The worldwide mental health treatment gap calls for scaling-up psychological interventions, which requires effective implementation in diverse cultural settings. Evidence from the field of global mental health and cultural clinical psychology indicates cultural variation in how symptoms of common mental disorders are expressed, and how culturally diverse groups explain the emergence of such symptoms. An increasing number of studies have examined to what extent cultural adaptation enhances the acceptability and effectiveness of psychological interventions among culturally diverse groups. To date, this evidence is inconclusive, and there is a lack of studies that dismantle the multiple types of modifications involved in cultural adaptation.Based on empirical evidence from ethnopsychological studies, cultural adaptation research, and psychotherapy research, the present paper offers a new conceptual framework for cultural adaptation that lays the groundwork for future empirical research.The cultural adaptation framework encompasses three elements: i) cultural concepts of distress; ii) treatment components; and iii) treatment delivery. These three elements have been discussed in literature but rarely tested in methodologically rigorous studies. Innovative research designs are needed to empirically test the relevance of these adaptation elements, to better understand the substantial modifications that enhance acceptability and effectiveness of psychological interventions.Using a theory-driven approach and innovative experimental designs, research on cultural adaptation has the potential not only to make psychological treatments more accessible for culturally adverse groups, but also to further advance empirical research on the basic question about the “key ingredients” of psychotherapy. The phenomenology of common mental disorders, as well as mind-body concepts, vary across cultures. Cultural adaptation may enhance the acceptability and effectiveness of psychological interventions. There is a lack of empirical evidence on the substantial modifications in cultural adaptation. Theory-driven, experimental approaches are needed in cultural adaptation research. The phenomenology of common mental disorders, as well as mind-body concepts, vary across cultures.Cultural adaptation may enhance the acceptability and effectiveness of psychological interventions.There is a lack of empirical evidence on the substantial modifications in cultural adaptation.Theory-driven, experimental approaches are needed in cultural adaptation research.

Background: Cultural adaptation of mental health care interventions is key, particularly when there is little or no therapist interaction. There is little published information on the methods of adaptation of bibliotherapy and e-mental health interventions. Objective: To systematically search for evidence of the effectiveness of minimally guided interventions for the treatment of common mental disorders among culturally diverse people with common mental disorders; to analyze the extent and effects of cultural adaptation of minimally guided interventions for the treatment of common mental disorders. Methods: We searched Embase, PubMed, the Cochrane Library, and PsycINFO for randomized controlled trials that tested the efficacy of minimally guided or self-help interventions for depression or anxiety among culturally diverse populations. We calculated pooled standardized mean differences using a random-effects model. In addition, we administered a questionnaire to the authors of primary studies to assess the cultural adaptation methods used in the included primary studies. We entered this information into a meta-regression to investigate effects of the extent of adaptation on intervention efficacy. Results: We included eight randomized controlled trials (RCTs) out of the 4911 potentially eligible records identified by the search: four on e-mental health and four on bibliotherapy. The extent of cultural adaptation varied across the studies, with language translation and use of metaphors being the most frequently applied elements of adaptation. The pooled standardized mean difference for primary outcome measures of depression and anxiety was -0.81 (95% CI -0.10 to -0.62). Higher cultural adaptation scores were significantly associated with greater effect sizes (P=.04). Conclusions: Our results support the results of previous systematic reviews on the cultural adaptation of face-to-face interventions: the extent of cultural adaptation has an effect on intervention efficacy. More research is warranted to explore how cultural adaptation may contribute to improve the acceptability and effectiveness of minimally guided psychological interventions for common mental disorders.

Introduction: The aim of this study is to describe the initial stages of the iterative and user-centered mobile mental health adaptation process of Step-by-Step (SbS), a modularized and originally web-based e-mental health intervention developed by the World Health Organization (WHO). Given the great need for improving the responsiveness and accessibility of health systems in host countries, the EU-funded STRENGTHS consortium studies the adaptation, implementation and scaling-up of SbS for Syrian refugees in Germany, Sweden and Egypt. Using early prototyping, usability testing and identification of barriers to implementation, the study demonstrates a user-centered process of contextual adaptation to the needs and expectations of Syrian refugees. Materials and Methods: N = 128 adult Syrian refugees residing in Germany, Sweden and Egypt took part in qualitative assessments. Access, usage, and potential barriers regarding information and communication technologies (ICTs) were assessed in free list interviews. Interactive prototypes of the app were presented in key informant interviews and evaluated on usability, user experience and dissemination strategies. Focus groups were conducted to verify the results. The interview protocols were analyzed using inductive and deductive thematic analysis. Results: The use of digital technologies was found to be widespread among Syrian refugees. Technical literacy and problems with accessing the internet were common barriers. The majority of the respondents reacted positively to the presented app prototypes, stressing the potential health impact of the intervention (n = 28; 78%), its flexibility and customizability (n = 19; 53%) as well as the easy learnability of the app (n = 12; 33%). Aesthetic components (n = 12; 33%) and the overall length and pace of the intervention sessions (n = 9; 25%) were criticized in regard to their negative impact on user motivation. Acceptability, credibility, and technical requirements were identified as main barriers to implementation. Discussion: The study provided valuable guidance for adapting the app version of SbS and for mobile mental health adaptation in general. The findings underline the value of contextual adaptation with a focus on usability, user experience, and context specific dissemination strategies. Related factors such as access, acceptability and adherence have major implications for scaling-up digital interventions.

Background: Most displaced people with mental disorders in low- and middle-income countries do not receive effective care, and their access to care has deteriorated during the Coronavirus Disease 2019 (COVID-19) pandemic. Digital mental health interventions are scalable when digital access is adequate, and they can be safely delivered during the COVID-19 pandemic. We examined whether a new WHO-guided digital mental health intervention, Step-by-Step, in which participants were supported by a nonspecialist helper, was effective in reducing depression among displaced people in Lebanon. Methods and findings: We conducted a single-blind, 2-arm pragmatic randomized clinical trial, comparing guided Step-by-Step with enhanced care as usual (ECAU) among displaced Syrians suffering from depression and impaired functioning in Lebanon. Primary outcomes were depression (Patient Health Questionnaire, PHQ-9) and impaired functioning (WHO Disability Assessment Schedule-12, WHODAS) at posttreatment. Secondary outcomes included subjective well-being, anxiety, post-traumatic stress, and self-described problems. A total of 569 displaced people from Syria with depression (PHQ-9 ≥ 10) and impaired functioning (WHODAS > 16) were randomized to Step-by-Step (N = 283; lost to follow-up: N = 167) or ECAU (N = 286; lost to follow-up: 133). Participants were considered to be lost to follow-up when they did not fill in the outcome measures at posttest or follow-up. Recruitment started on December 9, 2019 and was completed on July 9, 2020. The last follow-up assessments were collected in December 2020. The study team had access to the online platform, where they could see treatment arm assignment for each participant. All questionnaires were completed by participants online. Intention-to-treat (ITT) analyses showed intervention effects on depression (standardized mean differences [SMDs]: 0.48; 95% CI: 0.26; 0.70; p < 0.001), impaired functioning (SMD: 0.35; 95% CI: 0.14; 0.56; p < 0.001), post-traumatic stress (SMD: 0.36; 95% CI: 0.16; 0.56; p < 0.001), anxiety (SMD: 0.46; 95% CI: 0.24; 0.68; p < 0.001), subjective well-being (SMD: 0.47; 95% CI: 0.26; 0.68; p < 0.001), and self-identified personal problems (SMD: 0.49; 95% CI 0.28; 0.70; p < 0.001). Significant effects on all outcomes were maintained at 3 months follow-up. During the trial, one serious adverse event occurred, unrelated to the intervention. The main limitation of the current trial is the high dropout rate. Conclusions: In this study, we found that a guided, digital intervention was effective in reducing depression in displaced people in Lebanon. The guided WHO Step-by-Step intervention we examined should be made available to communities of displaced people that have digital access. Trial registration: ClinicalTrials.gov NCT03720769.

The World Health Organization is developing a range of interventions, including technology supported interventions, to help address the mental health treatment gap, particularly in low and middle-income countries. One of these, Step-by-Step, is a guided, technology supported, intervention for depression. It provides psychoeducation and training in behavioural activation through an illustrated narrative with additional therapeutic techniques such as stress management (slow breathing), identifying strengths, positive self-talk, increasing social support and relapse prevention. Step-by-Step has been designed so that it can be adapted for use in settings with different cultural contexts and resource availability and to be meaningful in communities affected by adversity. This paper describes the process of developing Step-by-Step and highlights particular design features aimed at increasing feasibility of implementation in a wide variety of settings.