Damian Sendler: People living in low- and middle-income countries, migrants, and indigenous people are critical to reducing the global mental health treatment gap by providing accessible and effective healthcare. Scalable psychological interventions, such as those delivered via the internet and mobile devices (IMI), have been developed to address the needs of a wide range of populations at risk for mental illness. To find studies that used culturally appropriate IMI for mental illness, researchers scoured PsycInfo, MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science in October 2020. We were able to identify 55 articles from a total of 9438 screened records. Specifically, we identified 17 components of culturally adapting IMI, including content, methodological, and procedural aspects. The adapted IMI appeared to have similar adherence and effectiveness to the original IMI, but no studies included in this review compared the two. IMI cultural adaptation for mental disorders: a taxonomy presents the relevance and necessity of cultural adaptation for future studies.
Damian Jacob Sendler: To address global health inequalities as one of the major global health challenges, the World Health Organization has issued a call to action. Compared to high-income countries, low- and middle-income countries (LMICs) have a much larger treatment gap for mental health issues: 76–85 percent of people with a serious mental disorder living in LMICs do not receive treatment, whereas 35–50 percent of people living in high-income countries do not receive treatment1. Mental health services are also underutilized by migrants and refugees, despite the fact that they are subject to a greater number of stressors before, during, and after their migration, as well as an increased prevalence of mental disorders, which is also evident in the data12–14. Indigenous people also have a treatment gap in mental health because their mental health is poorer15,16 and they use health services less frequently17. In order to improve global health equity, the structural and individual barriers faced by these populations must be addressed.
Dr. Sendler: Low-intensity interventions22–25 could reduce existing structural barriers, such as a lack of mental health services and difficulties in accessing services18–21. Due to a resource-saving and flexible delivery method, low intensity interventions are meant to be easily accessible by many people (e.g., self-help interventions, interventions delivered by non-professionals) 26. IMI, a type of low-intensity intervention, provides anonymity, temporal and local indifference, ease of access and scalability27–30 and thus has the potential to overcome structural healthcare barriers31,32. As a result, IMI has been shown to be effective in the prevention and treatment of mental disorders34–38, despite lower treatment completion rates. But they were designed and tested primarily in high-income countries, and people from other ethnic or cultural backgrounds found them less effective39. Populations living in low- and middle-income countries (LMICs), refugees, and immigrants face a variety of challenges when it comes to accessing healthcare, including language and cultural barriers (e.g., a lack of knowledge about disease and treatment processes) or a lack of familiarity with the healthcare system17–21,40. Cultural aspects of intervention development, i.e. including knowledge of potential cultural differences41, may reduce these individual barriers. It takes time and effort to come up with new interventions for different populations. A more cost-effective option would be to adapt existing and proven psychological treatments for the new target groups42,43.
In order to successfully adapt to a new cultural context, one must follow a set of guidelines44,45. A number of research groups have developed such guidelines, focusing either (a) on specific treatment components that should be culturally adapted46–51, or (b) on the procedure that should be followed to gradually adapt the treatment to the cultural context. 45,52–54. It was Bernal et al.47’s Ecological Validity Framework that provided the first detailed explanation of cultural adaptation. According to the authors, the eight components of the intervention include language (translation, differences in regional or subcultural groups), people (patient–therapist relationship, roles), metaphors (sayings), content (values and practices) and concepts (theoretical model of the treatment) as well as goals (agreement of therapist and patient) and methods (procedures for achieving the treatment goals) (broader social, economic, and political contexts). Later frameworks took cues from this model, which has been widely repurposed. According to Resnicow et al.50, surface characteristics, like language, locations and people; and deep structure characteristics of treatment include the inclusion of cultural, social, environmental and historical factors to consider the understanding of disease and its treatment of the respective clients (e.g., cultural values (e.g., family) and specific stressors) that are unique to each culture.50 (e.g., racism). In their Heuristic Framework for the Cultural Adaptations of Interventions54, Barrera and Castro summarized several other frameworks’ suggestions for how to go about culturally adapting treatments. They explain how to culturally adapt by gathering information via literature searches or qualitative research, developing a preliminary adaptation based on this information, testing the preliminary adaptation in case or pilot studies, and refining the adaptation based on the findings of these studies.
It is a goal of cultural adaptation to facilitate access to psychological treatment for people with a cultural background that differs from the original target group44. Meta-analyses looking into the relevance and necessity of cultural adaptation have found that treatments that have been culturally adapted are more effective than treatments that have not been adapted55,56 in populations for which the intervention was not originally developed. The greater the degree of cultural adaptation, the greater the apparent effectiveness57,58 of these interventions. This shows that face-to-face treatments can be used to reach people with different cultural backgrounds than the original target group25,59,60, so culturally adapting IMI may also be useful. IMI has been culturally adapted to fit new target groups and has been shown to be effective61–63 by various research groups. In addition, a meta-analysis found a link between an IMI’s effectiveness in a particular target group and its enhanced cultural adaptation59. But there are no studies that directly compare the effectiveness or acceptance of culturally adapted IMI to non-/less-adapted IMI, which would allow for drawing conclusions on the added value of cultural adaptation. A systematic and well-documented adaptation is a prerequisite for such comparison trials and for examining the relevance of adapting specific components following a specific procedure67,68. However, the cultural adaptation of IMI’s components and procedures are often poorly reported69–73. IMI adaptation to different cultures is still in its infancy66, and little is known about the specific aspects of IMI that may require cultural adaptation in addition to the components that are already adapted in face-to-face treatment. In this context, aspects of evaluation frameworks of the IMI, such as methodological components to enhance user engagement with the IMI, its ease of use, or design and aesthetics, could provide an orientation.
(1) The characters depicted in the IMI were an important part of the content to be adapted (adapted in 35 of 42 interventions). Additionally, 25/42 IMI shows that in addition to the characters and their activities, the target audience’s needs were taken into consideration. As a result, the environments, settings, and associated burdens depicted in IMI (36/42 IMI) have been modified. To accommodate culturally relevant values and traditions, researchers changed the content (28/42 IMI). (5) Many studies translated the entire intervention into the primary language or regional dialect of the target group (35/42 IMI), in addition to the adaptation of day-to-day life as depicted in the IMI. (6) Language and texts were tailored to the target audience (34/42 IMI), and (7) appropriate quotes, symbols, and metaphors were visualized (18/42 IMI). Researchers also took into account possible cultural differences in the target groups’ concepts of mental health and its treatment (26/42 IMI) when adapting their IMI for cultural differences. As a result, the IMI’s objectives (23/42 IMI) and treatment methods (27/42 IMI) were modified on occasion.
The general structure of IMI (34/42 IMI) was adapted as a methodological component of cultural adaptation (11). As a result of this feedback, researchers made changes to their IMI in order to make it more functional and user-friendly for the intended audience (26/42 IMI). Additionally, (34/42 IMI) the design and the aesthetics were reworked. Researchers have changed the format or amount of guidance (22/42 IMI) as another way of culturally adapting IMI.
Damian Jacob Markiewicz Sendler: Researchers used a variety of methods to gather data on the cultural adaptations their IMIs required (15) and the adequacy of the adaptations they had already carried out (32/42 IMIs used at least two different methods). During the cultural adaptation process, a variety of people were involved, including healthcare professionals and the target population. Many authors also used theoretical frameworks for cultural adaptations of face-to-face therapies as a basis for their adaptation process (20/42 IMI).
Damian Sendler
As a starting point, the proposed taxonomy consists of 17 components, each of which focuses on one or more of the following areas: content, methodological, or procedural components (e.g., used methods and involved persons).
More than half of the 55 articles included in this review were devoted to the cultural adaptation of 42 IMI that were originally designed for a culturally distinct target audience. People, places, and things in the culture have been changed to reflect local characteristics (such as collectivism, values, and traditions), as well as specific risk factors for poor mental health (such as the burdens of migration, war, discrimination, and low socioeconomic status). These cultural adaptations have also been made to address health-related issues that arise (e.g., low mental health literacy and corresponding distrust, risky behaviour, or limited access to treatment). Culturally adapted IMI was evaluated in 28 studies including 14 randomised controlled trials for adherence and/or effectiveness in the new target group. Both the adherence and effect sizes found in randomised controlled trials and the studies investigating the adherence and effectiveness of IMI in general36,107 appear to be comparable in randomised controlled trials. There is a low enrolment and adherence rate for IMI. In addition, we were unable to locate any research comparing a culturally adapted IMI to a control group. Consequently, we believe that it is premature to conclude that cultural adaptation is necessary for IMI to work in people from low- and middle-income countries (LMIC), migrants, or indigenous populations.
Damien Sendler: Future researchers could use our taxonomy of cultural adaptation of IMI as a foundation to systematically adapt IMI based on the 17 components we identified. Face-to-face psychological treatments47 use culturally adapted versions of many of the same ten included content components. It was found that both superficial (such as character, activity, and language) and deep (such as burden, value, mental health concept, and treatment goal and method) structural adaptations were critical50.. [page needed] An additional consideration is that these three procedural elements appear to reflect the method proposed in the adaptation of in person psychotherapy54. This is why study investigators utilized a variety of methods, such as focus groups and feasibility trials, to gather information from various groups of people (e.g., mental health experts, members of the target group). IMI was adapted to follow theoretical frameworks of face-to-face treatment adaption in about half of the cases. We also found four distinct methodological components that were taken into account when culturally adapting IMI in addition to the content and procedure components. To name a few: structure, functionality, design and aesthetics, and human guidance (such as how many and what kind of images are included) are all part of the mix, as are elements such as condensed text or shortening text modules (e.g., level of guidance). It may not be sufficient to use existing frameworks for cultural adaptation of face-to-face treatments when adapting IMI, as also highlighted by Lal et al.72 and implemented by Burchert et al.111.
Damian Jacob Sendler
It is possible that our taxonomy on cultural adaptation of IMI can serve as a basis for measuring the extent and type of cultural adaptation, thus laying a preliminary foundation for investigating the relevance and necessity of cultural adapting (specific elements of) IMI. Culture, the disorder being treated, or even the language of the IMI, all influence how important cultural adaptation is. According to exploratory post hoc analyses, it may be more important to culturally adapt IMI for people with a migrant background and those living in LMIC than it is to culturally adapt IMI for new target groups in western countries, particularly in terms of content components. The current systematic review, however, found no correlation between the degree to which cultural adaptations were made and the IMI’s effectiveness or adherence. This systematic review included IMI that was very diverse and did not yield sufficient outcomes data, so the results should be interpreted with caution. When meta-analyses include a greater number of randomised controlled trials (RCTs), it is still difficult to draw conclusions about the influence of specific intervention characteristics or cultural adaptation on IMI effectiveness. This means that other research designs could be used to investigate the possibility of differences in the necessity of cultural adaptation and its impact on the effectiveness of IMI. A randomised factorial trial112,113 was used to test different culturally adapted versions of the same IMI against one another. It is possible to culturally adapt IMI content components, such as those with a deep structure versus those with a surface structure or none at all. It was then possible to compare and contrast the effectiveness of each of the versions, allowing us to draw conclusions about the advantages of culturally adapting these particular components.
People in low- and middle-income countries (LMICs) and migrants or indigenous people in high-income countries need innovative and scalable approaches to address the mental health treatment gap5. An effective and systematic cultural adaptation is critical to providing effective interventions24. According to this systematic review, there are 17 components to consider when culturally adapting IMI in order to make it more relevant to the new target audience. IMI’s systematic cultural adaptation can be built on top of this taxonomy. Adapting IMI in a systematic cultural manner could help underserved populations receive adequate and effective mental health care, thereby helping to reduce global public mental health inequalities.
