Cultural Adaptation and user satisfaction of an internet-delivered cognitive behavioral program for depression and anxiety among college students in two Latin American countries: a mixed method approach (Preprint)

BACKGROUND To scale up mental health care in low-resource settings, digital interventions must consider cultural fit. Despite the findings that culturally adapted digital interventions have greater effectiveness, there is a lack of empirical evidence of interventions that have been culturally adapted or their adaptation documented. OBJECTIVE To document the cultural adaptation of the SilverCloud Health Space from Depression and Anxiety program for university students in Colombia and Mexico and evaluate user satisfaction with the adapted program. METHODS A mixed-methods process was based on Cultural Sensitivity and Ecological Validity frameworks. In phase 1, the research team added culturally relevant content (e.g., expressions, personal stories, photos) for the target population to the intervention. In phase 2, potential users (nine university students) first evaluated the vignettes and photos used throughout the program. They then participated in focus groups to evaluate and assess the cultural appropriateness of the materials. Their comments were coded into the eight dimensions of the Ecological Validity Framework. Phase 3 consisted of choosing the vignettes most highly rated by the potential users and making modifications to the materials based on the student feedback. In the final phase, 765 actual users then engaged with the culturally adapted program and rated their satisfaction with the program. RESULTS The potential users perceived the original vignettes as moderately genuine, or true, given median scores between 2.5 and 3 (out of a possible 4) and somewhat identified with the situations presented in the vignettes given median scores between 1.5 and 3. The majority of comments or suggestions for modification concerned language (57.5%), followed by concepts (22.8%). Much less concerned methods (10%), persons (4.1%), context (2.3%) or content (0.9%). There were no comments about metaphors or goals. Intervention materials were modified based on these results. Of the actual users who engaged with the adapted version of the program, 87.7%–96.2% agreed or strongly agreed that the modules were interesting, relevant, useful, and helped them to attain their goals. CONCLUSIONS We conclude that the adapted version is satisfactory for this population based on the focus group discussions and the satisfaction scores. Conducting and documenting such cultural adaptations and involving the users in the cultural adaptation process will likely improve the effectiveness of digital mental health interventions in LMIC and culturally diverse contexts.