Factors influencing access to mental health services among adolescents and young people living with HIV in Zambia: a qualitative study

TL;DR

Adolescents and young people living with HIV in Zambia face barriers to mental health care and could benefit from youth-centered, confidential, and integrated services.

Contribution

The study identifies specific barriers and proposes solutions like decentralized services and mHealth tools tailored for young people living with HIV.

Findings

AYPLHIV face socio-cultural, economic, and technological barriers to mental health care.

Decentralized services and community support could improve access to mental health care.

Youth-centered mHealth tools integrated into HIV care may enhance mental health support acceptability.

Abstract

AYPLHIV understand mental health but face socio-cultural, economic and technological barriers to care. This study suggests that decentralized services, stronger community and peer support and carefully designed mHealth tools–if youth-centered, confidential, affordable and integrated into HIV care–could help improve access and acceptability of mental-health support for young people living with HIV in Zambia and similar settings.

AYPLHIV understand mental health but face socio-cultural, economic and technological barriers to care. This study suggests that decentralized services, stronger community and peer support and carefully designed mHealth tools–if youth-centered, confidential, affordable and integrated into HIV care–could help improve access and acceptability of mental-health support for young people living with HIV in Zambia and similar settings.

AYPLHIV understand mental health but face socio-cultural, economic and technological barriers to care. This study suggests that decentralized services, stronger community and peer support and carefully designed mHealth tools–if youth-centered, confidential, affordable and integrated into HIV care–could help improve access and acceptability of mental-health support for young people living with HIV in Zambia and similar settings.

AYPLHIV understand mental health but face socio-cultural, economic and technological barriers to care. This study suggests that decentralized services, stronger community and peer support and carefully designed mHealth tools–if youth-centered, confidential, affordable and integrated into HIV care–could help improve access and acceptability of mental-health support for young people living with HIV in Zambia and similar settings.

Full text

Background

1

Adolescents and young people living with HIV (AYPLHIV) face an elevated risk of mental-health problems due to stigma, discrimination, and chronic disease stressors [1–3]. Globally, about one in three AYPLHIV experience depression or anxiety, with mental ill-health linked to poor adherence to antiretroviral therapy (ART), viral rebound, and suicidal ideation [4, 5]. Zambian studies indicate that approximately one in four adolescents living with HIV experience clinically significant depressive symptoms (25.3%) [36]. In a district-level study, Bwalya et al., used the Strengths and Difficulties Questionnaire (SDQ) to screen HIV-positive adolescents and found that more than 75% had emotional or behavioral difficulties [37].

The World Health Organization (WHO) identifies mental disorders as a leading cause of disability among adolescents, yet access to care in sub-Saharan Africa remains minimal [6]. In Zambia, approximately 1.5 million people live with HIV, and adolescents and young people (AYP) aged 15–24 years constitute 11% of this population [7]. With fewer than 10 psychiatrists serving a population of 18 million, most AYPLHIV rely on overstretched primary-health facilities that seldom offer structured psychosocial support [10]. Despite policy recognition, mental-health services (MHS) are highly centralized and under-resourced. The Mental Health Act (2019) provides a legislative framework for rights-based care, but implementation is constrained by insufficient funding, few trained specialists, and weak community integration [8, 9]. Socio-cultural beliefs, stigma, gender norms, economic and geographic inequalities further widen the care seeking and treatment gap [11, 12, 13].

Recent global evidence highlights the potential of digital and community-based innovations to address these gaps. Mobile-health (mHealth) platforms – ranging from SMS-based counseling to smartphone applications – offer confidential, low-cost, and scalable psychosocial support [14–17]. In Zambia, initiatives such as U-Report demonstrate that youth readily engage with digital tools for health information [18]. However, little is known about the cultural acceptability, and policy alignment of mHealth integration into mental-health delivery for AYPLHIV.

This study therefore explored AYPLHIV’s understanding of mental health, barriers and facilitators to accessing mental-health services, and the acceptability and policy alignment of integrating mHealth into mental-health delivery in Zambia.

Methods

2

Study Design

2.1

We used a cross-sectional qualitative study design guided by a phenomenological orientation – focusing on participants’ understanding of mental health, barriers and facilitators to access, and potential integration of mHealth innovations into existing service delivery systems. The analysis followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines to ensure methodological transparency, rigor, and credibility [38].

Study Setting

2.2

Data was collected in two contrasting districts, Lusaka (urban) and Shibuyunji (rural), to represent rural-urban diversity in access to mental-health among AYPLHIV.

Lusaka District, the capital city, has the largest concentration of AYPLHIV in the country due to high HIV prevalence and population density. Based on national program data, an estimated 11,837 AYP aged 15–24 years are living with HIV in Lusaka alone. Applying Zambia’s documented prevalence of 25.3% experiencing clinically significant depressive symptoms among AYPLHIV and more than 75% screening positive for emotional or behavioral difficulties, this suggests that 2,995 AYPLHIV may be living with depression and up to 8,878 may be experiencing broader psychosocial challenges in Lusaka district. Lusaka district also hosts Chainama Hills Hospital, the country’s main psychiatric facility, making it a critical reference point for understanding gaps in centralized mental-health care.

Shibuyunji district, by contrast, is a sparsely populated rural district with limited health-care infrastructure. ART program shows that about 825 AYP are living with HIV in Shibuyunji district. Applying the same Zambia-specific prevalence rates, approximately 209 of these AYPLHIV may be experiencing depressive symptoms, and 619 may have emotional or behavioral difficulties–often without access to specialized care. Shibuyunji’s health system relies primarily on primary-care clinics staffed by nurses and lay counsellors, with no resident mental-health specialists.

Together, these settings allowed the study to capture urban–rural contrasts in mental-health service availability, sociocultural norms, digital access, and health-system capacity. They also represent two areas where AYPLHIV are likely to face markedly different pathways to mental-health support, making them ideal for exploring contextual determinants of access.

The districts were purposively selected due to proximity, while providing an opportunity to capture contextual variations in access, infrastructure, and cultural norms influencing youth mental-health service utilization.

Data Collection

2.3.

We interviewed AYPLHIV through Focus Group Discussion (FGD) and In-Depth-Interviews (IDI), and policy makers using KIIs. Table 1 summarizes the respondent characteristics.

Adolescents and Young People Living with HIV (AYPLHIV)

2.3.1.

We administered four (4) FGDs and ten IDIs to AYPLHIV, with each FGD having with ten (10) participants. Two of the FGDs were sex disaggregated while the other two each had a combination of both male and female participants. One of the FGDs was conducted in a Shibuyunji district while the rest were done in Lusaka district. The 10 AYPLHIV who were interviewed through IDI had a lived experience with a mental health condition, hence, they were referred to as “expert clients” in this study. Of the 10 IDIs, six (6) were with males while four (4) were with female participants.

Policy makers

2.3.2.

We also interviewed four (4) policy makers to solicit insights on mental health policy and practice in Zambia. Of the four policy makers, one was a mental health practitioner at Zambia’s largest mental health hospital (Chainama Hills Hospital), representing the tertiary institution; one representing mental health associations/Civil Society Organization pressure group, two (2) selected from the Ministry of Health, that is, one from the provincial level (Provincial Mental Health Expert) and the other from the district level (District Mental Health Focal Point Person).

Sampling strategy

2.3.3.

Purposive sampling was used to ensure inclusion of diverse perspectives based on age, gender, and lived experience with mental-health challenges. AYPLHIV aged 18–24 years were identified and recruited through ART clinic registers with the support of healthcare providers and peer educators. Policymakers were identified through Ministry of Health referral pathways. Recruitment continued until thematic saturation was achieved, meaning that no new insights emerged from additional data collection.

Data Collection Procedures

2.4

Data was collected between February and September 2025 using semi-structured interview guides tailored for each participant group. The FGD, IDI and KII guides were developed specifically for this study, drawing on existing literature on adolescent mental health and mHealth in low- and middle-income countries, the World Health Organization service access framework, and the approved PhD protocol. Draft guides were reviewed by mental-health and HIV experts for content validity and piloted with a small group of AYPLHIV and one provider to refine wording and flow; no substantial structural changes were required following piloting. The English versions of all interview guides are provided as additional file 1.

Focus-Group Discussions (FGDs)

2.4.1

Focus-group discussions (FGDs) were conducted with AYPLHIV to explore shared experiences, community perceptions, and collective challenges related to mental health and service access. A total of four FGDs were held, three in Lusaka and one in Shibuyunji, with each group comprising between 8 and 10 participants. The sessions were facilitated by trained qualitative researchers fluent in English and the predominant local languages, including Nyanja and Lenje, to ensure participant comfort and accurate expression of ideas.

In-Depth Interviews (IDIs)

2.4.2

Ten in-depth interviews (IDIs) were conducted with AYPLHIV identified as “expert clients,” a group comprising youth with lived experience of mental-health challenges and established roles supporting ART adherence within their clinics. These interviews elicited detailed individual narratives, coping mechanisms, and personal encounters with the health system, providing rich insight into personal-level experiences that complemented the group perspectives gathered through FGDs.

Key-Informant Interviews (KIIs)

2.4.3

Four key-informant interviews (KIIs) were conducted with policymakers representing different administrative levels, including national-level officials from the Mental Health Unit, provincial representatives from the Provincial Health office, a district Mental Health Focal Person, and a civil society representative from the Mental Health Association. These interviews explored perspectives on mental-health policy implementation, intersectoral coordination, and perceived opportunities for incorporating digital innovations within existing service structures.

All interviews and discussions were conducted in private rooms within health facilities or offices, ensuring confidentiality and comfort. Each session lasted 45–90 minutes and was audio-recorded with participants’ consent. Field notes were taken to capture contextual observations and non-verbal cues.

Data Management and Transcription

2.5

Audio recordings were transcribed verbatim in the original language (Nyanja or Lenje mixed with English) and all translated into English by trained transcribers experienced in health research. Quality checks were performed by the principal investigator and an independent reviewer to ensure translation accuracy and retention of meaning.

All transcripts and field notes were uploaded into Ligre software version 6.5.1 for systematic coding and data management.

To maintain confidentiality, transcripts were anonymized by removing personal identifiers and assigning participant codes (e.g., P1, IDI3, KII2). Digital files were password-protected and stored on an encrypted device accessible only to the research team.

Data Analysis

2.6

As this was a qualitative study, no statistical tests were conducted; instead, data were analyzed thematically using an inductive–deductive hybrid approach guided by the World Health Organization’s Service Access Framework [39] in five stages.

First, the research team undertook a period of familiarization by reading all transcripts multiple times to gain a holistic understanding of participants’ narratives. Second, initial coding was carried out by developing an inductive codebook grounded in participants’ words and lived experiences, which was then complemented with deductive codes based on the study objectives. Third, related codes were organized into broader thematic categories reflecting key patterns across participants, including understanding of mental health, availability and access to services, barriers, facilitators, and opportunities for digital integration. Fourth, themes were reviewed and refined during peer-debriefing sessions between the two primary analysts to ensure consistency, coherence, and analytic validity. Finally, the resulting themes were interpreted through the socio-ecological model of health to illustrate how individual, community, and system-level factors interact to shape access to mental-health services.

Trustworthiness and credibility were strengthened through several qualitative rigor strategies. Investigator triangulation was applied, with multiple researchers independently reviewing and comparing coded data to minimize individual bias. Data triangulation was also employed by examining and contrasting perspectives obtained from AYPLHIV and policymakers, enabling a more comprehensive and multi-layered understanding of the phenomena under study. These approaches collectively enhanced the robustness, credibility, and confirmability of the findings.

Ethical Considerations

2.7

Ethical approval

for this study was obtained from the University of Zambia Biomedical Research Ethics Committee (UNZABREC), Reference No. 5864 - 2024, and from the National Health Research Authority (NHRA), Reference No. NHRA-1679/04/11/2024. All participants provided written informed consent prior to participation. Participants were informed about the voluntary nature of the study, their right to withdraw at any time, and the measures taken to ensure confidentiality. To safeguard participants’ wellbeing, psychosocial support was made available through referral to trained counselors at participating health facilities whenever needed. All identifying details were removed from transcripts and publications.

Results

3

Participant Characteristics

3.1

A total of 54 participants took part: 40 AYPLHIV (across FGDs), 10 expert-client IDIs, and 4 policymakers. AYPLHIV were aged 18–24 years, unemployed, and attending or having completed secondary education.

Understanding of Mental Health

3.2

AYPLHIV conceptualized mental health as “wellness of the mind”, encompassing thoughts and emotions. HIV disclosure often triggered distress, anxiety, and social withdrawal:

“When you are tested positive, you become sad, with many questions like ‘Why me?’ Then you start thinking that you can’t do any work or anything productive.” (AYPLHIV, FGD)

Participants associated mental well-being with having supportive family and community relationships, while isolation and stigma led to depression and suicidal ideation.

Access and Availability of Services

3.3

Mental-health services were largely available through public health facilities but described as limited, irregular, and poorly resourced. AYPLHIV appreciated counseling received at ART clinics but reported that services were often unavailable or not youth-friendly:

“They are here at the facility, even in the community, but they are not based at the hospital.” (AYPLHIV, FGD)

Policymakers echoed this, noting persistent gaps in decentralization and trained personnel:

“Resources at district facilities are limited in terms of staff, infrastructure, and essential medications.” (Policymaker, KII)

Barriers to Access

3.4

Socio-Cultural and Stigma-Related Barriers

3.4.1

Social stigma and gender norms constrained help seeking. The phrase “Mwamuna samalila” (“men don’t cry”) was used to describe masculine norms discouraging emotional expression:

“That saying is a challenge–society believes men cannot be vulnerable.” (Expert Client, IDI)

Cultural beliefs linked mental illness to witchcraft or curses, leading many to seek help from traditional healers instead of health facilities.

Trust and Confidentiality

3.4.2

Youth expressed fear of judgment and confidentiality breaches by providers:

“We fear that what we tell them may be revealed.” (AYPLHIV, FGD)

Economic and Geographical Barriers

3.4.3

Poverty and distance from health centers were major access barriers:

“Sometimes you have no money for transport, so you stay home even when you want help.” (AYPLHIV, FGD)

Technological Barriers

3.4.4

High data costs and low digital literacy limited access to online counseling tools:

“Most apps use English, and people who didn’t finish school can’t understand.” (AYPLHIV, FGD)

Facilitators to Access

3.5

Peer and Community Support

3.5.1

Peer groups and community organizations were identified as key facilitators:

“Our support group helps us talk freely; we learn it’s okay to have stress.” (AYPLHIV, FGD)

Faith-Based and NGO Involvement

3.5.2

Faith-based institutions provided counseling and mental-health education. Policymakers emphasized partnerships with NGOs to expand coverage:

“Private and faith-based organizations can help fill the gap where government services are limited.” (Policymaker, KII)

Decentralization and Provider Capacity

3.5.3

Policymakers stressed decentralizing mental-health services to district level and training lay counselors and peer educators:

“Training adolescents as peer providers can make services more relatable and youth friendly.” (Policymaker, KII)

Digital Integration

3.6

Both AYPLHIV and policymakers viewed digital tools as promising platforms for mental-health service delivery. Desired features included anonymity, data security, offline usability, and local-language options:

“The app should use different languages and have videos to help those who can’t read.” (AYPLHIV, FGD)

“Partnerships with telecom companies can make apps affordable and accessible.” (Policymaker, KII)

Youth emphasized the potential for mobile apps to reduce stigma by providing private and flexible access to counseling and psychoeducation.

Discussion

4

This study revealed that while AYPLHIV in Zambia understand mental health as “wellness of the mind,” access to care remains constrained by stigma, socio-cultural beliefs, economic hardship, and system inefficiencies. Five themes–understanding, access, barriers, facilitators, and digital integration–illustrate how individual experiences intersect with policy and technology contexts.

Understanding of Mental Health

4.1

Participants demonstrated a holistic view of mental health encompassing thoughts, emotions, and functioning, consistent with findings from other African contexts [1, 19]. Disclosure of HIV status often triggered anxiety, shame, and isolation–echoing studies in South Africa, Malawi, and Uganda where adolescents described psychological distress following diagnosis [20–22]. Limited mental-health literacy led youth to interpret symptoms as personal weakness, mirroring results from Uganda and Kenya [23, 24]. These findings underscore the need for integrating mental-health education and routine screening into ART programs to normalize care-seeking.

Availability and Access to Services

4.2

Both youth and policymakers described MHS as centralized and underfunded. Similar structural inequities are documented across LMICs [6, 25]. Zambia’s situation parallels WHO’s Mental Health Atlas 2020 report that highlights severe workforce shortages and limited community outreach [26]. Counseling embedded in ART clinics offers some psychosocial support but remains inconsistent and donor-dependent–patterns reported in Kenya and Tanzania [27, 28]. Evidence from Uganda and South Africa shows that task-shifting to nurses or lay counselors effectively increases service reach [29, 30]. Implementing such models through Zambia’s Mental Health Act could decentralize services and reduce inequities.

Barriers to Access

4.3

Cultural and Gender Norms

4.3.1

Cultural expectations, including male stoicism, discouraged emotional openness. Comparable studies in Nigeria and Uganda found that masculinized identities hinder men from acknowledging distress [31, 32]. Beliefs linking mental illness to witchcraft echo research from Ghana and Ethiopia [33, 34]. Addressing these beliefs requires community-driven education that engages traditional and faith leaders to demystify mental illness.

Stigma and Confidentiality

4.3.2

Fear of “double stigma” (HIV + mental illness) limited disclosure and utilization. Similar dual stigma effects are reported across sub-Saharan Africa [7, 35]. Youth concern about confidentiality breaches mirrors Kenyan and Zimbabwean studies showing mistrust of providers [19, 28]. Training providers in ethical counseling and privacy could restore confidence.

Economic and Geographic Constraints

4.3.3

Transport costs and unemployment were major obstacles, as also noted in regional research linking poverty to poor mental-health access [25, 30]. Integrating MHS into primary care and community outreach can reduce cost and distance barriers [29].

Technological Barriers

4.3.4

Limited digital literacy and high data costs constrain mHealth uptake, reflecting the “digital divide” affecting rural youth across Africa [14, 17, 18]. Affordable connectivity and inclusive design are prerequisites for equitable digital-health deployment.

Facilitators to Access

4.4

Peer-led support, NGO involvement, and faith-based initiatives emerged as key enablers. Peer mentorship has been shown elsewhere to enhance adherence, self-efficacy, and wellbeing [20, 27]. Policymakers emphasized decentralization and staff training–approaches aligned with WHO’s mhGAP Intervention Guide promoting community-based task sharing [26, 29]. Public-private partnerships for service delivery and technology development mirror successful models in Kenya and India [28, 30].

Digital Integration

4.5

Participants viewed digital platforms as confidential spaces to overcome stigma and distance. Youth-preferred features like anonymity, multilingual content, and offline access, mirroring evidence from Uganda and South Africa where mHealth interventions improved engagement [14, 16, 27]. Policymakers’ emphasis on telecom partnerships aligns with Zambia’s Digital Health Strategy 2022–2027 [17]. Nonetheless, sustainability depends on addressing literacy and cost barriers and involving youth in co-design, as recommended by Naslund et al [15].

Synthesis and Policy Implications

4.6

Findings confirm that effective improvement of youth mental-health access requires multilevel interventions. At the individual level, stigma reduction and psychosocial education are vital. At the community level, peer and faith-based networks can normalize help-seeking. At the system level, decentralization, task-shifting, and digital inclusion should be institutionalized through coordinated policy implementation. These recommendations align with WHO’s Comprehensive Mental Health Action Plan 2013–2030 and evidence that community-anchored, technology-enabled models yield sustainable mental-health gains in LMICs [6, 26].

Study Strengths and Limitations

5

This study is among the first in Zambia to explore both youth and policymaker perspectives on mental-health access among adolescents and young people living with HIV (AYPLHIV).

Its methodological rigor was enhanced through triangulation of data sources (FGDs, IDIs, and KIIs), inclusion of both urban and rural settings, and use of inductive–deductive thematic analysis to ensure comprehensive theme development. The involvement of policymakers provided a systems-level understanding that complemented the lived experiences of youth.

However, several limitations must be acknowledged. First, the study was conducted in only two districts, which may limit generalizability to other regions of Zambia. Second, participants were recruited from ART clinics, potentially excluding AYPLHIV not engaged in care. Third, the sensitive nature of mental-health discussions may have led to underreporting of distress due to social desirability bias, despite efforts to ensure confidentiality. Despite these limitations, the findings provide rich, contextualized insights into barriers, facilitators, and opportunities for digital and community-based innovations in mental-health access.

As with most qualitative studies, the aim was depth and contextual understanding rather than statistical generalization; the value of these findings lies in the insights they offer to inform policy, programme design and future mixed-methods research.

Conclusion and Recommendations

6

Conclusion

6.1

This qualitative study suggests that AYPLHIV in Zambia experience substantial and layered challenges in accessing mental-health services. Participants described how stigma, gendered cultural norms, economic hardship, long distances to facilities and the centralization of specialist care combine to limit help-seeking and continuity of support. Although many AYPLHIV were aware of mental health as “wellness of the mind”, fear of judgment, concerns about confidentiality and limited youth-friendly services appeared to discourage open disclosure of distress and engagement with available services.

Policymakers in this study recognized many of the same constraints and highlighted systemic gaps, including shortages of trained providers, limited implementation of the Mental Health Act and slow progress in decentralizing services. Both AYPLHIV and policymakers perceived peer support, community involvement and carefully designed digital tools as promising ways to make services more acceptable, accessible and responsive to young people’s needs.

Given the qualitative design, purposive sampling and focus on two districts, these findings are not intended to be statistically generalizable to all AYPLHIV in Zambia. Rather, they provide rich, contextualized and transferable insights that may help inform policy, programme design and future mixed-methods research on youth mental health within HIV care.

Recommendations

6.2

Drawing on these findings and recognizing existing resource constraints, we suggest the following priority areas for policy, programming and research:

Policy and System-Level Recommendations

6.2.1

Progressive decentralization of mental-health services:

Policy-makers could prioritize integrating basic mental-health assessment and psychosocial counselling into primary health care and ART programmes, particularly in rural and peri-urban areas, to reduce travel and cost barriers for AYPLHIV.

Operationalization of the Mental Health Act (2019):

Implementation of the Act may be strengthened through clearer operational guidelines, dedicated budget lines and systematic recruitment and training of mental-health professionals and lay counsellors, including those embedded in HIV clinics.

Institutionalization of youth-friendly care:

Ministries and implementing partners could incorporate mental-health modules into adolescent HIV services, school health programmes and adolescent-friendly corners, with attention to confidentiality, respectful communication and flexible service hours.

Community and Programmatic Recommendations

6.2.2

Support for peer-led and community-based initiatives:

Formalizing peer-counsellor roles within ART clinics and providing structured supervision and training may help sustain peer-support groups that AYPLHIV already find valuable. Partnerships with NGOs and faith-based organizations could expand the reach of psychosocial support in communities.

Stigma-reduction and mental-health literacy:

Community-level campaigns that involve traditional leaders, faith leaders and youth representatives could help reframe mental health from a purely spiritual or moral issue to one that is also social and medical, thereby normalizing help-seeking for HIV-related distress.

Inclusive digital access and literacy:

Collaboration with telecommunications companies could be explored to reduce data costs and support zero-rating or subsidized access to approved mHealth platforms. Programmes may also invest in digital-literacy activities for young people and caregivers so that mobile applications, SMS services and hotlines are usable by those with varying education levels and device types.

Research Recommendations

6.2.3

Evaluation of hybrid mHealth and peer-support models:

Future studies could assess the feasibility, acceptability and effectiveness of combined digital and peer-support interventions for AYPLHIV across different provinces and service settings.

Implementation and health-systems research:

Mixed-methods implementation research may help to understand how digital tools and decentralized mental-health services can be integrated into existing HIV and primary-care platforms, and how these changes influence help-seeking, adherence and retention in care.

Participatory and co-design approaches:

Further research that actively involves AYPLHIV, caregivers and frontline providers in co-designing interventions and digital tools could ensure that proposed solutions remain culturally appropriate, acceptable and sustainable.

Policy implication summary

7

Addressing mental-health needs among adolescents and young people living with HIV in Zambia is likely to require coordinated action at individual, community and system levels. The findings of this study point towards the potential value of combining decentralized, youth-friendly services with strengthened peer and community support and inclusive digital innovations. If adapted to local contexts and adequately resourced, such approaches could help reduce stigma-related barriers, improve the acceptability of mental-health care and support better engagement with HIV services. While further evaluation is needed, these insights can inform ongoing efforts to implement the Mental Health Act, advance the national digital health strategy and align HIV, mental-health and adolescent-health policies in practice.

Supplementary Material

This is a list of supplementary files associated with this preprint. Click to download.

• 1.17.2026Additionalfile1SemistructuredinterviewguidesforAYPLHIVandpolicymakersEnglishversion.pdf