Date of Award


Degree Type


Degree Name

Doctor of Philosophy (PhD)

Graduate Group

Epidemiology & Biostatistics

First Advisor

Elizabeth D. Lowenthal


The human immunodeficiency virus (HIV) infection and in utero exposure increase the risk of neurocognitive impairment among pediatric populations. In Sub-Saharan Africa, HIV is prevalent, but standardized cognitive screening does not exist. To facilitate access to neurocognitive screening in this setting, the Penn Computerized Neurocognitive Battery (PennCNB) was culturally adapted and translated for use in Botswana. The PennCNB streamlines the evaluation of neurocognitive functioning by measuring performance accuracy and response speed on major cognitive domains, which offers many advantages for implementation in resource-limited settings (e.g., automated scoring and data interpretation). This body of research prepares for the utilization of the tool in Botswana by examining measures of validity and engaging in pre-implementation inquiry to help address the substantial research-to-practice gap. HIV-affected children and adolescents (HIV-infected and HIV-exposed-uninfected) age 7-17 years were enrolled from a pediatric HIV clinic in Gaborone, Botswana for these studies. Participants completed the PennCNB assessment. Confirmatory and exploratory factor analyses demonstrated strong discriminant and convergent validity of the battery, thus supporting the design of the adapted PennCNB measuring four neurocognitive domains: executive functioning, episodic memory, complex cognition, and sensorimotor/processing speed. When evaluating the classification accuracy of the battery against the best, most feasible local data (e.g., clinical interview, pencil-and-paper psychological assessments, and school reports), the tool exhibited acceptable criterion validity. The children and adolescents rated the PennCNB as highly acceptable, which is promising for the success of implementation. To further understand factors likely to impact the successful integration of the tool into clinical settings, semi-structured interviews were completed with key stakeholders (e.g., mental health clinicians, non-mental health clinicians, and leadership) in the public medical sector. Results underscored the need for cognitive screening, revealed anticipated barriers and facilitators to using the PennCNB, and suggested implementation strategies. Overall, this research provided valuable insight into the psychometric properties of the adapted PennCNB and input to inform specific implementation strategies for Botswana. Future implementation of the tool will facilitate early detection of neurocognitive deficits, which is critical for supporting the functional and educational attainment of HIV-affected children and adolescents in this high-need and other resource-limited settings in the region.


Available to all on Friday, August 09, 2024

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Epidemiology Commons