Cultural adaptation of the New Forest Parenting Program (NFPP) for ADHD in HIV-infected children in Uganda: a feasibility and pilot investigation

Abstract

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) is highly prevalent among children and adolescents living with HIV (CA-HIV) in sub-Saharan Africa. In Uganda, the estimated prevalence of ADHD among CA-HIV is 25.5% (95% CI: 19.8–31.8). Despite this, there are no established interventions targeting ADHD in HIV care settings. This study aimed to adapt the New Forest Parenting Program (NFPP) for the Ugandan context and evaluate its feasibility, acceptability, and preliminary symptom change within a pilot feasibility context in managing ADHD among CA-HIV.

Methods

This study consisted of two sequential phases. Phase 1 involved participatory cultural adaptation of the NFPP guided by the PREMIUM framework, including structured stakeholder workshops. Phase 2 involved an uncontrolled pre–post feasibility pilot study conducted in two HIV care facilities among nine caregiver–child dyads. The adapted NFPP (NFPP-UG) was evaluated for feasibility, acceptability, perceived effectiveness, and risk of harm using a four-point Likert scale. ADHD symptoms were assessed at baseline and 3 months post-intervention using the CASI-PM-P.

Results

Phase 1 – Adaptation: The adapted NFPP (NFPP-UG) was rated feasible (mean score: 2.075), acceptable (mean score: 2.26), and perceived as potentially helpful (mean score: 2.24) by participating stakeholders (n = 17). Phase 2 – Pilot Feasibility Study (pre–post): ADHD symptom scores demonstrated preliminary reductions within a small uncontrolled feasibility sample (n = 9), with median scores decreasing from 10 (IQR: 8–14) to 2 (IQR: 1–7). The follow-up period was three months post-intervention. The adapted NFPP integrated additional components, including stress management techniques and adherence counselling, with cultural adaptation addressing local beliefs about ADHD, enhancing contextual relevance within the Ugandan setting.

Conclusion

The NFPP was culturally adapted for use in Uganda and demonstrated feasibility and acceptability within a pilot context. The observed symptom reductions should be interpreted cautiously given the small sample size and absence of a control group. A randomized controlled trial is required to formally evaluate effectiveness.

Clinical trial registration

Not applicable (this study was a feasibility pilot without randomization or control group).

Background

Children and adolescents living with HIV (CA-HIV) in Uganda and other sub-Saharan African settings are predisposed to Attention-Deficit/Hyperactivity Disorder (ADHD) among many other mental and neurological disorders [1, 2]. ADHD is one of the most prevalent neurodevelopmental disorders in this population, with prevalence rates among CA-HIV ranging from 6% to over 25%, often co-occurring with other conditions such as anxiety and conduct problems [3, 4]. ADHD in CA-HIV is associated with adverse psychosocial and academic outcomes, including academic underachievement, peer relationship difficulties, and family conflict, as well as poor adherence to antiretroviral therapy (ART), which may lead to ART regimen failure [5, 6]. The elevated prevalence may be related to both the neurodevelopmental impact of HIV and shared psychosocial risk factors, such as stigma and chronic stress.

In Uganda, despite the high prevalence of ADHD among CA-HIV, with 25.5% (95% CI: 19.8–31.8) of CA-HIV affected, there are few evidence-based non-pharmacological interventions to address these challenges and hardly established interventions targeting ADHD among children and adolescents living with HIV in sub-Saharan Africa, including Uganda. The New Forest Parenting Program (NFPP) is a structured, evidence-based behavioural intervention originally developed in the United Kingdom to manage ADHD symptoms in children aged 4 to 11 years. NFPP is grounded in social learning theory and behavioural principles, emphasizing the role of parent-child interaction in shaping child behaviour. Its core strategies include positive reinforcement, structured routines, and reduction of negative reinforcement cycles [7]. NFPP has demonstrated efficacy in high-income settings through multiple randomized controlled trials in community samples of children with ADHD [7, 8], with improvements observed in child ADHD symptoms, parenting practices, and family functioning; its brief format, individual focus, and cost-effectiveness made it a promising candidate for adaptation to the Ugandan context, where group-based programs and access to child mental health services remain limited. However, the NFPP has not been previously adapted for use in low-resource settings or for children with HIV. The adaptation process was guided by the PREMIUM framework [8], which provides a structured, implementation science-based approach for culturally adapting psychological interventions in under-resourced health systems, ensuring contextual relevance and potential for scale [9]. This study further evaluated the feasibility, acceptability, and preliminary outcomes of the adapted NFPP (NFPP-UG) in managing ADHD among CA-HIV in Uganda.

Methods

This study was conducted in two sequential phases from June 2022 to August 2023: (1) Adaptation of the NFPP, and (2) Feasibility and Pilot Testing of the adapted version (NFPP-UG). The overall study was a 12-month formative study, employing the PREMIUM framework (Program for Effective Mental Health Interventions in Under-Resourced Health Systems) to guide the adaptation process [9].

Phase 1: Adaptation of the NFPP

Study design and setting

The adaptation followed a participatory, theory-informed approach, involving stakeholders in consultative workshops at the study sites: the Joint Clinical Research Centre (JCRC) Lubowa in Central Uganda (Kampala) and Uganda Cares in Southwestern Uganda (Masaka).

Participants

Figure 1: Flow diagram showing [1] 10 stakeholders engaged in adaptation discussions; [2] 9 caregiver–child dyads [Nine primary caregivers of CA-HIV (aged 6–11 years) who met the screening cut-off for significant ADHD symptoms (see Measures) ] were purposively enrolled in pilot feasibility testing; [3] 8 Child and Adolescent Mental Health Specialists (CAMHS) participated in the adaptation workshops: the eight specialists were purposively selected from urban referral hospitals in Kampala (Butabika National Referral Mental Hospital) and Masaka (Masaka Regional Referral Hospital) based on their experience with CA-HIV and neurodevelopmental disorders [4]. HIV Clinicians: Key staff from the two study sites participated in consensus discussions. The total of 10 stakeholders refers exclusively to participants in the adaptation workshops (caregivers and clinicians combined). The 9 caregiver–child dyads were enrolled separately for the pilot phase, and the 8 CAMHS specialists participated in professional consultative workshops only. There was partial overlap between workshop participants and pilot caregivers; however, these samples served distinct methodological purposes (adaptation versus pilot testing).

Fig. 1.

Theoretical framework that guided the adaptation of the NFPP

Procedures

The adaptation process was led by a core team (a child psychiatrist and a clinical psychologist). Three one-day consultative workshops were held: (1) with caregivers; (2) with CAMHS; and (3) a consensus workshop with both groups. During workshops, participants reviewed the original NFPP manual and rated each of its eight core strategies across four dimensions—feasibility, acceptability, effectiveness, and risk of harm—using a structured 4-point Likert scale (described in Phase 2 Measures). Each strategy within the NFPP was evaluated across the four dimensions mentioned above. The average scores from the workshops provided insights into which strategies were most suitable for the Ugandan setting (Table 1). The PREMIUM framework guided the NFPP adaptation, ensuring contextual relevance while preserving the core evidence-based components of the intervention [9].

Table 1.

Ratings of NFPP treatment strategies across four dimensions (Feasibility, acceptability, effectiveness, risk of harm)

Possibility for parents / guardians / caregivers, with appropriate training and supervision, to deliver NFPP treatment strategy?	Feasibility of the NFPP	Acceptability of the NFPP	Effectiveness of the NFPP	Risk for harm of the NFPP
Assessment and Psychoeducation	2.4	2.5	2.2	2.8
Therapeutic relationship and Attributions	1.9	2.3	2.2	2.8
Parent Child relationship	2.2	2.5	2.2	2.9
Reciprocal parent child interaction	2	2.2	2.5	2.9
Scaffolding and NFPP Attention Training	2.2	2.2	2.2	2.8
Managing behaviour and self-regulation	2.1	2.1	2.2	2.8
Systems theory-generalizing and extending	1.7	2.2	2.3	2.8
Sustaining and Transferring	2.1	2.1	2.1	2.9
AVERAGE RATINGS	2.075 = Possible	2.26 = Acceptable	2.24 = Perceived potential effectiveness	2.84 = Indicates low perceived risk (higher scores represent lower perceived risk of harm)

Note:

(i) Ratings based on caregiver and CAMHS stakeholder reports (n = 17 total participants) using 4-point Likert scale

(ii) Ratings were based on a 4-point Likert scale (1 = Not at all, 4 = Very much). Means should be interpreted descriptively and not as categorical thresholds

Feedback from structured questionnaires and open discussions was thematically analyzed to identify culturally relevant modifications to the NFPP content, delivery format, and illustrative examples. Recommendations generated through this process were used to inform the iterative development of the adapted NFPP version (NFPP-UG). Feedback from these workshops guided the cultural adaptation of the NFPP to ensure it was relevant and effective in the Ugandan context (Table 2).

Table 2.

Suggested additional ADHD treatment strategies for the adapted Ugandan version of the NFPP (NFPP-UG) integrated within the eight processes / sessions

NFPP treatment strategies / processes / weekly sessions		Suggested additional ADHD treatment strategies
1	Assessment and Psychoeducation	• Component demystifying myths about cultural, religious, or traditional causes and treatment of ADHD • Seeking the opinion of parents/caregivers regarding cultural-social beliefs at the beginning of the NFPP intervention
2	Therapeutic relationship and attributions	• Screening for psychiatric disorders among parents/caregivers to CA-HIV with ADHD
3	Parent-Child Relationship	- No specific additional strategy
4	Reciprocal parent-child interactions	• Problem-solving component
5	Scaffolding and NFPP Attention Training	• Stress management component
6	Managing behaviour and self-regulation	• Adherence counselling component
7	Systems Theory generalizing and extending	- No specific additional strategy
8	Sustaining and transferring	- Transferring skills to the child. - All additional strategies should be reinforced in this final process to ensure long-term effectiveness.

Note: Ratings based on caregiver and CAMHS stakeholder reports (n = 17 total participants) using 4-point Likert scale

Key adaptations

The original NFPP manual includes eight core sessions focused on parent-child interaction, behaviour management, attention training, and managing defiance. Adaptations for the Ugandan context (NFPP-UG) included: (1) Content Contextualization: UK-based examples were replaced with locally relevant scenarios (e.g., non-compliance around chores or schoolwork). Role-plays and illustrations were simplified for literacy levels. (2) Additional Modules: New content on caregiver stress management and ART adherence support was integrated. A component to address local cultural and religious myths about ADHD was added. (3) Linguistic Adaptation: Materials were translated into Luganda following International Test Commission (ITC) guidelines (forward/back translation, expert panel review) [10]. (4) Delivery Format: Session flow was adapted to align with typical HIV clinic procedures. The adaptation phase concluded with the finalization of the NFPP-UG manual based on stakeholder consensus. No intervention was delivered in this phase.

Translation of the adapted NFPP version (NFPP-UG)

The adaptation of NFPP materials followed the International Test Commission (ITC) guidelines for the translation and cultural adaptation of psychological instruments [10]. These guidelines emphasize the importance of conceptual, linguistic, and functional equivalence through a systematic process that includes forward translation by bilingual experts, back-translation to check accuracy, review by an expert panel for consensus, and pre-testing in the target population. This process ensured that the Luganda version of the NFPP maintained fidelity to the original content while enhancing cultural and linguistic appropriateness for the target population (Fig. 2). The translation process involved forward and backward translation by bilingual mental health professionals, followed by a consensus workshop to refine the final version (Fig. 2).

Fig. 2.

Conceptual framework to guide the translation of the final Uganda version of the NFPP. Conceptual framework (above) for the cross-cultural translation and adaptation of the final Ugandan version of NFPP follow some of the guidelines for the cross-cultural translation and adaptation of psychological instruments as recommended by the International Test Commission (Muniz J, et al.,2013)

Phase 2: Feasibility and pilot testing

Study design

This phase was an uncontrolled pre–post feasibility and pilot study conducted from June to August 2023, aiming to assess the feasibility, acceptability, and preliminary outcomes of the NFPP-UG.

Setting

The study was conducted at two HIV care facilities in Uganda: the Joint Clinical Research Centre (JCRC) Lubowa in Central Uganda (Kampala) and Uganda Cares in Southwestern Uganda (Masaka). These facilities were chosen for their high caseloads of CA-HIV, established paediatric HIV clinics, and specialized care for CA-HIV.

Participants

Eligibility

CA-HIV aged 6–11 years registered at the study sites, with significant ADHD symptoms as per the CASI-PM-P cut-off (see Measures), and whose primary caregiver was over 18, had cared for the child for ≥ 1 year, and could communicate in English or Luganda.

Exclusion

CA-HIV with sensory/cognitive impairments or ongoing ADHD treatment; caregivers with uncorrected sensory impairments, significant cognitive limitations, active psychiatric conditions, or enrolled in another ADHD intervention.

Screening and recruitment

Out of approximately 475 CA-HIV aged 6–11 years at the sites, two hundred (200) CA-HIV attending these facilities were purposively selected and screened using the Child and Adolescent Symptom Inventory Progress Monitor – Parent/Teacher (CASI-PM-P), 48 version [11] Table 1. Selection was based on clinic visit schedules and caregiver availability during the study’s data collection period. This approach ensured adequate logistical feasibility and a manageable sample size for screening within the study timeframe. Out of the 200 participants screened, 103 were from JCRC [Central (Kampala)], while 97 were from Uganda Cares Masaka [Southwestern Uganda (Masaka)]. Out of the 200 (42%) CA-HIV screened using CASI-PM-P, 51 (25.5%) met the cut-off for significant ADHD symptoms, while 149 (74.5%) had no ADHD. Similarly, CAS-PM-P was used to screen for other related disorders (Conduct disorders, Oppositional Defiant disorders, etc.) (Table 4). From this group, a pilot sample of 9 caregiver-child dyads (5 from JCRC, 4 from Masaka) was purposively enrolled (Fig. 3). This sample size was deemed adequate for a feasibility pilot to assess processes, acceptability, and generate preliminary data to inform a future RCT. Selection of the nine dyads was purposive and based on logistical feasibility, caregiver availability, and representation from both study sites rather than statistical power considerations. No formal a priori power calculation was conducted because the study was not designed to test intervention effectiveness but to assess feasibility and implementation processes. As a feasibility study, it was not powered for efficacy testing but aimed to inform the design and implementation of a future larger-scale randomized controlled trial (RCT). The sample size was consistent with methodological guidance for feasibility studies, which prioritise process evaluation over hypothesis testing. The remaining 42 children were referred to mental health or psychosocial support services available within their respective HIV care clinics. They were not enrolled in the pilot intervention due to resource constraints, including limited staff capacity and the study’s design as a small-scale feasibility assessment.

Table 4.

Prevalence of ADHD and other psychiatric disorders among CA-HIV (N = 200)

Disorder	N = 200	Prevalence	95% CI
ADHD	51	25.5%	(19.8; 31.8)
ODD	22	11%	(7.3; 16.2)
CD	40	20%	(14.9; 26.2)
GAD	49	24.5%	(19.0; 30.9)
Social Phobia	14	7.0%	(4.1; 11.5)
MDE	19	9.5%	(6.1; 14.4)
Separation Anxiety	32	16.0%	(11.5; 21.8)

Fig. 3.

Flow diagram for the NFPP study

Intervention (NFPP-UG)

The finalized NFPP-UG manual (available from the corresponding author upon reasonable request) from Phase 1 was used. The intervention consisted of eight weekly, individual sessions delivered to the caregiver by a trained psychiatric clinical officer, each lasting 60–75 min. Sessions covered the adapted content, including psychoeducation, stress management, and adherence support. Children were indirectly engaged through caregiver-assigned homework and practice activities. The evaluation (using the CASI-PM-P) was done by two trained psychiatric clinical officers with prior experience in child and adolescent mental health. These officers received structured training on the adapted NFPP content and facilitation techniques, followed by weekly supervision provided by a child psychologist throughout the intervention period. Supervision sessions focused on fidelity to the manual, troubleshooting challenges, and reflective practice. Parents / caregivers received training in managing ADHD symptoms, improving parent-child interactions, and scaffolding behaviour management. The effectiveness of the intervention was evaluated by comparing pre- and post-intervention ADHD symptom scores using the CASI-PM-P. (Table 7).

Table 7.

ADHD scores pre- and post-intervention

	Pre -intervention	Post intervention
Median score (IQR)	10 (IQR: 8–14)	2 (IQR: 1–7)

Measures

Feasibility and acceptability

A structured feedback questionnaire was administered to caregivers post-intervention and used in Phase 1 workshops. Participants rated the intervention (or its strategies) across four domains (feasibility, acceptability, effectiveness, risk of harm) using a 4-point Likert scale (1 = Not at all, 2 = A little, 3 = Quite a bit, 4 = Very much). A mean score was calculated for each domain across relevant items; higher scores indicated greater perceived feasibility/acceptability/effectiveness or lower perceived risk.

ADHD and co-occurring symptoms

The Child and Adolescent Symptom Inventory Progress Monitor – Parent/Teacher (CASI-PM-P) 48-item version [11] was used. This is a parent-reported, DSM-5-aligned rating scale. It was administered via interviewer-assisted paper-pencil format. It screens for ADHD, Oppositional Defiant Disorder (ODD), Conduct Disorder (CD), Generalized Anxiety Disorder (GAD), Social Phobia, Major Depressive Episode (MDE), and Separation Anxiety. For ADHD, a participant was classified as having significant symptoms if they met either: a) a raw score of ≥ 5 (males) / ≥4 (females) on either the Inattentive or Hyperactive-Impulsive subscale, with items rated ‘often’ or ‘very often’ (score ≥ 2); or b) a T-score ≥ 65. These criteria, supported by prior validation [11], were used for screening and to define the pilot sample. The ADHD raw score (range 0–48) was used as the pre–post outcome measure.

Other Data: A socio-demographic questionnaire collected information on child and caregiver characteristics.

To maintain separation of roles and reduce bias, the ADHD assessments (screening and pre–post) were conducted by research officers, while the NFPP-UG intervention was delivered by different, trained psychiatric clinical officers.

Procedures

Following screening and recruitment, baseline (pre-intervention) CASI-PM-P assessments were completed. Caregivers then received the 8-week NFPP-UG intervention. Three months after the final session, post-intervention CASI-PM-P assessments and feasibility/acceptability questionnaires were administered.

Data analysis

Descriptive statistics (frequencies, percentages, medians, IQRs) summarized demographic and clinical characteristics. Mean scores with standard deviations were calculated for feasibility/acceptability ratings. The change in ADHD scores from pre- to post-intervention was described using medians and IQRs. Given the small pilot sample, a non-parametric paired test (Wilcoxon signed-rank) was conducted for exploratory purposes, with the results interpreted cautiously. Analysis was performed in Stata 17.

Results

Phase 1: Adaptation workshop findings

Each NFPP strategy was rated across four dimensions: feasibility, acceptability, effectiveness, and risk of harm. The mean ratings from the stakeholder workshops for the NFPP strategies were: feasibility = 2.075, acceptability = 2.26, effectiveness = 2.24, and risk of harm = 2.84 (Table 1). Feasibility and acceptability results are summarized in Table 1. Mean scores are presented descriptively and should not be interpreted as categorical thresholds or indicators of demonstrated effectiveness. Acceptability and perceived effectiveness were similarly assessed using parallel Likert-scale items. The strategies related to psychoeducation, scaffolding, and behavior management received the highest ratings. These ratings suggest moderate perceived feasibility and acceptability within the adaptation workshops, with low perceived risk (Table 1). Perceived effectiveness reflects stakeholder appraisal rather than empirically established clinical impact.

Suggested additional ADHD treatment strategies

The strategies related to psychoeducation, scaffolding, and behaviour management received the highest ratings. Participants and stakeholders suggested additional strategies for managing ADHD within the context of HIV care, which were integrated into the final version of the NFPP; these included demystifying cultural and religious myths about ADHD, incorporating stress management techniques, introducing adherence counselling to address ART-related challenges, and screening caregivers for psychiatric disorders (Table 2).

Phase 2: Feasibility and pilot study findings

Screening sample characteristics (n = 200)

The demographic characteristics of the screened sample (n = 200), including age, sex distribution, and study site representation, are presented in Table 3.

Table 3.

Demographic information of participants (n = 200)

Factor	Level	Freq (%) n = 200
Age (years)	Median (IQR)	9 (7,10)
Sex	Male	88 (44.0%)
	Female	112 (56.0%)
Study site	JCRC Lubowa	103 (51.5%)
	Masaka RRH	97 (48.5%)

Prevalence of significant ADHD and other disorder symptoms

The prevalence of ADHD in this study population was 25.5% (95% CI: 19.8–31.8) out of the 200 CA-HIV screened using CASI-PM-P. Out of the 200 CA-HIV screened using CASI-PM-P, 149 (74.5%) did not meet ADHD cut-off criteria. Of these 149, 107 (71.8% of those without ADHD; 53% of the total screened sample) had no lifetime mental health diagnosis based on structured MINI criteria [(diagnostic interview), rather than solely on symptom cut-off scores], while 42 met criteria for at least one other mental health disorder. Other commonly endorsed symptom clusters are summarized in Table 4.

Pilot sample characteristics (n = 9 dyads)

Child participants had a median age of 9 years (IQR: 7–10); 6 (66.7%) were male. Caregiver participants had a median age of 38 years (IQR: 32–42); 8 (88.9%) were female. Caregiver relationships were: biological mother (n = 6, 66.7%), aunt (n = 2, 22.2%), grandmother (n = 1, 11.1%). Most caregivers (n = 7, 77.8%) had completed primary education or less (Table 5).

Table 5.

Demographic characteristics of the pilot sample (n = 9 caregiver-child dyads)

Characteristic	Level	Frequency (%) or Median (IQR)
CHILD CHARACTERISTICS
Age (years)	Median (IQR)	9 (7, 10)
Sex	Male	6 (66.7%)
	Female	3 (33.3%)
CAREGIVER CHARACTERISTICS
Age (years)	Median (IQR)	38 (32, 42)
Sex	Female	8 (88.9%)
	Male	1 (11.1%)
Relationship to Child	Biological Mother	6 (66.7%)
	Aunt	2 (22.2%)
	Grandmother	1 (11.1%)
Highest Education Level	Primary school or less	7 (77.8%)
	Secondary school or higher	2 (22.2%)

Feasibility and acceptability

Post-intervention, caregivers rated the delivered NFPP-UG. The mean feasibility score was 2.08 (SD = 0.76), corresponding to “a little” on the 4-point scale. Acceptability (2.26) and perceived effectiveness (2.24) fell between “a little” and “quite a bit,” while the risk-of-harm score (2.84) indicated a low perceived risk. The feasibility, acceptability, perceived effectiveness, and risk of harm ratings for the NFPP-UG intervention are presented in Table 6.

Table 6.

Feasibility, acceptability, perceived effectiveness, and risk of harm ratings for the NFPP-UG intervention (n = 9 caregivers)

Domain	Mean Score (SD)
Feasibility	2.08 (0.76)
Acceptability	2.26 (0.68)
Perceived Effectiveness	2.24 (0.71)
Risk of Harm	2.84 (0.43)

Note: Ratings were collected using a 4-point Likert scale (1 = Not at all, 2 = A little, 3 = Quite a bit, 4 = Very much). Mean scores closer to 4 indicate a stronger positive rating for Feasibility, Acceptability, and Perceived Effectiveness. For Risk of Harm, a higher mean score indicates a lower perceived risk

ADHD symptoms pre- and post-intervention

ADHD symptom scores showed improvement post-intervention. The median pre-intervention score was 10 (IQR: 8–14), and the median post-intervention score was 2 (IQR: 1–7) (Table 7). Exploratory analysis with the Wilcoxon signed-rank test showed a statistically significant reduction (z = − 2.67, p = 0.008); however, this result must be interpreted with caution due to the small, non-randomized sample.

Discussion

This study culturally adapted the New Forest Parenting Program (NFPP) for children and adolescents living with HIV (CA-HIV) in Uganda and evaluated its feasibility within a pilot sample. Using a participatory adaptation process guided by the PREMIUM framework, the intervention was modified to enhance contextual relevance while retaining its core theoretical components. The findings demonstrate preliminary feasibility and acceptability within a small uncontrolled sample; therefore, these observations should be interpreted as implementation signals rather than evidence of intervention effectiveness. Importantly, this study was not designed to establish intervention effectiveness.

Caregiver and stakeholder ratings suggested that the adapted NFPP was perceived as possible to implement within the local HIV care context and acceptable to participating caregivers. Mean ratings also indicated that stakeholders considered the intervention potentially helpful in managing ADHD-related behaviours. The risk-of-harm score reflected a low perceived risk, with higher scores corresponding to lower perceived harm. These ratings should be interpreted descriptively and reflect implementation perceptions within a feasibility study rather than evidence of clinical efficacy.

The participatory adaptation process appears to have strengthened contextual fit. Stakeholders emphasized the importance of incorporating stress management strategies, addressing local explanatory models of ADHD, and integrating adherence counselling components relevant to HIV care. This aligns with existing literature demonstrating that culturally responsive adaptation enhances acceptability and implementation feasibility in low-resource settings [9, 12, 13]. By engaging caregivers and clinicians in the adaptation process, the intervention was grounded in lived experience and service delivery realities, which likely contributed to its perceived feasibility.

Feasibility and cultural relevance

The study rated the NFPP as feasible and acceptable within the pilot context (Table 1). Mean scores fell between “a little” and “quite a bit” on the 4-point scale, indicating moderate perceived feasibility and acceptability rather than strong endorsement; These findings are consistent with prior research highlighting the importance of culturally adapting parenting interventions to improve acceptability in diverse settings [14–19]. However, these ratings reflect stakeholder perceptions within a pilot context and should be interpreted as indicators of implementation feasibility rather than evidence of intervention effectiveness.

The high level of acceptability of the NFPP among caregivers, even in a context where mental health literacy is often low, further underscores the value of participatory approaches in intervention design; other previous studies support the value of participatory approaches in intervention design, particularly in contexts where mental health literacy may be low [20–22]. By involving caregivers in the adaptation process, this study mirrors findings from Chowdhary et al. (2016), who noted that community involvement enhances buy-in and improves the acceptability of mental health interventions, particularly in settings with limited mental health services [9]. In this study, participatory engagement appears to have facilitated contextual alignment rather than demonstrated clinical efficacy.

Cultural adaptation was central to improving contextual fit and perceived acceptability within this pilot context. Uganda’s context presents unique challenges, where cultural and religious myths often hinder the recognition and treatment of neurodevelopmental disorders [23–25]. By integrating culturally sensitive elements such as stress management and the demystification of ADHD myths, the adapted NFPP (NFPP-UG) addressed these barriers effectively. These adaptations were designed to enhance acceptability and comprehension rather than to modify core therapeutic mechanisms. This approach is similar to other low-resource settings, where overcoming stigma and cultural misconceptions is essential for mental health interventions to be accepted [25].

The inclusion of stress management techniques was especially important for caregivers of CA-HIV, who face multiple stressors related to their child’s illness, economic hardships, and social stigma [26–29]. Caregiver well-being is known to be a critical factor in the success of parenting interventions [7]. By equipping caregivers with the tools to manage their stress, the intervention aimed to support not only the management of the child’s ADHD symptoms but also overall caregiver well-being. While this study was not powered to evaluate caregiver mental health outcomes, incorporating stress management elements may have contributed to the favorable feasibility and acceptability ratings observed. This study contributes implementation-focused evidence demonstrating that a structured parenting intervention can be culturally adapted and feasibly delivered within pediatric HIV services in a low-resource setting.

ADHD symptom reduction and prevalence

Exploratory analysis indicated a reduction in caregiver-reported ADHD symptom scores between baseline and post-intervention assessment, with median scores decreasing from 10 (IQR: 8–14) to 2 (IQR: 1–7) (Table 7). Although this pre–post change reached statistical significance, interpretation should remain cautious given the small uncontrolled feasibility sample (n = 9), the absence of a comparison group, and reliance on caregiver-reported outcomes. Accordingly, these findings should be viewed as exploratory and hypothesis-generating rather than as evidence of intervention effectiveness.

Nevertheless, the observed reduction in ADHD symptom scores is broadly consistent with existing evidence demonstrating that parent-mediated behavioural interventions can contribute to improvements in ADHD-related behaviours across diverse settings [7, 30–33]. For example, Sonuga-Barke et al. (2013) reported that structured parenting programmes such as the New Forest Parenting Program (NFPP) were associated with reductions in ADHD symptoms among children receiving parent-focused behavioural support [8]. The structured weekly sessions used in the present intervention may have contributed to improved caregiver understanding of ADHD-related behaviours and enhanced caregiver capacity to apply behavioural management strategies in the home environment.

In addition to the exploratory symptom changes observed in the pilot sample, this study also identified a substantial proportion of children and adolescents living with HIV (CA-HIV) who screened positive for significant ADHD symptoms. Specifically, 25.5% of screened children met the cut-off for elevated ADHD symptoms (Table 4). This prevalence is consistent with previous studies conducted in sub-Saharan Africa that have reported comparable or slightly lower estimates of ADHD symptoms among CA-HIV populations [3, 34, 35]. The elevated prevalence of ADHD in this population may reflect the combined influence of neurodevelopmental vulnerabilities associated with HIV infection and broader psychosocial stressors linked to chronic illness [6, 36, 37].

Notably, symptoms of other mental health conditions, including generalized anxiety disorder (GAD) and conduct disorder (CD), were also frequently reported among screened participants. However, the present intervention focused specifically on ADHD due to its well-documented impact on daily functioning, academic performance, and behavioural regulation.

ADHD symptoms such as impulsivity, inattention, and behavioural dysregulation may interfere with the structured routines required for consistent medication adherence and clinic attendance, which are essential components of HIV care in children and adolescents.

Importantly, untreated ADHD symptoms may also complicate adherence to antiretroviral therapy (ART), highlighting the relevance of early identification and management of ADHD within paediatric HIV care settings. Taken together, these findings underscore the potential importance of integrating mental health screening and parent-mediated behavioural interventions within routine HIV services for children and adolescents.

ADHD and ART adherence

The link between ADHD symptoms and poor ART adherence has been documented in both low- and high-resource settings [5]. Symptoms such as inattention and impulsivity interfere with a child’s ability to adhere to complex medication regimens, particularly in the context of chronic conditions like HIV.

However, ART adherence was not measured in this study, and no conclusions can be drawn regarding intervention effects on HIV treatment outcomes. While reductions in ADHD symptom scores were observed, any suggestion that this may translate into improved ART adherence remains speculative and should be interpreted cautiously.

Existing literature indicates that mental health interventions can positively influence HIV treatment engagement [38, 39]. Future studies incorporating objective adherence measures will be necessary to evaluate whether behavioral interventions targeting ADHD symptoms yield measurable HIV-related clinical benefits.

Novel findings and implications for policy and practice

A key contribution of this study lies in demonstrating that the NFPP can be culturally adapted and delivered within a pilot HIV care context in Uganda. This contribution is methodological and implementation-focused rather than efficacy-based.

While prior literature has suggested that improved behavioral regulation may support adherence in chronic illness contexts [5], the present study does not provide direct evidence for such an effect. Rather, it establishes feasibility and acceptability within a pilot framework.

Accordingly, implications for practice should be framed cautiously. The findings support further evaluation of integrated mental health interventions within HIV care but do not justify scale-up without rigorous effectiveness and implementation trials.

Limitations and future research

Despite these promising feasibility findings, several limitations should be considered. First, the pilot study involved a small purposively selected sample (n = 9 caregiver–child dyads), limiting statistical power and generalizability. Second, the uncontrolled pre–post design precludes causal inference regarding intervention effects. Third, the short follow-up period restricts conclusions regarding the durability of symptom change. Finally, outcomes relied primarily on caregiver report, introducing the possibility of reporting bias. These limitations are consistent with the exploratory nature of feasibility studies. Consistent with the objectives of feasibility research, the present study was designed to assess implementation processes rather than to establish intervention effectiveness.

Future studies should include adequately powered randomized controlled designs and assess broader outcomes, including parental psychological distress, caregiver stress burden, child HIV clinical indicators (e.g., adherence), school functioning, and quality of life. Longer follow-up periods will be essential to determine sustainability of observed changes.

Further research should also examine implementation fidelity, scalability across diverse regions, and economic considerations. Cost-effectiveness analysis and hybrid effectiveness–implementation designs would be particularly valuable before considering integration into routine HIV services.

Conclusions

This study culturally adapted the New Forest Parenting Program (NFPP) for children and adolescents living with HIV (CA-HIV) in Uganda and demonstrated its feasibility and acceptability within a small pilot sample. The participatory adaptation process, grounded in the PREMIUM framework, enabled contextual tailoring while preserving core theoretical principles.

Observed reductions in ADHD symptom scores provide preliminary signals warranting further evaluation but should not be interpreted as evidence of intervention effectiveness. Given the small sample size, absence of a control group, and short follow-up, findings are best understood as hypothesis-generating.

Overall, this adaptation represents an incremental step toward integrating culturally responsive parenting interventions into pediatric HIV care. However, integration into routine services should only be considered following rigorous effectiveness and implementation trials.

Abbreviations

ADHD

Attention-Deficit/Hyperactivity Disorder

ART

Antiretroviral Therapy

CA-HIV

Children and Adolescents living with HIV

CAMHS

Child and Adolescent Mental Health Specialists

CASI-PM-P

Child and Adolescent Symptom Inventory Progress Monitor-Parent/Teacher

CD

Conduct Disorder

GAD

Generalized Anxiety Disorder

HIV

Human Immunodeficiency Virus

IQR

Interquartile Range

JCRC

Joint Clinical Research Centre

NFPP

New Forest Parenting Program

ODD

Oppositional Defiant Disorder

PREMIUM

Program for Effective Mental Health Interventions in Under-Resourced Health Systems

RRH

Regional Referral Hospital

SUD

Substance Use Disorder

Author contributions

Dr. Richard Stephen Mpango (RSM), Mr. Wilber Ssembajjwe (WS), Dr. Allan Kalungi (AK), Professor Eugene Kinyanda (EK) and Professor Fred Ssewamala have made substantial contributions to conception, design, acquisition of data, drafting the manuscript, revising it critically and gave the final approval of this version to be published. WS did the analysis and interpretation of data. Each author participated sufficiently in this work and takes public responsibility for appropriate portions of the content.

Funding

This work was funded by the Fogarty International Center of the National Institutes of Health under Award Number D43TW011541.

Data availability

All data and materials in this manuscript, additional files and figures attached are freely available with no restrictions. The adapted NFPP-UG manual is available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

All procedures performed in this study involving human participants were conducted in accordance with the ethical standards of the institutional and national research committees and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study obtained ethical approvals from the Uganda Virus Research Institute’s Research and Ethics Committee (GC/127/953) and the Uganda National Council of Science and Technology (SS1721ES). Participants were given information about the study by trained study Psychiatric Nurses / Psychiatric Clinical Officers, and informed consent and assent were sought before enrolment into the study. Participants found to have ADHD and other disorders were provided healthcare and support at the two specialised health facilities [Joint Clinical Research Centre (JCRC) Lubowa, Central Uganda (Kampala), and Uganda Cares, Southwestern Uganda, Masaka].

Consent to participate

Informed consent and assent were obtained from all individual participants included in the.

Consent to publish

Consent for publication was not applicable.

Author’s information

Dr. Richard Stephen Mpango is a Psychiatric Epidemiologist and Clinical Psychologist currently working as a Senior Lecturer at Soroti University-Uganda, a CHILD Global Research Fellow (CHILD GRF) at the Brown School, Washington University in St. Louis, USA and previously worked a ‘Scientist A’ at MRC/UVRI and LSHTM Uganda Research Unit (2014-2025). Institutional affiliations are below: ¹Mental Health Project, MRC/UVRI and LSHTM Uganda Research Unit, P. O. Box, 49, Entebbe, Uganda. ²Brown School, Washington University in St. Louis, Missouri 63130, USA. ⁵Department of Mental Health, School of Health Sciences, Soroti University, Soroti, Uganda. Tel: +256 772 592504, +256 446556 & +256 702 592504. E mail: rmpango@sun.ac.ug & richmpan@live.com.

Competing interests

The authors declare no competing interests.