring data of referrals, and b) in-depth interviews with youth (n = 82), HCP (n = 10), YPM (n = 8), and staff (n = 6). Descriptive statistics were generated and thematic analysis of coded transcripts and written memos performed.ResultsNearly half of youth enrolled (48% of females, 41% of males) were referred to a HCP at least once. The first referral was most often for sexual violence (35%) and/or suicidal ideation/depression (29%). All referred youth aged 15–17 years and over 80% of referred youth aged 18 + agreed to see a HCP. HCP referred 15% for additional services outside the clinic. Twenty-nine youth, all HCP, all YPM, and all staff interviewed discussed the safety protocol. Most youth felt “encouraged,” “helped,” “unburdened,” and “relieved” by their meetings with HCP; some expressed concerns about meeting with HCP. The safety protocol helped HCP recognize the need to integrate care for violence and mental health with medication adherence support. HCP, YPM, and study staff raised implementation challenges, including youth choosing not to open up to HCP, time and resource constraints, deficiencies in HCP training, and stigma and cultural norms inhibiting referrals outside the clinic for emotional trauma and mental health.ConclusionsImplementing a safety protocol within an HIV clinic-based research study is possible and beneficial for youth and HCP alike. Implementation challenges underscore that HCP in Zambia work in over-stretched healthcare systems. Innovative strategies must address deficiencies in training and resources within HIV clinics and gaps in coordination across services to meet the overwhelming need for violence and mental health services among youth living with HIV.
Highlights
Adolescents and young adults face high levels of violence victimization in Sub-Saharan Africa (SSA), with the prevalence of physical, emotional, or sexual violenceMerrill et al glob health res policy (2021) 6:40 ranging from about 30 to 50 percent in some African settings [1, 2]
Among youth living with HIV, experiences of violence and mental health problems have been associated with negative HIV outcomes, including incomplete antiretroviral therapy (ART) adherence and virologic failure [7,8,9,10]
The safety protocol for this study was designed based on the resources and infrastructure of the study setting, the challenges raised in the in-depth interviews (IDI) echo findings from other studies in SSA on the importance of: (a) strengthening referral networks and coordination across services [19, 20, 39, 40]; (b) increasing the capacity of clinic providers to respond to a range of violence and mental health issues facing youth [40, 41]; (c) tackling broader contextual factors at play, such as cultural norms that minimize experiences of emotional violence and stigma around mental health [41]; and (d) encouraging an integrated approach to care for youth at HIV clinics [39]
Summary
Adolescents and young adults face high levels of violence victimization in Sub-Saharan Africa (SSA), with the prevalence of physical, emotional, or sexual violenceMerrill et al glob health res policy (2021) 6:40 ranging from about 30 to 50 percent in some African settings [1, 2]. Adolescents and young adults face high levels of violence victimization in Sub-Saharan Africa (SSA), with the prevalence of physical, emotional, or sexual violence. Among youth living with HIV, experiences of violence and mental health problems have been associated with negative HIV outcomes, including incomplete antiretroviral therapy (ART) adherence and virologic failure [7,8,9,10]. We identified few studies describing safety protocol implementation experiences in SSA for violence [19] or mental health [20], which is critical for building consensus around best practices for safety planning in these research areas [21]. We designed and implemented a safety protocol within Project YES! (Youth Engaging for Success), which enrolled 276 youth living with HIV (ages 15–24 years) in a randomized controlled trial of a peer-mentoring intervention across four HIV clinics in Ndola, Zambia
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