No implementation without cultural adaptation: a process for culturally adapting low-intensity psychological interventions in humanitarian settings

Background Despite the widely recognised importance of cultural adaptation to increase the effectiveness of psychological interventions, there is little guidance on itsprocess. Developed based on existing theory, we applied a four-step process to culturally adapt a low-intensity psychological intervention for use in humanitarian settings. Methods The four-step process was applied to adapt a WHO low-intensity psychological intervention (i.e. Problem Management Plus, or PM+) for use with displaced Venezuelans and Colombians in Colombia. First, a rapid desk review was used as an (1)information gatheringtool to identify local population characteristics. Next, the results were taken forward for the (2) formulation ofadaptation hypotheses, whereby PM+ protocols were screened to identify components for adaptation, drawing on the Ecological Validity Model. Third, the elements flagged for adaptation were taken forward for (3)local consultationto firstly, verify the components identified for adaptation, to identify other areas in need of adaptation, and thirdly, to adapt the intervention protocols. Finally, the adapted intervention protocols were reviewed through (4)external evaluationswith local experts. Results Theinformation gatheringphase yielded key information on the socioeconomic aspects of the groups targeted for intervention, the availability and need for mental health and psychosocial support, and existing barriers to accessing care. Theadaptation hypothesesphase further identified the need for clearer explanations of key concepts, the need for sensitive topics to match local attitudes (e.g., domestic violence, thoughts of suicide), and the identification of culturally appropriate social supports. Building on these first two phases,local consultationsubsequently resulted in revised PM+ protocols. The adapted protocols differed from the original format in their focus on the problems unique to these population groups, the way that psychological distress is expressed in this context, and the inclusion of locally available supports. The results of theexternal evaluationsupported the adaptations made to the protocols. Conclusion The proposed four-step process offers a useful guide forhowto adapt low-intensity psychological intervention within humanitarian settings. Despite some limitations, we show that even when time and resources are scarce it is possible and necessary to culturally adapt psychological interventions. We invite further testing, replication, and improvements to this methodology.