CHWs found the intervention useful in addition to their existing knowledge and skills and were able to deliver IPT-G successfully. Our research team found that through task shifting, IPT-G can be disseminated to other adolescents in similar settings so long as recommended by WHO, training and continuous supervision of CHWs is upheld (WHO, 2007). We can now embrace findings from other studies where non-specialist (CHWs) can be trained on specific skills to deliver an intervention with similar effectiveness just like when being delivered by specialists in mental health (Kredo et al., 2014; Murray et al., 2017). In cognizance of Universal Health Care, we too lend our voice towards the need to consider CHWs to be involved in mental health care delivery to cover for the shortage of trained mental health specialist (Ministry of Health, 2020). The CHWs were very satisfied with their achievements, and some shared their experiences on the milestones towards IPT-G delivery:
"At the beginning of the sessions, there were challenges because all the people were still new, so it is later that people came to know each other and developed trust in the group and everyone could say all her issues". (SK, age 50, Kariobangi)
The intervention empowered some of the adolescent mothers to help others, which was one of our intended purpose towards disseminating benefits to the community level.:
“Even the sessions were very good; because some used to come and tell you, I have this and that problem and I passed through this, but I went and did what you told me, and I have succeeded, you get it? One member in our group, I recall, and even at the moment, she normally rings me and tells me, ‘that thing helped me, and I am able to help others’.” (NG, age 43, Kangemi)
The IPT-G sessions formed part of the entry point to enlarging the scope of their social support and even after the intervention they continued to share their issues:
“So, it was a very big problem at the beginning, but I am glad that as the sessions were proceeding, we became good friends; actually, we developed a rapport, and even until now, some still call ‘when are we meeting again?’ [Laughter] - -.” (EO, age 24, Kariobangi)
Others were of the view that follow-up is of importance because most of the participants open-up to their issues at the middle of the sessions:
“What I can say; when I joined- let me talk about group two, we came well but after attending like three sessions is when you could see them now pouring out [Laughter] they tell you all their troubles in life- -.” (FC, age 30, Kangemi)
The CHWs were now able to connect easily with the adolescent mothers after bonding with them during the sessions:
“So, we are also still doing follow-ups. Some even call by themselves, sometimes I call them, some even when they come for clinics, they just come looking for us which is good so, so they trust us. So, there is that trust, there is that friendship, there are so many benefits that came out of this, so I was just gladly sharing.” (EO, age 24, Kariobangi)
Our adolescent participants benefited from the IPT-G as they narrated how they could now communicate, interact with others, manage their anger, and even resume work for an income. It is worth noting that in a study that assessed interpersonal relationships between youth and their families or caregivers it was found that poor relationships were strongly related to depression symptoms (Miller et al., 2016; Spence et al., 2016).
“I am called JI, and it helped me now I can talk to people, I was hopeless but now…. yes, I am of importance. When I saw that I am this way, I felt that there is no life and that I am not important.” (JI, age21, Kangemi)
One of the adolescent mothers narrated how HIV-related stigma used to torment her before the before our intervention:
“ I know myself since I know how I used to feel; when I sit down, I ask myself, ‘what kind of life is this?’ I used to feel guilty. I don't want people's stories. I just feel that a story may arise and reach the point of the infection, so what will I say? You know at that point you will just be forced to remain silent; you will not talk- you will never have what to say because they are negative, and you are positive, and they want to talk about that infection - -.” (JA, age22, Kariobangi)
It was clear that irritability was negatively affecting communication with their partners as one of the participants narrated how she used to live while having depressive symptoms:
“In the past, whenever I could get angry, I could not cook…. I cannot eat, if it is talking to people, I cannot talk to him; everybody sits apart when it comes to washing, everybody washes their clothes.” (SK, age23, Kangemi)
Besides, adolescent participants could appreciate that IPT-G helped them alleviate depressive symptoms (social isolation, anger, hopelessness, and low mood). Most of them reported better sleep patterns, good appetite, increased social interactions, and decreased HIV-related stigma. Our study population was noted to have several challenges which seemed to support previous studies where they found out that adolescents living with HIV are more vulnerable to mental health disorders due to medical and psychosocial stressors associated with HIV/AIDS (Mellins & Malee, 2013; Nanni et al., 2015). There is no doubt that our intervention addressing depression will improve adherence to ART among our study participants, which is key to good quality of life (Sin & DiMatteo, 2014).
“It has helped me when I am with people I have accepted myself the way I am and then anger issues nowadays are not there, at least I can make friends; in the past, I could not make friends, but now at least I can sit with somebody and share something with her that is helpful.” (SA, age23, Kariobangi)
Isolation was one of the maladaptive behaviors associated with depressive symptoms as indicated by on of the adolescent mother:
“I used to lock myself in the house, but currently, I can get out and make stories with neighbors, when I am called for a job I can go.” (RA, age 18, Kangemi)
The male partner’s role towards how relationships evolve through pregnancy and motherhood among adolescents is worth looking into to help adolescent girls in abusive marriages. One qualitative study suggested that postpartum adolescents living with their partners or caregivers will benefit from social support as postpartum adolescents transit early motherhood challenges (UNESCO, 2017). See vignette from our participants here highlighting this point further:
“I am FW; it has helped me I am not the same as I used to be; I used to be angry; I could get out of the house at night due to anger. Now we talk well in the house… yes [Laughter].” (FW, age21, Kariobangi)
We noted the devastating effects of depression as highlighted by one of the participants on how isolation, marital conflict, and persistent distress used to affect her daily living:
“I think I was depressed; I used to sit in the house and had no friends. But when I started coming to this group, I found friends here, outside I have also made friends. I used to be stressed as to why my husband doesn't go to work and frequent disagreements. But since I started coming here for advice, I realized that I am not the only one who has problems, so for me, it has gotten out; I just feel that it has helped me a lot, stress is usual, but for now, I feel stress free.” (FW, age21, Kariobangi)
Our study acknowledges that adolescents living with HIV are vulnerable to negative community perceptions, which agrees with a similar study in Uganda (Ashaba et al., 2019). These could manifest with suicidal ideations.
“At the first time, I wanted to kill myself [Inaudible], I have children and they could become orphans. The moment I came in this group, it has helped me until now my children are grown, and I have even started working harder because the other one is in grade two, the other is still little, but you advised me.” (PN, age24, Kariobangi)
Spouses supporting postpartum adolescents with financial and social provision to return to school are likely to minimize future unplanned or unwanted pregnancies and enable them to acquire better lives and even for their children (Human Rights Watch, 2018). One of the participants acknowledged therapy sessions improved her interpersonal relationship with her male partner and could enjoy functional changes in her life.
“We have agreed with my husband that I am going back to school - -In the past, I used to wonder how he views me.” (JI, age21, Kangemi)
HIV affects adolescents and the unpleasant outcomes are indirectly transferred to the child (González et al., 2017) as shown by one, the participants who feel could have died of a stressful life, but the sessions helped her.
“I give back thanks for he has brought us from far because right now I could be in the ground [Laughter], so may God give him (YO) strength for him to continue with that spirit.” (PN, age24, Kariobangi)
Early sexual intimacy with the opposite gender predisposes girls to unplanned and unwanted pregnancy with possibilities of dropping out of school and even lack skills to gain employment (Erken, ArthurErken, A., & Schensul & Schensul, 2019). Research has shown that early unintended pregnancy is a risk factor for later HIV infections among adolescents (Christofides et al., 2014). HIV-related stigma remains to be addressed fully in SSA. Systematic reviews have associated it with delays in treatment and difficulties in adhering to ART (Ammon et al., 2018; Croome et al., 2017). As an illustration to share this point further, one of our participants was grateful for participating in the sessions and shared her positivity:
“I can remember there is one who said after the sessions, ‘nowadays I can get out and talk with women, I can go out of the gate because when I was alone, I felt that I am not okay because I have HIV and I have given birth at a younger age. But now I have gotten that courage after these sessions to go outside I can talk, I have that courage,’ so that made her feel that they are many and she is not alone.” (LN, age 34, CHA, Kangemi)
One of the CHV encountered sudden death outside the study area, which caused a lot of grief among the participants. Besides, we realized most of our CHWs had experienced the loss of a loved one and were also struggling with healing, which our sessions also supported them as they narrated to us. The CHWs were affected by the loss of a colleague (CA), and in addition to other previous bereavement worsened their state (Shear, 2012), and IPT-G helped them cope:
“CA also left me, he was my friend, and it drew me so much down, but now I am fine, isn't it? - - During CA’s time of demise, it was like everybody in Kangemi felt like was carrying something [Silence].” (LN, age 34, CHA, Kangemi)
One of the CHW expressed how IPT-G helped her process the thoughts and emotions of loss and grief associated with past incidents:
“It has helped me a lot, the second thing let me say I was given a husband by Kangemi people, when we were doing training, and I lost the husband (refers to CA, deceased CHV), so IPT helped me to go through the loss and grief, anyway it was not a real husband [Laughter]. But he was a very good friend of mine. Anyway, when I was undergoing through the sessions, I lost most of very important people, but IPT helped me. You know when we were talking to these girls, and they are also expressing, ‘I lost my kid, I lost my daddy,’ and I was also like it was like me losing the people whom I care about, so we were going through these together. It was a process for all of us, so it healed me, and it healed them; that was very good.” (EO, age 24, CHV, Kariobangi)
The community health assistant was mourning the loss of her child during the sessions and had to say this in appreciation of the intervention:
“- - and when I came here, I was so much stressed, and it could have resulted in depression because there is something, I lost my child on delivery, then I lost both parents at the same time. So, when we started talking, I felt that I had put the load down, you get it? so when we continued and reached the middle, and I realized that I am good.” (NG, age 43, CHV, Kangemi)
Continuous supportive supervision was appreciated by the CHWs and they felt that all their concerns arising from the weekly session was addressed promptly and adequately. During our group sessions, supportive supervision emphasized joint problem solving, mentoring, and two-way communication between the researchers and the CHWs (Lehmann & Sanders, 2007; Lewin et al., 2005).
“It was just like Kangemi; at first for the people with whom you are not familiar enough, they could not open up; you ask her a question, and she feels like where do you want to lock and take her? But now the second time they will be free, and the third time she will feel like ‘I can remember what happened to me and how it is on somebody else,’ because we had supervision like from CHA and MK and could correct us when wrong and it becomes normal.” (SN, age 65, Kariobangi)
Furthermore, it was very encouraging to hear from the CHWs that our participants after intervention became role models in the community by imparting skills of managing their day-to-day life issues. For CHWs and adolescents to be able to understand the concept of IPT-G and even use it to help others, the learning cycle was achieved by both actual experiences and empowering them to practice through supportive supervision (Huber, 1991; Newell, 2005)
“I think even these girls have become role models in the community…we told them ‘if you find somebody who is in a situation maybe you can assist and feel that it closer to yours or it is similar to yours, you are now empowered, and you can help this person at your level and if you feel that it is difficult is when you can refer.’ Still, now they are doing on their own, which is good.” (EO, age 24, CHV, Kariobangi)
One of the CHA affirmed that time for IPT-G sessions was easily embedded into their routine activities since it consumes 90 minutes only once a week.
“Not a burden because it was usually once a week, and if you are meeting those clients later, it is the one in which you can negotiate the time that you will meet, so I don’t think, maybe if others think otherwise.” (LN, age 34, CHA, Kangemi)
Nevertheless, several CHWs acknowledged the lack of designated space for mental health services as one of the limitations towards adopting IPT-G delivery to routine PMTCT services:
“I think for us (in) Kariobangi we had a big challenge when it came to the venue of the meeting because sometimes you find we are here sometimes we are displaced at the tent, maybe the other tent is very dirty, sometimes we are in this other tent we come here displaced, so it was a very big challenge [Cross talk] - -.” (EO, age 24, Kariobangi)
The space to administer mental health services was missing within the health centers as shown by how we had to improvise a room for the sessions:
“We were okay; we had been given the maternity, a place somewhere…. You see, if we close the middle of the room too and pull the curtains, it was so good; it didn't have an issue.” (LN, age 34, Kangemi)
Another CHW seemed helpless of the situation and consented to the state of the available space despite all the challenges associated with it:
“But let’s just say it was okay; even if it is bad, it is our place, so we cannot say that it is bad [Laughter], but it was fine.” (JA, age 24, Kangemi)
The lack of specified venue for mental health services posed uncertainty on effective service delivery for the CHWs:
“The space was okay; it was somewhere where we don’t have issues with noise, but we don’t know next.” (SN, age 65, Karionbangi)
We were able to form a strong collaborative team by creating a WhatsApp group and took issues of the CHWs and PPA with a lot of importance by demonstrating practical empathy, thus improving commitment for all of us in the study process. The use of technology proved equally useful, just like a Nigerian study on psychological intervention for adolescents living with HIV where support groups were engaged using Facebook groups for a 5-weekly session. The ability for them to interact, learn more about HIV, share experiences, and their fears affirmed that social media could help them cope with their status (Dulli et al., 2018).
“When I lost my child on delivery, I also want to thank YO, I don’t know what to tell him, but there is a time I looked and realized that he is a very different person. We hadn’t known each other- we had known each other for only three days, but when I had a problem he came with MK to my house and consoled me, and I felt that it wasn’t even about friendship, they are just part of like my family, and he helped me.” (LN,age 34,CHA,Kangemi)
One of the CHW underscored the potential impact IPT-G could have in the community as indicated in her explanation:
“- - it has changed us, as much as we were the teachers, but we feel that it helped us. So I just pray that more of that kind comes and the way I said that when you just change one person he/she will change five others and those five others will change others and at the end of the day you may find that you have changed the whole country and even the world, so thank you”. (JA,age 24,Kangemi)
Generally, our findings of challenges affecting PPA did not come as a surprise considering previous studies had also identified that perinatal adolescents, who are also parenting, face several difficulties, such as social stigma, lack of emotional support, poor healthcare access, and stresses around new life adjustments (Kumar et al., 2018). Our IPT-G intervention helped adolescents by improving their interpersonal relationships, communication processes, and overall mental health.
We were able to qualitatively establish acceptability and feasibility of IPT-G delivered to postpartum adolescents living with HIV by CHWs in primary health care settings. The two study sites make the findings more reliable for a representative outcome for low-resource urban settings.
Despite all the exciting, positive impact on the participants’ lives from this intervention, as seen from the qualitative findings, the sample size was not powered. Thus, other quantitative results may not offer strong enough argument when discussing the intervention’s impact on this vulnerable population.