Zimbabwe HIV Wellbeing Scale Exposes the Limits of Imported Mental Health Metrics
Adolescents living with HIV in Eastern and Southern Africa face a double burden: treatment adherence pressures and the mental health demands that often accompany chronic illness during adolescence. In Zimbabwe, researchers set out to build a wellbeing measure that reflected the lives of young people already receiving HIV care, rather than relying on instruments developed in high-income settings and then simply translated across contexts. The resulting work around the Zvandiri Character Strength scale did more than generate a new questionnaire. It tested whether wellbeing itself could be measured in a way that respected the relational, culturally embedded realities of adolescents living with HIV.
The answer was sobering. The scale did not support a single interpretable total score.
A Scale Built Around Lived Experience, Not Imported Assumptions
The project used a multi-stage development process between 2022 and 2025. It began with a scoping and systematic review, then moved through qualitative discussions, expert panel input, construct and item prioritisation, cognitive interviews, iterative item reduction, and psychometric testing using exploratory factor and Rasch analyses. This was not a narrow psychometric exercise built around a predetermined construct. It was an attempt to define what wellbeing actually means for adolescents living with HIV in Zimbabwe, and then to see whether measurement tools could keep up.
The review identified a familiar problem in global mental health measurement: multiple positive psychological constructs overlap conceptually, yet many are captured with instruments designed in high-income settings and not adequately validated for adolescents in Africa. That mismatch matters in HIV care, where wellbeing is not an abstract endpoint. It influences medication adherence, disclosure, engagement with services, and the ability to sustain treatment during a developmental period already marked by social vulnerability.
What Adolescents Said Wellbeing Looks Like
Qualitative work pointed to six recurring elements: connectedness, hope, self-acceptance, self-efficacy, purpose, and flourishing. Those domains sit close to everyday clinical experience. Adolescents rarely describe wellbeing as a purely internal state. Instead, wellbeing appears relational, shaped by family ties, peer belonging, social support, and the environment around them. Distress and wellbeing also coexisted, rather than appearing as clean opposites.
This is where conventional measurement can fail. A questionnaire that assumes wellbeing is simply the absence of symptoms risks missing how a young person can feel hopeful and burdened at the same time, or how affirmation from others may shape responses more strongly than private emotional state. In adolescents living with HIV, those nuances are not theoretical. They affect how answers are given, what the answers mean, and whether the resulting score has clinical value.
Item Reduction Improved Brevity but Not Measurement Coherence
The initial item bank was reduced first to a 53-item candidate scale, then to the ZCS 38, and finally to the ZCS 25. Each reduction reflected both quantitative findings and participant feedback. At face value, shortening the instrument should have improved feasibility. In practice, the psychometric results pointed in another direction.
Responses were highly positive, but the pattern was not clean. The analyses showed disordered thresholds, ceiling effects, weak internal structure, and fluctuating retrospective ratings. Those findings are important because they suggest the response categories were not functioning in a stable way and that many participants clustered near the top end of the scale. When nearly everyone answers in a strongly positive direction, the instrument loses its ability to distinguish between levels of wellbeing. A measure that cannot spread responses across a range of experiences cannot reliably track change or separate one adolescent’s state from another’s.
The ceiling effect is especially troubling in this context. If a scale consistently compresses responses toward the most favorable end, it can create the illusion of good wellbeing while obscuring real distress, unmet needs, or intervention targets.
Why Social Desirability Cannot Be Ignored
Participant feedback suggested the positive responses likely reflected affirmations, and were partly linked to social desirability. That finding fits the setting. Adolescents living with HIV often learn how to speak about resilience, gratitude, and coping in ways that align with expectations from clinicians, counselors, or peers. In a supportive intervention environment, the impulse to give affirmative answers may be strong even when internal distress persists.
This does not mean the adolescents were insincere. It means the instrument may have been capturing a mixture of lived wellbeing, relational cues, and the social pressures attached to answering questions about strength and happiness. A wellbeing scale built for this population has to account for that. Otherwise, the measure may become a record of how socially acceptable the answers sound rather than how young people actually feel.
No Single Score, But a Clearer Path for Future Measurement
The study’s central conclusion was direct: the ZCS scale did not support a single interpretable total score. For researchers and program designers, that finding is more useful than a false sense of precision. A total score implies one coherent construct, but the developmental work showed that wellbeing in this group is likely better understood as domain-specific and context-dependent.
Future measurement, the investigators argue, should begin with clearer construct definition, response-process validation, domain-level testing, and explicit decisions about the intended purpose of the measure. The choices are not interchangeable. A tool designed to capture lived wellbeing may need different structure from one designed to detect intervention-relevant change or domain-specific positive outcomes. If the purpose is blurred at the start, the score will be blurred at the end.
For HIV programs working with adolescents in Zimbabwe and similar settings, the practical message is straightforward. Wellbeing cannot be assumed to behave like a universal, portable endpoint. Instruments built elsewhere may miss the relational core of adolescent life with HIV, and even well-developed local tools may fail unless the construct is defined with exceptional care. Psychometrics can only work when the lived experience behind the items has been mapped with equal rigor.
This study leaves a useful but unfinished task: creating measures that can distinguish hope from compliance, support from social pressure, and genuine change from polite agreement. Those distinctions will shape the next generation of wellbeing research in adolescent HIV care.