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. Author manuscript; available in PMC: 2023 Dec 15.
Published in final edited form as: SSM Ment Health. 2023 Aug 9;4:100254. doi: 10.1016/j.ssmmh.2023.100254

Adapting a substance use screening and brief intervention for peer-delivery and for youth in Kenya

Florence Jaguga a, Mary A Ott b, Edith Kamaru Kwobah a, Edith Apondi a, Ali Giusto c, Julius Barasa d, Gilliane Kosgei d, Wilter Rono d, Mercy Korir d, Eve S Puffer e
PMCID: PMC10688596  NIHMSID: NIHMS1944693  PMID: 38047062

Abstract

Background:

Substance use is a major problem among youth in sub-Saharan Africa, yet interventions that address this problem are scarce within the region. Screening and brief intervention is a cost-effective, efficacious, and easy to scale public health approach to addressing substance use problems. We conducted a pilot study to evaluate the feasibility of implementing a peer delivered screening and brief intervention program for youth in Kenya. The goal of this paper is to report on the process of adapting the Alcohol Smoking and Substance Involvement Screening Test for Youth- linked Brief Intervention (ASSIST-Y-linked BI) program for peer delivery and for the Kenyan context prior to the pilot.

Methods:

The adaptation process was led by a multi-disciplinary team comprised of psychiatrists, pediatricians, and psychologists. We utilized the ADAPT-ITT framework to adapt the ASSIST-Y-linked BI. The ADAPT-ITT framework consists of 8 phases including Assessment, Decision making, Adaptation, Production, Topical Experts, Integration, Training, and Testing the evidence-based intervention. Here, we report on phases 1–7 of the framework. The results of the pilot testing have been published elsewhere.

Results:

Overall, we made surface level adaptations to the ASSIST-Y-linked BI program such as simplifying the language to enhance understandability. We maintained the core components of the program i.e., Feedback, Responsibility, Advice, Menu of Options, Empathy, Self-efficacy (FRAMES).

Conclusions:

Our paper provides information which other stakeholders planning to implement the ASSIST-Y-linked BI for youth in sub-Saharan Africa, could use to adapt the intervention.

Keywords: screening, brief intervention, substance use, youth, adapt, ADAPT-ITT

Introduction

The World Health Organization (WHO) defines youth as the period between 15 and 24 years of age (United Nations, 2022.). This period is often characterized by initiation of substance use (Degenhardt et al., 2016). A global survey found the average age of onset for substance use to be 16–19 years (Degenhardt et al., 2016). In sub-Saharan Africa, an estimated 41% of youth have used at least one substance in their lifetime (Olawole-Isaac et al., 2018). In Kenya, a nationwide survey conducted by the National Authority for the Campaign Against Alcohol and drug Abuse (NACADA), among secondary school students with a mean age of 16 years, found that the lifetime prevalence of alcohol, khat, prescription drugs, and tobacco use was 23.4%, 17.0%, 16.1%, and 14.5% respectively (NACADA, 2016). Khat is a plant cultivated in Eastern Africa whose leaves are chewed for their stimulant effects. Khat leaves contain stimulants such as cathinone, cathine and norephedrine (Wabe, 2011). Musyoka et al., (2020) in a study conducted among first year university students in Kenya found that the lifetime prevalence of any substance use was 25%.

Substance use among youth is associated with significant negative health and social consequences. In the 2010, Global Burden of Disease study, substance use disorders (SUDs) were the second leading cause of disability among the mental and SUDs for children, adolescents and youth aged 0–24 years (Erskine et al., 2015). In a study conducted among upper secondary school students in Norway, substance use was linked to lower grades and poorer attendance of classes (Heradstveit et al., 2017). Ritchwood et al., (2015)in a metanalysis reported a significant relationship between substance use and risky sexual behavior. The deleterious effects of adolescent substance use on neurocognition has also been well documented (Lisdahl et al., 2013).

In Sub-Saharan Africa, substance use among youth has been linked to depression (Gaitho et al., 2018), school truancy, suicidal ideation and plans, loneliness, sleeping problems, sadness, and poverty (Peltzer, 2009). Unfortunately, substance use interventions in sub-Saharan Africa including Kenya are scarce (Jaguga & Kwobah, 2020; Parcesepe et al., 2020). These interventions are even scarcer for youth (Jaguga et al., 2022; Parcesepe et al., 2020).

Screening and brief intervention (SBI) is a public health approach for the identification and early intervention for risky substance use (World Health Organization, 2003). SBI often includes: (i) Screening using a validated tool to determine the level of involvement with substance use; (ii) A brief intervention, which is a discussion between the healthcare worker and the patient using motivational interviewing techniques (10). The brief intervention is offered to those at risk of experiencing harm from their pattern of substance use. The goal of the BI is to encourage the patient to reduce or stop substance use to prevent the associated health and social consequences of harmful use (World Health Organization, 2003).

SBI is considered best practice by the United Nations Office on Drugs and Crime in the prevention and early intervention of substance use among youth (UNODC, 2018) It has been found to be effective in reducing low, moderate, and high-risk substance use among youth in the US (Winters et al., 2014), Czech Republic (Harris et al., 2012) and South Africa (Carney et al., 2020). In addition, brief interventions are cost-effective (Anderson et al., 2009), take a short time to deliver (generally 1–2 sessions) (Winn & Paquette, 2017; World Health Organisation, 2003) and are therefore easy to scale-up. Another strength of brief interventions is that they can be delivered by lay providers (Winn & Paquette, 2017; Winn et al., 2019). This is particularly important in low-and-middle income countries (LMICs) where primary health care workers are few and often face heavy workload (Peltzer et al., 2008).

To address the problem of limited access to substance use interventions for youth in Kenya, we conducted a pilot study to explore the feasibility and acceptability of a peer delivered substance use SBI program for this population. Peer-providers are youth providing basic counseling in youth clinical settings. Several SBI based programs have been developed for implementation among youth. These include the Alcohol Smoking and Substance Involvement Screening Test for Youth- linked Brief Intervention (ASSIST-Y-linked BI) guidelines (Humeniuk et al., 2016), Substance use Screening and Intervention Implementation Guidelines (American Academy of Pediatrics, n.d.), Teen Intervene (Winters et al., 2012), and Project Amp (Winn & Paquette, 2017) developed by researchers in the United States (US). We found no SBI program developed or adapted for use among Kenyan youth. All the SBI programs above had been developed for delivery by health care workers except Project Amp which had been designed for peer-delivery.

This study utilized the ASSIST-Y linked BI (Humeniuk et al., 2016) since the original ASSIST-linked BI (World Health Organization, 2003) from which the ASSIST-Y-linked BI had been adapted, had been found to be efficacious among youth from LMICs including Brazil and India (Humeniuk et al., 2012). All other programs had been developed and tested in the US. Even though the ASSIST-linked BI had been tested in LMICs, it had not been tested among Kenyan youth. Further, it was designed for delivery by primary health care workers. We therefore made the decision to adapt the ASSIST-Y-linked BI (Humeniuk et al., 2016) for peer-delivery and for the Kenyan context.

To adapt the intervention, we used the ADAPT-ITT, a framework originally developed for contextualizing HIV Evidence Based Interventions (EBIs) (Wingood & Diclemente, 2008) but has been used to adapt mental health interventions for youth in Africa (Munro-Kramer et al., 2020). The ADAPT-ITT framework consists of 8 phases including Assessment, Decision making, Adaptation, Production, Topical Experts, Integration, Training, and Testing the EBI (Wingood & Diclemente, 2008).

The goal of this paper is to describe the process of adapting the ASSIST-Y-linked BI for peer delivery and for the Kenyan context, using phase 1–7 of the ADAPT-ITT framework. Findings will be useful for other countries in sub-Saharan Africa interested in implementing a peer-delivered ASSIST-Y-linked BI for youth.

2.0. Methods

2.1. Setting

The pilot study was conducted at a youth clinic (Rafiki Clinic) run by the Academic Model Providing Access to Health Care (AMPATH) (3). AMPATH is a large chronic disease program in western Kenya and is a partnership between Moi Teaching and Referral Hospital, Moi University, and North American Universities led by Indiana University. Rafiki clinic has a total enrolment of 799 youth, 80% of whom are living with HIV and 99% are aged 15–24 years. The clinic serves about 300 youth monthly and is staffed by 10 staff: 1 pediatrician, 2 clinical officers, 1 psychological counselor, 1 nutritionist, 2 social workers, 1 pharmacist, 2 nurses. Although Rafiki Clinic majorly serves youth living with HIV, its vision is to become a center of excellence for adolescent and youth health. It is against this background that we saw it important to broadly adapt the ASSIST-Y BI for the Kenyan youth, irrespective of their HIV status.

Four peer providers, young adults aged 18–27 years, work full-time at Rafiki clinic. At each clinic visit, youth first consult with a peer provider in a private room before proceeding for clinician review. During the consultation, peer providers perform antiretroviral therapy adherence counseling or offer basic counseling on mental health related issues the youth may have such as dealing with stressful situations at school or at home. Prior to the pilot study, all peer providers had received basic training in HIV adherence counseling, and general mental health issues such as stress management, but none on substance use SBI.

2.2. ADAPT-ITT Framework

Adaptation of the ASSIST-Y-linked-BI was guided by the ADAPT-ITT framework (Wingood & Diclemente, 2008). The ADAPT ITT framework consists of 8 phases including Assessment, Decision making, Adaptation, Production, Topical Experts, Integration, Training, and Testing the EBI. The aim of assessment is to assess the target population’s perceived need for the intervention. The goal of phase 2 i.e., decision making, is to review the existing EBIs, decide which one to select for the new target population, and decide whether the EBI should be adopted or adapted. During phase 3, the EBI is presented to the target population and feedback sought from them on its content. Phase 4, production, entails incorporating feedback from the target population into a first draft of the EBI while maintaining fidelity to the core components of the EBI resulting in a first draft of the EBI. Phase 5 entails review of the draft EBI by topical experts, to obtain technical feedback on the document as well as feedback on issues such as readability. The aim of phase 6, Integration, is to integrate content provided by the topical experts into the adapted EBI. The integration of content from the topical experts results in a second draft of the adapted EBI. During Phase 7, providers implementing the EBI receive training on how to deliver the adapted intervention. Phase 8, Testing, involves conducting a pilot test with the target population, during which trained providers implement the adapted EBI. Feedback is then obtained from the target population and other stakeholders who observed implementation of the EBI on whether they think the intervention content, and delivery are relevant, useful, and appropriate (Wingood & Diclemente, 2008). This paper provides a description of phase 1–7 of the ADAPT-ITT framework.

2.3. ADAPT-ITT Phases, Methods, Results

The process was led by a multidisciplinary team of two Kenyan psychiatrists, two psychologists (both from the US), two pediatricians (one Kenyan, and another from the US), and Kenyan peer providers with collective experience in adapting EBIs in LMICs, implementation science, substance use treatment, adolescent and youth health, and youth counseling. Here, we describe how step 1–7 of the ADAPT-ITT framework was operationalized.

2.3.1. Phase 1: Assessment

Methods:

We held two meetings, one with staff and peer-providers stationed at Rafiki clinic, and a second one with youth and peer-providers working in community-based clinics outside Rafiki, to determine the need for substance use interventions among youth in western, Kenya. The meetings were held in July 2021 and were facilitated by the lead investigator (F.J.). During the meetings, field notes were taken.

Results:

There was consensus that substance use was a key problem among youth in Kenya and there were no well-established interventions to address the problem. Stakeholders expressed the need for a brief, easy to scale treatment aimed at addressing youth substance use.

2.3.2. Phase 2: Decision making:

Methods:

In August 2021, the adaptation team conducted a literature search on substance use SBIs with the goal of finding a youth focused intervention that had been developed or tested among youth in sub-Saharan Africa and delivered by peer-providers.

Results:

We found several potential youth-focused SBI based programs that addressed both alcohol and other substance use, none of which had been developed or adapted for use among Kenyan youth:

The Alcohol Smoking and Substance Involvement Screening Test for Youth- linked Brief Intervention (ASSIST-Y-linked BI) by University of Adelaide (Humeniuk et al., 2016) is a single session brief intervention adapted from the WHO ASSIST-linked BI (World Health Organization, 2003). It is based on the Feedback, Responsibility, Advice, Menu of options, Empathy and Self-efficacy (FRAMES) model and motivational interviewing techniques and was designed for delivery by primary health care workers. The WHO ASSIST-linked BI had been tested and found to be efficacious among youth drawn from LMICs including Brazil and India (Humeniuk et al., 2012). We found no evidence of versions of the ASSIST-Y-linked BI adapted for the Kenyan context, and for implementation by peer providers.

The Substance use Screening and Intervention Implementation Guidelines (American Academy of Pediatrics, n.d.), describe a single session intervention, and was developed for adolescents in the US. It utilizes the feedback Listen Options (FLO) model, is based on motivational interviewing principles, and is designed to be delivered by pediatricians. We found no literature indicating that it had been implemented outside the US or delivered by peer providers.

“Teen Intervene” (Winters et al., 2012), is a three-session motivational interviewing style brief intervention for adolescents in the US and is designed to be delivered by primary healthcare workers. The first two sessions target the adolescent with session one focusing on an assessment of the adolescents’ substance use pattern and related consequences, an assessment of their willingness to change, examination of the pros and cons of substance use and goal setting. The second session focusses on the students’ progress in achieving the goals, identifying high risk situations and triggers, discussing strategies to deal with social pressures to use drugs, a repeat assessment of willingness to change, and goal setting. A third session involves delivering the same MI interviewing style to the primary caregiver (Winters et al., 2012).“Teen intervene” has been adapted and tested for use among adolescents in South Africa (Carney et al., 2019) and found to be feasible and acceptable (Carney et al., 2020).

Project Amp (Winn & Paquette, 2017) is a four-session SBI based program that is designed to be delivered among youth. The first session focusses on introduction and exploring the youths’ strengths and goals. The aim of session 2 is to explore the concept of wellness with the youth. The third session focuses on helping the youth understand the role of peer pressure and social networks in bringing about positive behavior change, and the goal of session 4 is to wrap up and set long term goals. Project Amp is based on principles of motivational interviewing, trauma-informed care, and peer recovery support. Project Amp was developed and tested among youth in the US (Winn & Paquette, 2017). We did not find any evidence indicating that Project Amp had been tested in a LMIC or in Africa.

For our pilot, we selected the ASSIST-Y-linked BI (Humeniuk et al., 2016) for two reasons. First, the WHO ASSIST-linked BI (from which the ASSIST-Y-linked BI was adapted) was the most widely tested. A cross-national (Brazil, India, Australia, US) randomized control trial found the intervention to be efficacious in reducing the level of substance involvement for participants with moderate risk substance use (Humeniuk et al., 2012). Secondly, the ASSIST-Y-linked BI is a single session intervention which we felt would be relatively more feasible for a peer provider to deliver compared to a multi-session intervention.

Description of the ASSIST-Y-linked BI.

The first step in the ASSIST-Y-linked BI entails screening to check for level of involvement with substance use using the ASSIST-Y tool. The tool enquires about lifetime use of 9 substances (alcohol, tobacco, cannabis, cocaine, inhalants, amphetamines, opioids, hallucinogens and sedatives). Endorsement of lifetime use is followed by an assessment of pattern and impact of substance use over the past 3-month period. The level of substance involvement is categorized as moderate or high risk and cut-off scores vary for each substance. Unlike the adult version, the ASSIST-Y has no ‘low risk’ category. The ASSIST-Y-linked BI is based on motivational interviewing techniques and the FRAMES model (i.e., providing feedback on screening results; ensuring responsibility on the part of the youth; giving clear advice to stop/cut down substance use; giving menu of options on alternative healthy behaviors to engage in; expressing empathy; and encouraging self-efficacy) (Humeniuk et al., 2016).

The ASSIST-Y-linked BI proposes the following steps for delivering the brief intervention: 1. Asking clients if they are interested in seeing their questionnaire scores; 2. Providing personalized feedback to clients about their scores 3. Giving clients advice about how to reduce risk associated with substance use; 4. Allowing clients to take ultimate responsibility for their choices; 5. Asking clients how concerned they are by their scores; 6. Weighing up the good things about using the substance against the; 7. less good things about using the substance; 8. Summarizing and reflecting on clients’ statements about their substance use with emphasis on the ‘less good things’; 9. Asking clients how concerned they are by the ‘less good things’; 10. An assessment of readiness or confidence to initiate change using the readiness and confidence rulers. 11. Giving clients take-home materials to bolster the brief intervention (Humeniuk et al., 2016).

The adaptation team described above reviewed the ASSIST-Y-linked BI and agreed to: Retain the core components (FRAMES) of the intervention since they have been shown to contribute to effectiveness; and adapt the manual to tailor it to the cultural context in Kenya, and for peer delivery. The adaptation team prepared a first draft of the intervention manual for presentation to the youth and peer-providers.

2.3.3. Phase 3: Adaptation:

Methods:

We held a one-day workshop in October 2021 to present the draft ASSIST-Y-linked BI to youth aged 15–24 years and peer providers. We purposively identified youth based on age and gender and invited them to attend the workshop. A total of 12 youth attended the workshop: 3 youth aged 15–18 years (2 male; 1 female); 3 youth aged 19–24 years (2 female; 1 male); 6 peer-providers from various youth groups (2 female; 4 male). The workshop was facilitated by a 1 Psychiatrist (F.J.) and 4 Psychologists (J.B, G.K., M.K., W.R.).

We utilized two small group activities and role-plays to present the ASSIST-Y-linked BI to the youth. For group work, youth were divided into two groups with one group reviewing the ASSIST-Y tool, and the other reviewing the brief intervention. Each group then gave feedback on their sections at a plenary session and the entire team deliberated and built consensus on the changes to be made to the ASSIST-Y-linked BI manual. The facilitators also conducted one-role play of the ASSIST-Y-linked BI and requested feedback from the youth and peer-providers. The review process was guided by a questionnaire that sought feedback on issues such as whether the content was understandable to the youth, whether the content was appropriate for youth in Kenya, whether there was anything the youth might find to be confusing, and recommendations on changes to be made.

Notes were taken during the workshop ensuring to clearly describe the youths’ recommendations.

Results:

The main adaptations made during the workshop were related to issues of understandability, and appropriateness of the language. The youth and peer-providers identified several issues and proposed changes such as including street names for the substances to the ASSIST-Y, simplifying the language of the manual, and removing potentially offensive language. The proposed changes are presented on table 1.

Table 1:

Youth and peer feedback on the ASSIST-Y-linked BI during the adaptation workshop

Section of the SBI Youth feedback Recommendations
ASSIST-Y Street names for substances were missing in the ASSIST-Y Examples of street names added: Alcohol (makali, tei, pombe, maji, keg); Tobacco (fegi, sigara, moshi, kuber, master fwaka, lyft); Cannabis (blunt, ndom, ngwai, bangi, kachom, shada, shash, weed, ndukulu, hela, kwaburu, kete a); Cocaine (coke, crack, white paper, coke powder etc.); Khat (miraa, mogoka); Inhalants (glue, petrol, paint thinner, bieri, gum, mafuta ya ndege, gaga); Sedatives / Sleeping Pills (valium, mchele); Hallucinogens (LSD, acid, mushrooms/mash, trips, ketamine, taptap); Opioids (heroin, morphine, codeine, unga, tramadol, pethidine, betapine etc.)
The word “urge” was not familiar with some youth. The youth proposed that the words “push” and “craving” be put in brackets whenever the word “urge” appeared in the questionnaire
The words “legal”, “health”, “social” and “financial” were not easily understood. The youth proposed that a description for these terms be added in brackets to the questions.
The phrase “normally expected” was not well understood. The youth proposed that the phrase “day to day roles and responsibilities at home, school, work” be added in brackets next to the phrase “normally expected” to make it easier for the youth to understand.
“…expressed concern” was not easy to understand. The youth proposed that this be replaced with “…shown concern”
ASSIST-Y feedback report card The youth felt that some medical terms were difficult and not easily understandable; the peer providers also felt that they may not be able to explain to the youth certain difficult medical terms e.g., emphysema The youth proposed that medical terms such as “emphysema” be replaced with simple phrases e.g. “lung disease”
Brief Intervention In the responsibility section of the BI, the statement “What you do with this information is up to you”, sounded offensive to the youth and peer-providers. They proposed that the sentence be replaced with “…you are ultimately responsible for the decisions you make.”
Readiness ruler: The youth reported difficulty rating readiness to change using a 10-point ruler. In addition, they did not understand the backward question i.e., why a 9 and not an 8. The youth and peer-providers proposed that a 3-point scale as below to aid in understanding.
1.“I’m very ready to reduce/stop using…”
2.“I’m still thinking about whether I should reduce/stop using …”
3. “I’m not ready to reduce/stop using…”
We presented the scale as a staircase instead of a ruler and added cartoon images to enhance understandability (Fig 1).
Within the menu of options, the following issue was raised by the youth:
The youth and peer providers felt that “Keeping a diary of substance abuse (where, when, how much used, how much spent, with whom, why)” was not a relatable option for cutting down or stopping substance use. They felt that this option was bothersome, and that the diary could be accessed by someone else.		 The youth proposed that the “Keeping a diary of substance use” be removed from the menu of options
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2.3.4. Phase 4: Production:

The adaptation team discussed and agreed to incorporate all the feedback from the adaptation workshop into a second draft of the ASSIST-Y-linked BI manual. In preparing this revised draft (draft two), the adaptation team ensured to maintain fidelity to the core elements of the ASSIST-Y-linked BI i.e., Feedback, Responsibility, Advice, Menu of options, Empathy, Self-efficacy.

2.3.5. Phase 5: Topical Experts:

Methods:

In November 2021, we identified 2 experts, one psychiatrist with experience in developing and testing substance use interventions, and one socio-behavioral scientist with experience in developing, adapting, and testing behavioral interventions for youth. We developed an expert review guide that sought for feedback on issues such as the appropriateness of the manual language and content for the youth population, whether the steps in the intervention manual were logically flowing, and whether the intervention was deliverable by a peer. Draft two of the ASSIST-Y-linked BI manual and the review guide were emailed to the experts. One expert returned their written comments while the other gave feedback at a virtual meeting.

Results:

Overall, experts confirmed that the draft two ASSIST-Y-linked BI manual was appropriate for the youth and for delivery by peer providers. The experts recommended that the intervention be translated to Swahili.

2.3.6. Phase 6: Integration:

Due to time and resource limitations, the adaptation team agreed to skip translating the intervention to Swahili, and to only recruit youth who could speak English for the pilot study.

2.3.7. Phase 7: Training:

Methods:

In December 2021, we trained 3 peer providers from Rafiki clinic, on how to deliver the ASSIST-Y-linked BI. The training was conducted over 5 days using lectures, quizzes, and role-plays. The training was facilitated by 2 Psychiatrists (F.J. and E.K.) and 4 Psychologists (J.B, G.K., M.K., W.R.) with experience in conducting mental health trainings for lay-providers. During the training, the facilitators took note of issues raised concerning understandability of the ASSIST-Y-linked BI. At the end of each day, the peer-providers and facilitators discussed and built consensus on adjustments to the manual. The manual was thus revised continuously throughout the training.

Results:

Feedback obtained throughout the training sought to address practical issues related to delivery of the intervention. During the training, the peer-providers reported that the manual was difficult to navigate. In response to this feedback, the adaptation team enhanced instructions and added arrows, guides, probes, prompts to the manual to make it easier to navigate. A second key feedback from the peer providers was that counseling youth who were ambivalent or in the pre-contemplation stage was a challenge. For example, the peer-providers reported that counseling youth who refused to see their ASSIST-Y scores, or youth who were not ready to cut down/stop using substances was challenging. In response to this, the adaptation team developed a section at the end of the manual with scripts outlining how to respond to youth resistant to change. The scripts were developed based on motivational interviewing strategies, and the FRAMES components. The scripts were role-played by the peer-providers during the training and were found to be helpful and acceptable. Following the training, the adaptation team prepared a final revision of the ASSIST-Y-linked BI manual incorporating changes proposed during the training. This resulted in a final manual that was delivered by the peer-providers during the pilot study.

3.0. Discussion

Substance use is a major problem among youth in Africa (Olawole-Isaac et al., 2018) and has significant negative implications (Erskine et al., 2015; Heradstveit et al., 2017). Implementing EBIs to address this issue should therefore be of high priority. This paper describes the process of adapting the ASSIST-Y-linked BI to tailor it to the cultural context in Kenya, and for peer delivery. To the best of our knowledge, this is the first paper to provide a step-by-step description of adapting the ASSIST-Y-linked BI for peer-delivery, and for the Kenyan context.

We utilized the ADAPT-ITT framework to conduct our adaptation. Although the ADAPT-ITT framework was developed to guide modification of HIV prevention interventions, it has been successfully utilized for interventions targeting other disorders. For example, Munro-Kramer et al (30), utilized the framework to guide adaptation of a sexual violence prevention intervention for youth. To the best of our knowledge, this is the first study to utilize this framework to adapt a substance use intervention. By using the ADAPT-ITT framework, we were able to systematically tailor the ASSIST-Y-linked BI to our context, and for peer-delivery. A second strength of the ADAPT-ITT framework is that it allows for rich feedback to be obtained from a broad range of stakeholders. In our study, we obtained views on the ASSIST-Y-linked BI from youth, peer-providers, and topical experts. We found the ADAPT-ITT model to be practical and affordable to implement. We were able to complete the adaptation process over a 6-month period. In addition, costs incurred were reasonable, and related to the costs of meals for the adaptation workshop and for the peer-provider training.

Overall, we made surface adaptations to the ASSIST-Y-linked BI. Our adaptations focused on modifying the language to make it more understandable to the Kenyan youth and peer-providers. For example, we added street names for substances to the ASSIST-Y to ensure accurate reporting of substances used. We also added instructions, probes, and sample scripts to the manual to make it easy for the peer-providers to administer the intervention. Such adaptations are necessary for ensuring that the intervention is culturally appropriate and could improve acceptability of the intervention. We made no modifications to the core components (FRAMES) of the intervention. We also maintained the intervention dosing, i.e., we maintained it as a single session intervention. Maintaining the core components is useful in guaranteeing fidelity to the original intervention, and in ensuring effectiveness of the adapted intervention.

From January 2022 to April 2022, we piloted and evaluated the adapted program with 100 youth (aged 15–24 years). We obtained both qualitative and quantitative feedback from the youth and peer-providers on the feasibility and acceptability of the intervention. Findings of this pilot study have been published elsewhere (Jaguga et. al. 2023).

4.0. Conclusion

In sum, we made surface level adaptations to the ASSIST-Y-linked BI and maintained the core components of the program. This paper provides evidence to support the utility of the ADAPT-ITT framework for youth substance use interventions. Further, it provides information upon which other stakeholders, planning to implement the ASSIST-Y-linked BI for youth in sub-Saharan Africa may use to adapt their intervention.

Figure 1:

Figure 1:

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Adapted version of assessing readiness to change

Acknowledgments

We acknowledge the youth, peer providers, and content experts whose input was invaluable in adapting this intervention

Funding

This work was funded by the Fogarty International Center of the National Institutes of Health under grant #D43TW009345 awarded to the Northern Pacific Global Health Fellows Program.

Abbreviations

ADAPT-ITT

Assessment, Decision making, Adaptation, Production, Topical Experts, Integration, Training, and Testing the evidence-based intervention

AMPATH

Academic Model Providing Access to Health Care

ASSIST-Y-linked BI

Alcohol Smoking and Substance Involvement Screening Test for Youth- linked Brief Intervention

EBIs

Evidence Based Interventions

HIV

Human Immunodeficiency Virus

IREC

Institutional Research Ethics Committee

FRAMES

Feedback, Responsibility, Advice, Menu of options, Empathy and Self-efficacy

LMICs

Low-and-Middle Income Countries

NACADA

National Authority for the Campaign Against Alcohol and drug Abuse

SBI

Screening and Brief Intervention

SUDs

Substance Use Disorders

US

United States

WHO

World Health Organization

Footnotes

Ethics statement:

Ethical approval to conduct the study was sought from the MTRH/ Moi University Institutional Research Ethics committee (IREC) and from the Indiana University Institutional Review Board. Written informed assent was sought from the youth aged 15–17 years, while written informed consent was sought from youth aged 18–24 years prior to data collection. We sought and obtained waiver of parental consent from IREC for participants below 18 years.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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