Guided Act and Feel Indonesia – Internet-based Behavioral Activation Intervention for Depression in Indonesia: A Systematic Cultural Adaptation

Abstract

Depression is one of the leading causes of the global disease burden, affecting millions of people worldwide. The availability of mental health treatment, however, remains very limited in many low-middle income countries, including Indonesia. Internet-based interventions are known to have the potential to deliver mental health treatment economically and appropriately according to numerous studies conducted in high-income countries. In the current study, we describe a systematic cultural adaptation of an internet-based behavioral activation intervention for depression in Indonesia, named Guided Act and Feel Indonesia. During the adaptation, relevant stakeholders were involved, including licensed clinical psychologists, mental health communities, lay counselors, and patients. The adaptation used the formative method for adapting psychotherapy (FMAP) to adapt eight important cultural elements (language, persons, metaphors, content, concepts, goals, methods, and context). The intervention was adapted from the original Dutch version called Doe en Voel, consisting of 8 structured modules that are offered in a secure online environment. The adapted version is being delivered during an ongoing randomized controlled trial with non-face-to-face support from lay counselors who work under the supervision of licensed clinical psychologists. The challenges that were faced during the cultural adaptation are discussed.Guided Act and Feel Indonesia-Intervensi Aktivasi Perilaku Berbasis Internet untuk Depresi di Indonesia: Adaptasi Budaya yang Sistematis AbstrakDepresi adalah salah satu penyebab utama beban penyakit global yang mempengaruhi jutaan orang di seluruh dunia. Namun, ketersediaan perawatan kesehatan mental masih sangat terbatas di negara-negara yang berpenghasilan rendah termasuk Indonesia. Kemudian, intervensi depresi berbasis internet telah diketahui memiliki potensi untuk memberikan perawatan kesehatan mental secara ekonomis dan tepat sesuai dengan berbagai penelitian yang dilakukan di negaranegara berpenghasilan tinggi. Pada studi ini, peneliti mendeskripsikan adaptasi budaya secara sistematis dari intervensi aktivasi perilaku berbasis internet untuk depresi di Indonesia, bernama Guided Act and Feel Indonesia. Selama proses adaptasi, para pemangku kepentingan yang relevan dilibatkan, termasuk psikolog klinis berlisensi, komunitas kesehatan mental, konselor, dan pasien. Adaptasi menggunakan metode formatif untuk adaptasi psikoterapi (FMAP) untuk mengadaptasi delapan elemen adaptasi budaya penting (bahasa, orang, metafora, konten, konsep, tujuan, metode, dan konteks). Intervensi ini diadaptasi dari versi asli Belanda yakni Doe en Voel, yang terdiri dari 8 modul terstruktur yang ditawarkan pada lingkungan online yang aman. Versi yang disesuaikan kemudian disampaikan selama percobaan terkontrol secara acak yang berlangsung tanpa tatap muka dari konselor yang bekerja di bawah pengawasan psikolog klinis berlisensi. Tantangan yang dihadapi selama adaptasi budaya juga dibahas dalam penelitian ini.

Cultural adaptation of internet interventions for refugees: Results from a user experience study in Germany

“…(g) The modules should be kept shorter, which was previously suggested (Abi Ramia et al, 2018; Burchert et al, 2019), and (h) providing a mobile version of the intervention might be a better way to reach refugees (Juniar et al, 2019), given the high use of smartphones compared to desktop computers (Emmer et al, 2016). Furthermore, our participants considered it important (i) to promote the refugees' understanding of western disease- and treatment concepts as well as the healthcare systems, similar to previous findings (Arjadi et al, 2018b; Kizilhan, 2017). (k) This highlights the importance of psychoeducational elements and explanations of exercises and their purposes, in order to bridge diverging explanatory models and to increase the positive expectancy (Gearing et al, 2013; Hinton and Jalal, 2014) as well as trust in the programme, which is shown to be specifically difficult for refugees (Majumder et al, 2015).…”

“…Concerning the non-western background, there are several recommended adaptations along with differences in socialisation and everyday habits of refugees. (e) Audio-visual elements should be preferred over text, which corresponds to earlier research (Abi Ramia et al, 2018; Arjadi et al, 2018b; Patel et al, 2017). (f) In order to make the content more understandable (Juniar et al, 2019; Salamanca-Sanabria et al, 2019), language should be held as simple as possible; metaphors and puns should not be used.…”

“…It may, however, not be valid to transfer those frameworks to the adaptation of Internet-based interventions (Lal et al, 2018). Only very recently, some studies have described and published the process of culturally adapting their Internet-based interventions for people with a diverging cultural background (Abi Ramia et al, 2018; Arjadi et al, 2018b; Juniar et al, 2019; Lal et al, 2018; Salamanca-Sanabria et al, 2019). Thereby, it seems crucial to ensure relevance and sensitivity for the respective target groups by adapting the delivery methods and language (e.g., quotes), illustrations and pictures, as well as personal stories and example characters (Abi Ramia et al, 2018; Juniar et al, 2019; Salamanca-Sanabria et al, 2019).…”

The Cultural Adaptation of Step-by-Step: An Intervention to Address Depression Among Chinese Young Adults

“…This study also highlighted that it is important to learn from both providers/experts and users’ perspectives to enhance the applicability of the program and also maintain the therapeutic quality of the intervention. Arjadi and colleagues ( 33 ) applied the Ecological Validity Model to adapt an internet-based behavioral activation intervention addressing depression for Indonesian people. In addition, an internet-based intervention for depression was culturally adapted for Colombian university students using this model ( 34 ) and was evaluated ( 35 ).…”

Cultural adaptation of Internet- and mobile-based interventions for mental disorders: a systematic review protocol

“…Previous reviews and meta-analyses have summarised studies that conducted IMI in LMIC [53] and investigated the extent and effectiveness of cultural adaptation of IMI for the treatment of common mental disorders among people with diverse cultural backgrounds [48]. Yet, the procedure of the cultural adaptation is often only poorly reported [43,52,[54][55][56]. This makes it difficult to identify components of the cultural adaptation that may contribute to an enhanced acceptance and effectiveness of IMI, such as the language, illustrations, or example characters [43,54,56,57].…”