<p>Panel of experts’ content validation results.</p>

We subsequently assessed the ZCS 25 using retrospective pretest, post-test and follow-up administration. The review identified conceptually overlapping positive psychological constructs, many of which are measured using instruments developed in high-income settings and not adequately validated for ALHIV in Africa. Qualitative work highlighted connectedness, hope, self-acceptance, self-efficacy, purpose, and flourishing as key.

Discussions also highlighted that wellbeing was relational, contextually situated, and often co-occurring with distress. Quantitative testing showed highly positive responses, disordered thresholds, ceiling effects, weak internal structure, and fluctuating retrospective ratings. Participant feedback suggested that positive responses likely reflected affirmations, and were partly linked to social desirability.

In conclusion, the ZCS scale did not support a single interpretable total score, but its development offers important methodological lessons. Future measurement should begin with clearer construct definition, response-process validation, domain-level testing and explicit decisions about whether the measure aims to capture lived wellbeing, domain-specific positive outcomes or intervention-relevant change.</p></div>