Development of a Systematic Framework for Cultural Adaptation and Contextualization of Evidence-Based Psychological Interventions

Abstract Background Innovative interventions to address mental health needs in low- and middle-income countries (LMICs) have increased. Before implementation, it is important to culturally adapt these interventions. There is a pressing need for a systematic approach that is feasible in settings with resource constraints, to guide not only content modification but also implementation elements to inform scalability and quality assurance. We harmonized existing guidance in cultural adaptation to develop a transparent framework for rapid and systematic cultural adaptations. We piloted this approach in Nepal for Group Problem Management Plus (PM+), a trans-diagnostic, task sharing intervention, for adults with psychological distress in humanitarian settings. Methods Building upon the ecological validity model, a 10-step process was used to adapt the Group PM + intervention in preparation for a feasibility trial in Nepal. A process evaluation was conducted after the trial to gather feedback on the adaptations. Detailed documentation tools were used to ensure rigor during the adaptation process. Findings The complete adaptation included a 10-step process; 1) Identify mechanisms of action, 2) Conduct a literature desk review for the culture and context, 3) Conduct a Training of Trainers (ToT), 4) Translate intervention materials, 5) Conduct an expert read-through of the materials, 6) Qualitative assessment of intervention population and site, 7) Conduct practice rounds, 8) Conduct an adaptation workshop with experts and implementers, 9) Pilot test the training, supervision, and implementation, and 10) Review through process evaluation. An iterative process with rapid modification of content and procedures was necessary. For Group PM+, key adaptations were harmonizing the mechanisms of action with cultural models of distress; modification of recruitment procedures to assure fit between cultural models of distress and population; and development of a skills checklist to monitor facilitator engagement with mechanisms of action. Conclusion A 10-step cultural adaptation process could feasibly be implemented in a humanitarian setting to rapidly prepare a psychological intervention for widespread implementation. Having a standard systematic approach will help develop a body of literature and lessons to facilitate the process for greater cultural appropriateness and effectiveness of psychological interventions worldwide.