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

conclusion : This study showed the utility of using Ecological Validity Model and a four-point procedure model for cultural adaptation and achieved a culturally appropriate adaptation of the bit-by-bit program for chinese young adults. Results : We adapted the text and illustrations to fit the culture among chinese young adults. Eight elements of the intervention were chosen as the targets of cultural adaptation ( e.g., language, metaphors, content ). Samples of major adaptations included : adding scenarios related to university life ( relevance ), changing leading characters from a doctor to a peer and a cartoon ( acceptability ), incorporating two terminology versions ( traditional Chinese and simplified Chinese ) in the intervention ( comprehensibility ), and maintaining cardinal curative components ( completeness ). Methods : cultural adaptation was carried out in four phases following ecological Validity Model : ( 1 ) stagecoach arrange and adept consultation ; ( 2 ) preliminary contentedness adaptation ; ( 3 ) iterative content adaptation with residential district members ; ( 4 ) finalized adaptation with community feedback meetings. cognitive interview was applied to probe for relevance, acceptability, comprehensibility, and completeness of illustrations and text. Six mental health experts and 34 taiwanese young adults were recruited for key informant interviews and focus group discussions. setting : Digital genial health interventions leverage digital communication engineering to address the mental health needs of populations. culturally adapting interventions can lead to a successful, scalable genial health intervention implementation, and cultural adaptation of digital genial health interventions is a critical component to implementing interventions at scale within context where mental health services are not well supported.


Digital genial health interventions leverage digital communication technology to address the mental health needs of populations. These interventions incorporate information provision, screening, judgment, and monitor, interposition, and social confirm ( 1 ). Key advantages of using this innovative technology include reductions in discussion barriers such as time and geographic boundaries, and treatment costs while offering timely responses to mental health needs ( 2, 3 ). A meta-analysis of 17 trials of 1,480 participants showed that computerize and web-based treatment were effective at reducing natural depression and anxiety compared with passive control ( 4 ). A taxonomic follow-up of 89 studies demonstrated that about 81 % of digital mental health programs are effective or partially effective at reducing a kind of symptoms of coarse mental disorders and improving wellbeing ( 5 ). In reply to the global want for scalable mental health interventions, the World Health Organization developed Step-by-Step ( SbS ), a transdiagnostic and guide digital mental health treatment chiefly targeting symptoms of park mental disorders, including depression ( 6 – 10 ). The platform use narrative stories with illustrations to teach participants behavioral energizing techniques and skills ( for example, natural process scheduling ), supply information ( for example, list for social and health service providers ), augmented with nonspecialist guidance ( 10 ). It consists of five 20–30 minutes sessions that teach techniques of stress management, planning physical and social activities, reducing avoidance cope, improving self-acceptance, and preventing relapse. The narrative stories involved a character ( service recipient, the junior leading fictional character ) who learned how to better cope with casual stressors in different scenarios ( for example, family conflicts, feeling isolated ) and manage their mood based on cognition imparted by a repair ( service provider, the senior lead character ). behavioral activation, as the effect curative technique, gets participants active agent in casual life by scheduling activities to enhance their temper and are effective in managing depressive disorder symptoms ( 11 ). In sessions of SbS, lists of activities are offered for users who can choose from these activities or come up with their own. besides, a list of social and health service providers was provided to increase social interaction by seeking help from others. The intervention capacity, guidance model, and mobile application are three essential components of the program ( 7 ), which can be adapted for versatile cultural groups. SbS has been adapted for Filipino migrant workers ( 8 ), and syrian refugees, Lebanese, and Palestinians in Lebanon ( 12 ) through a cultural adaptation process involving community engagement with key local community members and stakeholders. culturally adapting interventions is one of the keys to successful scalable mental health interposition implementation ( 13 ). cultural adaptation is “ the taxonomic alteration of an evidence-based treatment ( or treatment protocol ) to consider linguistic process, cultural, and context in such a way that it is compatible with the customer ’ s cultural patterns, think of, and values ” ( 14 ). Incorporating cultural elements, including apparitional belief and sociable norms, and take account of the local anesthetic context and needs of the aim population can improve service users ’ attitudes toward the treatment ( 15 ). several studies have highlighted considerations for incorporating polish in the execution of genial health interventions in low-and-middle-income countries ( 16 – 19 ), but these studies focus on nontechnology-supported treatment. relatively few cultural adaptation studies for digital genial health interventions have been conducted within this context, leaving a critical gap in the literature. Abi Ramia and colleagues ( 12 ) culturally adapted a digital mental health intervention in Lebanon through learning participants ’ receptiveness to the program, its subject, execution, and prospective use with local communities and stakeholders. Garabiles and colleagues ( 8 ) completed a cultural adaptation to enhance the acceptability, relevance, comprehensibility of the treatment and its message ( for example, storyline, example, and characters ) while maintaining the completeness of the therapeutic components. previous employment adopted a framework for steering on what elements should be adapted ( 20 ) and rationale behind adaptations ( 8 ) to ensure the thoroughness of the cultural adaptation within the digital format. Digital genial health intervention adaptation must meet community needs without the reliance on explanations and modifications by human supports ( 8, 21 ), which highlights the importance of creating interposition material that can stand alone. several models are known for cultural adaptation with distinguishing features ( 22 ), such as tailoring for specific heathen groups ( 23, 24 ), therapeutic process and skills ( 25 ), elements within the interposition ( 26 ), specific domains that have a poor fit between the intervention and the community ( 27 ), and heuristic considerations including affected role engagement, mechanism, and discussion outcomes ( 28 ). Frameworks applied for cultural adaptation of digital mental health intervention include Ecological Validity Model ( 26 ), Heuristic Framework ( 28 ), integrative Cultural Adaption Model ( 29 ), Formative Method for Adapting Psychotherapy ( 30 ), and four-point Framework ( 31 ), and all of which were designed to inform the adaptation process except the Ecological Validity Model ( EVM ) ( 26 ). The ecological Validity Model addressed eight culturally sensitive domains within an interposition, which are lyric ( i.e., culturally appropriate and syntonic terminology ), people ( i.e., ethnic/racial similarities ), metaphor ( i, common symbols and concepts shared within the cultural group ), content ( for example, cultural cognition about values, customs, and traditions ), concepts ( for example, culturally and contextually accordant treatment constructs ), goals ( i.e., formation of an agreement on the treatment goal ), methods ( i.e., procedures/model used to accomplish the treatment finish ), and context ( i, psychological, developmental, social, economic and political context ) ( 32 ). Using the Ecological Validity Model ( 26 ), eight culturally sensitive dimensions for intervention were explored with mental health providers to culturally adapt a web-based depression interposition for Latino adolescents ( 20 ). This study besides highlighted that it is important to learn from both providers/experts and users ’ perspectives to enhance the applicability of the plan and besides maintain the curative quality of the interposition. Arjadi and colleagues ( 33 ) applied the Ecological Validity Model to adapt an internet-based behavioral activation treatment addressing depression for indonesian people. In addition, an internet-based interposition for depression was culturally adapted for colombian university students using this model ( 34 ) and was evaluated ( 35 ). evidence from a meta-analysis of eight randomized controlled trials showed that the potency of minimally guided digital mental health interventions to reduce symptoms of coarse genial disorders was enhanced by cultural adaptation ( 36 ). cultural adaptation of digital mental health interventions is a vital component to implementing interventions at scale within context, particularly where mental health services are not well supported. Frameworks for cultural adaptation are generally used to inform adaptation dimensions for intervention contented and to inform the process of the adaptation ( 37 ). The stream report adopted the EVM ( 26 ) to inform which interposition elements should be culturally adapted. The model, including eight culturally medium dimensions ( i.e., language, persons, metaphors, subject, concepts, goals, methods, context ) was previously applied in cultural adaptation studies ( 20, 22, 34 ). For the framework informing the strategies and work of cultural adaptation, the current study did not follow any existing cultural adaptation summons model ( 22, 37, 38 ) since they were not appropriate for digital genial health program as digital mental health interventions minimize contact between the providers and service users. The main concenter of the adaptation cogitation was on the treatment content ( for example, text, storyline, and illustrations ), which comprise the self-guided information received by the serve users. A process exemplary with four phases was applied to emphasize the input provided by representatives of the interposition aim population and the adaptation of the materials ( 8 ) .


We selected the EVM model developed by Bernal and colleagues ( 26 ) to inform the domains of the content modifications to ensure lyric, persons, metaphors, subject, concepts, goals, methods, and context in this interpretation of the SbS intervention were acceptable, relevant, comprehensible, and complete for chinese young adults .

Participants and Data Collection

purposeful sampling was used to invite six Chinese mental health experts from Macao and mainland China for key witness interviews ( KIIs ). All of them earned advanced graduate student degrees in mental health fields, including guidance, clinical psychology, and psychiatry and had extensive know working with chinese clients. We balanced the sampling to represent both Cantonese speaking experts and Mandarin public speaking experts since our aim in the adaptation was to develop programs for these two distinct linguistic and cultural groups. All interviews lasted for 90 to 120 minutes and were audio recorded with consent from participants. chinese young adults who were 18 years or older and lived in Macao for at least one year were eligible to participate in the concenter groups ( FGDs ). Participants were recruited through goal-directed sample in cooperation with the General Association of chinese Students of Macao, the largest nongovernmental organization that works for chinese students in Macao. We composed four homogeneous groups based on arouse ( female or male ) and origin of parentage ( Macao Chinese or mainland Chinese ) to encourage all participants to speak freely among peers. We conducted 18 FGDs, five each with Macao Chinese women and men, and four each with mainland taiwanese women and men. The median number of participants in Macao male group, Macao female group, mainland male group, and mainland female group are 6 ( 6–7 ), 6 ( 5–8 ), 5 ( 4–6 ), and 7 ( 5–8 ). There were 41 participants in total, and each FGD lasted about 3 hours. All FGDs were recorded with written consent. The FGDs were open groups, with not all participants attending all sessions. In order to maintain a group size of about eight participants, new participants were recruited by snowball sampling throughout the study. basic demographic information ( senesce, sex, marital condition, highest education level, whether they were born in Macao, phone number of years living in Macao, and subcontract experience in Macao ) was collected before KIIs and FGD, and in addition, data on depressive ( 39 ) and anxiety symptoms ( 40 ), and wellbeing ( 41 ) was collected from FGD participants. Data was obtained through on-line surveys using Qualtrics ( Figure 1 ). FIGURE Figure 1 Data collection process .


The study was conducted in four phases from May 2019 to December 2019 ( see Figure 2 ). The phases were : ( 1 ) adept consultations ; ( 2 ) preliminary content adaptation for the intervention materials ; ( 3 ) iterative contentedness adaptation with community members ; ( 4 ) finalized adaptation with residential district feedback meetings. FIGURE Figure 2 Cultural adaptation process .

Phase One: Stage Setting and Expert Consultations

Community engagement is important for cultural adaptation ( 22 ). In our study, stakeholders, including a WHO technical foul officer, mental health experts, and local community groups, were involved in unlike phases. In phase one, we set up a steering group to collaborate with stakeholders and implement the report. The steering group included the project principal research worker ( PI ), a professor in clinical psychology and populace health who previously completed another cultural adaptation of the intervention with a unlike population ( 8 ), a professor in communication ( co-PI ), and two taiwanese alumnus students, who had a clinical psychology, anthropology, and public health background, and who were responsible for data solicitation and analysis. As the treatment developer, WHO provided technical defend and advice for the sketch. The steering group besides built upon an existing and collaborative relationship with the Student Affairs Office ( SAO ) of the University of Macau and the General Association of chinese Students of Macao ( AECM ) to support the learn. The final step of Phase One was the behavior of six semistructured, KIIs with mental health experts from May to June to understand the mental health context of chinese unseasoned adults. Before the interviews, the mental health experts independently reviewed the SbS program corporeal to ensure the efficiency of the interviews. During the interview, the interviewer ( a graduate student in the steering group ) started the conversation with a welcome afford, the introduction of the broadcast and the function of the interview, and oral inform consent was obtained. After starting the recording, the interviewer began with an open question about their have with taiwanese clients in general, followed by their professional perspectives on particular age groups and about the mental health context in Macao. After questions about major mental health problems, existing mental health services, and node ’ s typical coping strategies, we focused on the contented of SbS with questions related to the appropriateness of the program, delivery method acting, characters, storyline, illustrations, and expressions. The notetaker ( the early graduate student in the steering group ) organized the notes after the interview .

Phase Two: Preliminary Content Adaptation for the Intervention Materials

The contentedness of the master version of SbS was written in English. In phase two, a team member with a minor in translation studies translated the english lyric into the taiwanese language, and a unlike team penis who was bilingual ( English & Chinese ) conducted backward transformation to check the accuracy of the translation. We recruited a creative narrative writer with a background in chinese education to change the storyline for taiwanese students based on the feedback in Phase One from KIIs with the genial health experts. We besides hired a local professional illustrator with a background in ocular artwork & art education to design the main characters and the illustrations in session one for future discussion. A simplified chinese version was adapted from the traditional chinese translation to ensure that both Macao Chinese and mainland Chinese could utilize the program materials .

Phase Three: Iterative Content Adaptation With Community Members

For phase three, the study team worked in junction with AECM, who was creditworthy for participant recruitment. We had a Mandarin working group with one facilitator and three note-takers who spoke Mandarin as their first speech vitamin a well as a yue working group with one facilitator and two note-takers who are yue speakers. They were all trained in properly organizing focus groups and in avoiding lead questions or intimidating questions by the PI and co-PI. The note-takers besides prepared PowerPoints with all materials in one seance before the FGDs, which would be shown to the participants during the FGDs. The main purpose of the FGD was to adapt the storyline and to apply a bottom-up approach to generate the illustrations with participants, meaning that participants would provide ideas for the illustrations based on the text and discussion, and then the illustrator would develop the illustrations based on ideas generated from the FGDs. Illustration adaptation and FGDs discussions were iterative and concluded when FGD participants were satisfied with the illustrations. All concentrate groups were conducted in a private meet room with a projector at a servicing center of AECM. The working groups were matched with participants by linguistic process. During the FGD, the facilitator presented the program introduction, the determination of the sketch, and basic rules for the discussion and started the discussion with participants ’ shortstop self-introduction as an ice-breaking bodily process. After that, facilitators focused on the materials using cognitive interview strategies ( 8 ). Participants were asked to describe what they thought was occurring in the treatment textbook, and follow-up questions were used to guide their comments on how the text and illustrations should be changed or developed. Detailed interview guide for focus group discussion is presented in Supplement 1 .

Phase Four: Finalized Adaptation With Community Feedback Meetings

For phase four, we had two more residential district meetings with the local anesthetic students who participated in the FGDs when we presented the new illustrations and suggested changes from the results of FGDs. Feedback was collected and analyzed to inform the promote changes. adaptation decisions were finalized during the community feedback meet. finally, the adaptation results were documented according to the eight elements of the EVM ( 26 ) .


The notetaker of the KIIs took detailed notes and organized the notes with audio recordings during and after the KIIs. The notes were synthesized by the notetaker and the interviewer using excel. The main thematic codes were taiwanese mental health, cultural considerations, likely aim tailoring groups, and the SbS digital intervention. The eight elements of the EVM model were used as sub-theme codes under SbS digital intervention to further synthesize the adaptation of materials of the intervention. Two working groups led by the calibrate students in the steer groups took detail notes during all FGDs. Suggestions for changes of text & storyline, the ideas for illustrations, and rationale for changes were recorded. After the FGDs, we organized steering group meetings to discuss the suggestions to ensure they were pass and consistent with the theorize discussion mechanism of symptom improvement. The results of the FGDs and steering group meetings were coded using excel through the lens of the Bernal ’ s EVM model ( 26 ). The results of all likely changes were presented in the community feedback meetings in the last phase to finalize the adaptation .

IRB Approval

IRB approval was granted by the University of Macau .


Participants’ Characteristics

A total of 41 chinese young adults participated in the FGD ( 26 Macao Chinese ). Among local students ( 19.84 year, 18–25 ), ten-spot of them are male, and 23 were born in Macao. Among nonlocal students ( 19.26 year, 18–21 ), seven of them of male. descriptive statistics and means and standard deviations of depression, anxiety, and subjective wellbeing are shown in board 1. postpone Table 1 Sociodemographic and clinical feature .

Cultural Adaptation

Eight dimensions within the EVM ( 26 ) were applied for cultural adaptation of chinese SbS, which are language, people, metaphor, content, concepts, goals, methods, and context to enhance relevance, acceptability, and comprehensibility while maintaining the completeness of curative elements of the intervention .


respective issues related to comprehensibility and acceptability were identified in terms of linguistic process during FGDs. In terms of comprehensibility, several FGDs pointed out that the translations were pleonastic across sessions. This was improved by either combining alike expressions or skipping excess content while maintaining the coherence of the storylines and therapeutically meaningful components. Examples of changes are shown in board 2. table Table 2 Samples of adaptation. One major adaptation was made to increase the acceptability of the linguistic process. The use of encouragement and positive feedback such as “ Well done ! ” were not seen as culturally reproducible and were not acceptable. Participants reported that taiwanese rarely express compliments verbally. Since these messages are crucial and designed to motivate users to continue the program, alternatives were needed. In order to enhance the acceptability of the habit of encouragement and compliments, we generated illustrations that expressed boost, and modified messages to be acceptable if displayed with the example ( Figure 3 ). The encouragement phrases were modified to explicitly emphasize the action they took and positive feedback, such as “ you did a good job ” and “ you did very well. ” FIGURE Figure 3 Senior leading characters ( after adaptation ) ; illustrations of expression of encouragement .


A large deviation between preferences for the serve supplier character between KIIs and FGDs was noted. The characters inaugural suggested by the experts in KII, were a kind beget character, a middle-aged female professional, and a cartoon ( see Figure 4 ). A middle-aged male professional character ( see Figure 4 ) was added as requested by the local male group. We used a bottom-up overture that allowed participants to develop the characteristics of a character, including name, appearance, professional background. Both male groups considered that the human figures were not a satisfactory as the cartoon character as a human figure reminded the participants ’ unpleasant feel with their mother or authorities in school, whereas the cartoon design was more approachable and comfortable to accompany with. Female groups preferred to talk with their peer or senior female students ( Shijie ). As a leave, both male groups adopted a cartoon character, and both female groups adopted a young and know female calculate as the sophisticate number in the original SbS to guide them through the program and to enhance the acceptability of SbS. Details of modification are shown in table 2. FIGURE Figure 4 Senior leading characters ( before adaptation ). The cartoon figure was named “ elf ” in the local male interpretation and “ Xiao Q ” in the nonlocal male version. The local female group picked the young female character ( Figure 3 ), which was originally designed as the former service recipient role, and named it Jessica. Details of adaptation for characters are shown in table 2. Among local females, calling a friend or scholar by their dub or english name is common, so we kept the English name for the senior ahead fictional character. The nonlocal female expressed that they tended to talk with a close girl-friend but was besides uncoerced to seek advice from a professional when they were upset. therefore, a young, reliable, female figure was used as the overhaul supplier character for the nonlocal female group. similarly, they picked the young female character but maintained her identity Dr. Chen ( Dr. as in PhD in psychology or rede, not a aesculapian doctor of the church, expressed as Boshi, rather than Yisheng, in Chinese ) to show her professionalism. The adapt and finalized senior leading characters are shown in Figure 3 .


A few adaptations were made to improve the context where metaphors were used. According to KIIs, metaphor and cultural stories could be used when necessary but should be used conservatively as they might require cognition of these stories to internalize the mean. To make the narrative clean and more relevant to new adults ’ life experience, we added metaphors suggested by FGDs ( Table 2 ). Some metaphors were thought to be excessively abstract and besides exaggerated, and hence we made changes, such as “ carrying the weight of the world on your shoulder ” and “ I could have slept for a thousand years ”. We modified them according to the FGDs ’ suggestion ( mesa 2 ) .


In the digital treatment SbS, content comprised narratives, characters, and illustrations. It contains particular cultural cognition related to local values, customs, and traditions within a unique socioeconomic cultural background. frankincense, content is a all-important separate of this exemplify narrative interposition to enhance its cultural acceptability and relevance .


The KIIs suggested that problems like syndicate conflicts, addiction problems, and dating problems as relevant scenarios for young adults because they were more common issues in young adults. The storyline was modified according to KIIs ’ feedbacks for FGDs. Male groups had very different feedback from the female groups. First, in terms of the background stressor of the junior leading characters, the male groups suggested “ getting into a different university from their girlfriend ’ sulfur and conflicts in romantic kinship, ” they felt had firm relevance to the report. The female groups expressed that not every college scholar can relate to issues with their suggest collaborator, although go steady is common in university. They suggested moving the stressor scenario as a romanticist relationship in a late seance and habit “ a kin member diagnosed with a severe illness ” as the primary trigger of the stress reaction. second, in the original version, we included a scenario that narrated a friend came to the junior run character ’ s home and talked with the character when the fictional character was deplorable. Females reflected that that is what a close acquaintance would do and agreed on the scenario, but the males reported that they rarely comforted a close supporter by merely talking. rather, they would first do something to help their friend perturb from the unpleasantness, such as playing video recording games together. After a while, they would start to talk about the concerns. frankincense, we adapted this scenario to include video game act for the male versions. Both female and male groups shared like challenges related to school work, such as problems in dealing with a noncontributing teammate in a group visualize ( described as a “ free-rider ” in FGDs ). Generally, all groups agreed that the free-rider issue was common to college students, and they felt it was hard to talk about the consequence with the team extremity while not hurting their relationship. therefore, we included the free-rider write out in the history and modified it from our original theme, which was a worry about grades and falling behind in studies. We besides adjusted the narratives by modifying some of the elements, such as department of transportation, interaction with friends, and places ( see Figure 5 ). FIGURE Figure 5 Examples of culture-related elements included in the content .


The junior leading characters ( the early service recipients ) were created by following several criteria : matching the target population ’ s sex, long time, and expressive style of full-dress ( Figure 6 ). They were given a common chinese name. The female groups preferred the female junior leading character to be younger and barren compared to the elder run characters. They anticipated a change of appearance ( for example, appearing confident, with a more colorful outfit ) to show that the character felt better after joining the program. local male FGDs suggested categorizing the pre-intervention and post-intervention characters by the invest discolor, in which a colored blue T-shirt imply sadness and forlornness and a yellow shirt showed happiness and department of energy. The fictional character ’ s dress can be used to distinguish the stipulate of the character before and after the program. local male FGDs pointed out that one peer figure was not masculine enough and suggested to change the hairdo and confront ( Figure 7 ). FIGURE Figure 6 Junior leading characters ( former service recipients ). FIGURE Figure 7 Adaptation of a peer quality .


The illustrations were generally created based on ideas generated in FGDs. The participants decided how the illustrations looked, such as the character ’ s facial expression, dress, and elements of the illustration. For exemplar, FGDs suggested an illustration of holding hand in a heart for the textbook of accepting help oneself from others can make their life better ( Figure 8 ). FIGURE Figure 8 Sample example : “ accepting help from other can make your life sentence better ” .


Concepts of stressors and symptoms should be accordant with the cultural and target population ’ s experience to make sure the terms used are relevant, acceptable, and comprehensible. several changes were made in terms of symptoms because participants reported that the descriptions or the presence of the symptoms were not allow according to their experience ( board 2 ) .


Having a congruent finish of the intervention program and the needs of clients should be reproducible in digital genial health interventions. Participants in KIIs and FGDs believed that the program could be used to cope with meek and moderate climate symptoms ( for example, depression, anxiety ), which is matched with the aim of the designed platform. Nevertheless, experts and laypersons suggested framing the broadcast as a stress management cock or academic performance creature alternatively of mental health intervention in rate to reduce the mark of using a mental health intervention, which is a common treatment barrier among chinese young adults ( 42 ). According to KIIs, feeling stressed or complaining is a sign of incompetence among chinese males, suggesting that this is a samara element of “ face ” within this group. In summation, as mentioned by the local anesthetic male FGDs, people who look dejected would blame themselves for being useless and not being able to change themselves or their situations. frankincense, incorporating the notion of competence enhancement as one of the goals in the market software of the program would make the platform more appealing to chinese males .


respective features were designed to achieve the goals of the plan within the chinese cultural context. First, the blueprint of the digital platform allowed electric potential service-users to use it anytime wherever they are to reduce mark about using mental health services. Second, although some mentioned that plus feedback in the exercise was pleonastic, we kept the positive feedback for all activities or adapted to a shorten version to emphasize their force ( for example, “ you did it well ” ), which related to the male core values and is besides a motivation enhancing remedy strategy. Third, we adapted the plan list of activities for all groups to make the list more relate to each level. For case, we added “ go out, watch a movie ” for nonlocal females, “ go for a walk ” for nonlocal males, “ plan in some time to run/jog ” for local females, and “ go out with supporter, go for a ride, vigil Facebook video recording ” for local males to the number of things one could do. The adapted number contained specific activities that are more appeal to one group and offered more suggest activities for potential scheduling .


Considering context is authoritative in the adaptation of this program to Chinese new adults because of the singular needs and experience at their developmental stage. With the partner NGO support, this program has the electric potential to be disseminated to most chinese young adults and increase the approachability of this intervention. During the FGDs, we were mindful that they had concerns more than merely psychological and emotional health. They believed some of the worries were related to their academician and career development, but they had few resources for these concerns. thus, we modified the list of local services to meet the needs of young adults, such as genial health care and career development to make the broadcast fit the local context in this population .


We applied the Ecological Validity Model ( 26 ) and followed the four-phase march outlined previously ( 8, 31 ) to adapt the SbS program for chinese young adults. We generated illustrations using a bottom-up overture, suggested as a preferable method acting for double adaptations in the previous adaptation of SbS among Filipino migrant workers ( 8 ). overall, we adapted the SbS to achieve acceptability, relevance, comprehensibility, and completeness of the program for the chinese population. To our cognition, this study is the first one to culturally adapted a digital, illustrate narrative intervention for Chinese, specifically chinese youthful adults. several issues should be highlighted to enhance cultural adaptations. First, a proper model and a rigorous process are essential to cultural adaptation. We employed the EVM ( 26 ) to inform cultural adaptation of SbS for a taiwanese population, which allowed us to look beyond translation and to understand and collect the core cultural factors ( for example, value and spirit ) to embed into the text and illustrations. Metaphors and characters reflected the epistemology and social relations within the context. Capturing the culturally sensitive elements and applying them to the mental health interposition is known to improve the affect of the treatment ( 43, 44 ). In summation, guided by a rigorous 4 stage adaptation serve ( 8, 31 ), the current cultural adaptation was achieved systematically and received meaningful and valuable information from genial health experts and likely intervention beneficiaries. Second, a successful cultural adaptation required the contribution of both experts and laypersons ( 8, 12 ). From our KIIs and FGDs, we noticed the discrepancy in preferences for leading characters between experts and laypersons. Most experts suggested senior and experienced genial health professional while FGDs favored peers and nonhuman figures. This can be interpreted in separate due to the lack of professional models in the study context ( 45 ), and desire on the separate of experts to put forward professional images in this broadcast. On the other hand, the experts provided valuable information to guide us through the storyline allowance process before FGDs. During KIIs, the experts shared their impression and experience working with chinese young adults and suggested possible themes. It is important to balance the information and perspectives obtained from experts and service users. feedback from the electric potential service users can best inform preferences for illustrations and for cultural factors, while experts are well positioned to provide suggestions related to clinical efficacy and common psychiatric problem and stressors. Third, including layman with proper characteristics in cultural adaptation can enhance the cogency of the treatment. The current adaptation of SbS was adapted for chinese youthful adults with mood symptoms and early psychological difficulties, so integrate participants who were taiwanese young adults and with a certain flat of symptoms would be beneficial to the cultural adaptation. The recruit participants in this report demonstrated minimal symptoms, since it is difficult to engage people who are actively depressed to engage in the rigorous and time-consuming cultural adaptation process, so there may be a gap between what people with depression and nondepressed participants might prefer in the platform and how they might perceive the text and illustrations ( 46 ). Given this business, we focused on adaptations that are broadly relatable to the majority of the aim population ( for example, emphasis their forte in encouraging messages ) because they are living a exchangeable cultural environment and sharing similar cultural feel and we believe this sufficiently informed an adequate begin point to engage the population. Fourth, community betrothal is key to a successful cultural adaptation deoxyadenosine monophosphate well as interposition implementation ( 47 ). Studies show that association participation, as conventional social ties, contributes to political faith and social trust among the participants in China ( 48 ). In this current report, we worked with the biggest local NGO that serves chinese students. collaboration with a local partner made the process of cultural adaptation fluent, as they assisted with providing distance, access to the target population, and useful suggestions about the eventual program execution. final but not least, culturally adapted interventions need to be examined. well adapt interventions enhance the treatment effect ( 36 ). frankincense, an evaluation of intervention potency is necessity not entirely to evaluate the effect of the intervention but besides to evaluate the sufficiency of the cultural adaptation. We adapted SbS for Chinese new adults, which is a culturally tailored guided self-help intervention for depression. Supported by an app-based delivery mood, the chinese SbS is expected to be satisfactory by youthful adults as they are broadly perceived acknowledged to be adept in digital technology. Compared with traditional face-to-face interventions, it is more accessible and promising to reduce the stigma of using a mental health interposition, which is a common barrier to genial health services among chinese young adults ( 42 ). A majority of participants reported poor wellbeing in our report, and the adapted treatment is besides possibly beneficial for the general population to learn coping skills for moo mood, stress, and aroused difficulty. however, this culturally adapted version needs far evaluation ( 28, 29 ). Informed by several process models for cultural adaptation, a feasibility study is planned with a modern group of chinese adolescents, in order to test its acceptability with the target population. This learn will involve cognitive interview to ascertain if the material requires foster modification to illustrations or program narratives before testing of the potency of this culturally adapted intervention in a randomize controlled trial .


The study has several limitations. First, the FGD participants reported minimal depressive symptoms and might perceive the broadcast differently from those with higher levels of depression. however, we besides noticed that a majority of participants from the two communities reported a abject level of wellbeing, which indicates that while they did not mean cut-off scores for depression, they however reported distress. The adjacent phase in our research process is to conduct a feasibility study with adolescents who report significant depressive symptoms. This discipline will provide the opportunity to evaluate how the intervention is perceived and ensure that the contented is optimized for the target population. second, the FGD participants were chiefly from three major universities/colleges out of the ten in Macao ( approximate 70 % of Macau university/college students attend one of these schools ) and no out-of-school young adults were included. The acceptability of the program remains strange for students in early colleges ( e.g. nursing college ) and working young adults, who might have different life experiences from the FGD participants. This may affect the generalizability of the adjust materials. however, this chinese tailored version may be applied to other chinese young adults who study afield and alone minimal adjustment would be expected when needed, which might increase the coverage of the intervention. Third, the stratums of local and nonlocal groups might not amply capture the unevenness in the sociodemographic characteristics of young adults in Macao. We besides attempted to divide the stress groups into Macao local Chinese and mainland taiwanese groups, since we believe that there are cultural differences between these chinese populations, which may influence the choose adjust subject. however, we noted that there were 3 participants not born in Macao joining Macao Chinese groups, and 1 player born in Macao joining the mainland Chinese group. The 3 Macao Chinese lived in Macao for 7, 13, and 17 years and perceived themselves as a member of the local residential district. however, the player from mainland Chinese group was actually a Macao house physician but perceived himself as a member of the nonlocal community. He did not consider himself a extremity of the local Macao Chinese residential district because he was raised and educated in mainland China and had lived in Macao for 5 years. This highlights the complexity of place-based identity in cultural studies. fourthly, the size of the steering group was minor. It included members with clinical psychology, communication, anthropology, and chinese cultural background. Although the steering group did not include experts who developed the intervention, they were consulted at respective stages in the adaptation process and provided extra feedback on the modifications. guidance on the optimum number of people and types of expertness to include in the steer group is not presently available. future studies should strive to include even more divers perspectives, including people with expertness in human-centered design, which may complement expertness in psychology, communication, and public health for cultural adaptation studies of digital mental health programs. Fifth, although the bottom-up set about allowed participants to generate ideas for the illustrations on their own, the participants appeared to be exhausted in the insistent resource work, which may reduce the efficiency of the focus group discussion. future studies should consider including participants with proper clinical characteristics and diverse backgrounds to enhance the cogency of adjust materials and the program for the target population. Using fresh participatory strategies to enhance the dynamic of the discussion is recommended and might include games and mix media synergistic exercises .


This study demonstrated the utility of two guidelines for cultural adaptation of SbS. It achieved a culturally appropriate version of the SbS program for taiwanese young adults by adapting the elements of the program ( e.g., language, metaphor, contented ). The current cultural adaptation study provides an example for future cultural adaptations of digital mental health interventions .

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation .

Ethics Statement

The studies involving human participants were reviewed and approved by University of Macau Research Ethics Panel. The patients/participants provided their written informed accept to participate in this study.

Author Contributions

HS managed the datum, performed courtly analysis, conducted investigation, and drafted the manuscript. RL assisted with probe, analysis, and drafting paper. AL provided resourses, assisted investigation, reviewed and edited the blueprint. WC reviewed and edited the draft. CL provided resourses, reviewed and edited the draft. BH conceptualized the project, handled stick out presidency, provided resourses, drafted the manuscript, and supervised the analyze. All authors contributed to the article and approved the submitted translation .


fund was provided by the Macau Foundation, the University of Macau grant MYRG2018-00241-FSS, and the Johns Hopkins University Center for Global Health .

Conflict of Interest

The authors declare that the inquiry was conducted in the absence of any commercial or fiscal relationships that could be construed as a potential conflict of interest .


The authors would like to thank the World Health Organization for the support and guidance of the Step-by-Step project, particularly Dr. Ken Carswell. The authors thank taiwanese mental health experts : Mr. Chan Fong Lao from Psychotherapy Center of the Women ’ s General Association, Dr. Ka Man Choi from Conde S. Januário Hospital, Mr. Kuai Long Sou and Dr. Mek Wong from Student Counselling section of Student Affairs Office of University of Macau, Prof. Yutao Xiang from University of Macau, and Prof. Jie Zhong from Peking University. The authors thank Mr. Chi Seng Cheang for creating illustrations, Ms. Sin Leng Wong for writing the stories according to KIIs ’ feedback, and the General Association of chinese Students of Macao for participant recruitment and providing venue and equipment for stress group discussion. We besides thank GCMH research members Chi Ian Chang, Tong Chao, Chia-yu Lin, Hongyi Sun, and Yanlin Gao for their support in note-taking and logistics of focus group discussions. finally, the authors thank the chinese unseasoned adults for their fourth dimension, feat, and steering in the adaptation of Step-by-Step .

Supplementary Material

The Supplementary Material for this article can be found on-line at : hypertext transfer protocol : // # supplementary-material


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