From formative research to cultural adaptation of a face-to-face and internet-based cognitive-behavioural intervention for Arabic-speaking refugees in Germany

Abstract

Background This study aims to provide a transparent and replicable documentation approach for the cultural adaptation of a cognitive-behavioural transdiagnostic intervention (Common Elements Treatment Approach, CETA) for Arabic-speaking refugees with common mental disorders in Germany. Method A mixed-methods approach was used, including literature review, interviews, expert decisions and questionnaires, in order to adapt the original CETA as well as an internet-based guided version (eCETA). The process of cultural adaptation was based on a conceptual framework and was facilitated by an adaptation monitoring form as well as guidelines which facilitate the reporting of cultural adaptation in psychological trials (RECAPT). Results Consistent with this form and the guidelines, the decision-making process of adaptation proved to be coherent and stringent. All specific CETA treatment components seem to be suitable for the treatment of Arabic-speaking refugees in Germany. Adaptations were made to three different elements: 1) Cultural concepts of distress: a culturally appropriate explanatory model of symptoms was added; socially accepted terms for expressing symptoms (for eCETA only) and assessing suicidal ideation were adapted; 2) Treatment components: no adaptations for theoretically/empirically based components of the intervention, two adaptations for elements used by the therapist to engage the patient or implement the intervention (nonspecific elements), seven adaptations for skills implemented during sessions (therapeutic techniques; two for eCETA only) and 3) Treatment delivery: 21 surface adaptations (10 for eCETA only), two eCETA-only adaptations regarding the format. Conclusion The conceptual framework and the RECAPT guidelines simplify, standardise and clarify the cultural adaptation process.

Standardised research methods and documentation in cultural adaptation: The need, the potential and future steps

“…Regarding specific therapeutic elements, all studies conducted a careful analysis of interventions to address the most common symptoms of psychological distress in their respective target populations. As an example, three studies discussed the inclusion or exclusion of problem solving in their respective interventions ( Böttche et al, 2021 , this issue; Kananian et al, 2021 , this issue; Unterhitzenberger et al, 2021 , this issue). This discussion showed that, on the one hand, problem solving seemed to be a helpful intervention to address the refugees’ most pressing concerns, such as asylum status or family reunification.…”

“…In addition, researchers expressed difficulties in making decisions about cultural adaptations based on the evidence they had gathered on their target population. Two studies specifically focused on this decision-making process from formative research to adaptation (i.e., Böttche et al, 2021 , this issue; Lotzin et al, 2021 , this issue). Only one study documented the decision-making process itself, that is, the opinions expressed by the different researchers on the team.…”

“…Aside from CCD, other aspects that are relevant for cultural adaptation were mentioned, such as cultural resources ( Mewes et al, 2021 , this issue), gender and religious aspects ( Kananian et al, 2021 , this issue), or cultural concepts other than CCD (e.g., attachment). Researchers considered the use of specific treatment elements in function of participants’ needs and conditions, such as problem solving ( Böttche et al, 2021 , this issue; Kananian et al, 2021 , this issue).…”

“…Only one study documented the different views of the team members as a basis for decisions ( Lotzin et al, 2021 , this issue). Another study mentioned the risk of excluding other groups if adaptations are too specific for one particular group ( Böttche et al, 2021 , this issue). Our experiences show that the decision of what to adapt, and why , remains a subjective process to some extent.…”

“…Several studies went through an iterative process of piloting, feedback, and further adaptation. Some of the projects used culture-sensitive interventions and further adapted them to their target population ( Böttche et al, 2021 , this issue; Kananian et al, 2021 , this issue; Lotzin et al, 2021 , this issue). Keeping track of this process and documenting the different stages of adaptation is a labour-intensive and time-consuming process.…”