The authors assert that to their knowledge, procedures contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. To see the consent form we used, please see Appendix 5.


Arjadi R, Nauta MH, Chowdhary N, Bockting CLH (2015) A systematic review of online interventions for mental health in low and middle income countries: a neglected field.

Global Mental Health 2, e12. 2015.10.

Benish SG, Quintana S, Wampold BE (2011) Culturally adapted psychotherapy and the legitimacy of myth: a direct-comparison meta-analysis. Journal of Counseling Psychology 58, 279–289.

Bernal G, Rodriguez D (2012) Cultural Adaptations: Tools for Evidence-Based Practice With Diverse Populations. American Psychological Association, Washington DC, p. 14.

Carswell K, Harper Shehadeh M, Watts S, van’t Hof E, Abi Ramia J, Heim E, Wenger A, van Ommeren M (2018) Step by Step: a new WHO online intervention for depression. Manuscript in preparation.

Chowdhary N, Jotheeswaran AT, Nadkarni A, Hollon SD, King M, Jordans MJD, Rahman A, Verdeli H, Araya R, Patel V (2014) The methods and outcomes of cultural adaptations of

119 psychological treatments for depressive disorders: a systematic review. Psychological Medicine 44, 1131–1146. S0033291713001785.

Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M (2013) Developing and

evaluating complex interventions: the new Medical Research Council guidance. International Journal of Nursing Studies 50, 587–592. https://

Cuijpers P, Karyotaki E, Reijnders M, Purgato M, Barbui C (2018) Psychotherapies for depression in low- and middle-income countries: a meta-analysis. World Psychiatry 17, 90–101.

Drennan J (2003) Cognitive interviewing: verbal data in the design and pretesting of questionnaires.

Journal of Advanced Nursing 42, 57–63.

Gearing RE, Schwalbe CS, MacKenzie MJ, Brewer KB, Ibrahim RW, Olimat HS, Al-Makhamreh SS, Mian I,

Al-Krenawi A (2013) Adaptation and translation of mental health interventions in Middle Eastern Arab countries: a systematic review of barriers to and strategies for effective treatment

implementation. The International Journal of Social Psychiatry 59, 671–681.


Griner D, Smith TB (2006) Culturally adapted mental health intervention: a meta-analytic review.

Psychotherapy (Chicago) 43, 531–548.


Hall GCN, Ibaraki AY, Huang ER, Marti CN, Stice E (2016) A meta-analysis of cultural adaptations of psychological interventions. Behavior Therapy 47, 993–1014. 10.1016/j.beth.2016.09.005.

Harper Shehadeh M, Heim E, Chowdhary N, Maercker A, Albanese E (2016) Cultural adaptation of minimally guided interventions for common mental disorders: a systematic review and meta-analysis.

Jmir Mental Health 3, e44. https://

Heim E, Harper Shehadeh M, van ’t Hof E, Carswell K (in press) Cultural adaptation of scalable interventions. In

Cultural clinical psychology and PTSD (eds. A Maercker, E Heim and LJ Kirmayer). Hogrefe Publishing, Boston, MA.

Hwang W-C (2006) The psychotherapy adaptation and modification framework: application to Asian Americans. The American Psychologist 61, 702–715. 1037/0003-066X.61.7.702.

International Telecommunications Union (2017) ITU Statistics [Online]. Available: Statistics/Pages/stat/default.aspx. [Accessed 30 March 2018.]

Karam EG, Mneimneh ZN, Karam AN, Fayyad JA, Nasser SC, Chatterji S, Kessler RC (2006) Prevalence and treatment of mental disorders in Lebanon: a national epidemiological survey. The Lancet 367, 1000–1006. https://

Kohrt BA, Rasmussen A, Kaiser BN, Haroz EE, Maharjan SM, Mutamba BB, de Jong JTVM, Hinton DE (2014) Cultural concepts of distress and psychiatric disorders: literature review and research recommendations for global mental health epidemiology. International Journal of Epidemiology 43, 365–406.

Patel V, Chowdhary N, Rahman A, Verdeli H (2011) Improving access to psychological treatments:

lessons from developing countries. Behaviour Research and Therapy 49, 523–528.

120 Saez-Santiago E, Rodriguez-Hernandez N, Nunez-Mendez A, Bernal G (2017) Cultural adaptation of a school based depression prevention program for adolescents in Puerto Rico. In Handbook of Multicultural School Psychology: An Interdisciplinary Perspective (eds. EC Lopez, SG Nahari, and SL Proctor), p. 175. Proctor Routledge, New York.

UNHCR (2018) Situation Syria Regional Refugee Response [Online]. Available: syria/location/71. [Accessed 10 April 2018.]

United Nations Children’s Fund (UNICEF), United Nations High Commissioner for Refugees (UNHCR) and the United Nations World Food Programme (WFP) (2017) Vulnerability Assessment of Syrian Refugees in Lebanon 2017. [Online]. Available:

download/61312. [Accessed 19 September 2018.]

Willis GB, Artino AR (2013) What do our respondents think we’re asking? Using cognitive

interviewing to improve medical education surveys. Journal of Graduate Medical Education 5, 353–


Appendix 1

Table A1 Shows the steps and criteria for participant selection for the cognitive interviewing.

Recruitment of participants

Centres were selected based on the availability of mental health services, on their participation in the National Mental Health Programme activities, and on typical patients’ demographics (Lebanese, or Syrian or Palestinian nationalities)

In total, three mental health professionals and 13 PHCC front-line workers were interviewed, 64 community members including Lebanese, Syrian and Palestinian nationalities participated in FGDs, and two community members were interviewed individually for more in-depth information

PHCCS helped recruit participants from among their beneficiaries for the FGDs by approaching them while in the waiting room. Two front-line workers were interviewed from each centre and one or two FGDs took place in each centre for women (n = 38) and men separately (n = 26) People of these three

nationalities, above 18 years of age, and with primary school level literacy (in order to be able to engage with the Step-by-Step materials) were included in the study

The focus group participants were not screened for depression.

Participants completed a written consent form with the assistance of the data collector where necessary and were remunerated US$15 for their time


Appendix 2

Interview questions and example adaptation monitoring form – Mental Health Experts/Front-line personnel

Date of interview:

Population with which the interviewee works: (Lebanese, Palestinian, Syrian)

Area of Lebanon in which the interviewee works: Year of experience in mental health:

Sex of interviewee:

Thank you for being willing to provide feedback on this e-Mental Health intervention for populations living in adversity. We will be showing you segments of the intervention. At various points, we will stop to ask you questions about its relevance and acceptability. If you notice something prior to the point at which we stop, please call out and we will stop immediately. As you listen and read, please ask yourself the following questions:

Does the content make sense for – or is it relevant to – Lebanese nationals and Syrian or Palestinian refugees?

Is the content appropriate for the target population? i.e., is it meaningful, understandable and not offensive or upsetting? How could we change the content or the visuals or any other aspects of the intervention to make it more relevant and acceptable?

Please keep in mind that you are seeing one version of the story. There will be several other versions with different characters (show the different characters).

Participants can choose which character to watch. The story you will watch is also the female version. There will be a male version with different activities but the same strategies.

Can we begin?


Appendix 3

Table A2 Shows some examples of original story activity suggestions alongside suggestions from partipants to make amendments.


Appendix 4

Table A3 shows the changes pertaining to the different aspects of the content and delivery method of the intervention.


Appendix 5

Focus Group Discussions with Potential Users Consent form Ministry of Public Health in Lebanon

My name is ---. I am working with the Ministry of Public Health in Lebanon on a research project conducted by the World Health Organization with the Ministry of Public Health in Lebanon, and supported by a charitable foundation in Switzerland, Fondation d’Harcourt. I am inviting you to participate in a focus group discussion in order to give us in-depth feedback on the content of an internet-based mental health program. This program is called ‘Khoutweh Khoutweh’.

Before we begin, I would like to take a few minutes to explain why I am inviting you to participate and what will be done with the information you provide. Please stop me at any time if you have questions about the focus group. After I’ve told you a bit more about the project, you can decide whether or not you would like to participate.

‘Khoutweh Khoutweh’ is a minimally guided, electronic self-help program aimed at addressing the mental health needs of Lebanese nationals and Palestinian and Syrian refugees living in situations of adversity in Lebanon and experiencing difficult emotions. This intervention will eventually be used in selected primary health centres in Lebanon. Before using this intervention, we want to make sure that it is relevant, and that the content is easy to understand and accept- able. We are inviting you to participate in a focus group discussion to provide in-depth feedback on whether the content of the intervention is understand- able, acceptable, and relevant. You have been selected from the beneficiaries of this primary health centre/ non-governmental organization to participate in the research. The interview will take a maximum of 3 hours. Approximately 10 other participants will also be asked to participate.

If you agree to participate, we will show you the content of the intervention and you will be asked to answer several questions along with a group of other participants. Questions will address the

relevance and acceptability of the translated and adapted text, audio scripts and illustrations to your culture. Your participation is entirely voluntary and you have the right to withdraw your consent or discontinue participation at any time without penalty. If at any time and for any reason you would prefer not to answer any questions, please feel free to skip those questions. If at any time you would like to stop participating, please tell me. Your decision to withdraw will not involve any penalty or loss of benefits to which you are entitled. Discontinuing participation in no way affects your

relationship with your health center, the non- governmental organization or any of the three partners that are implementing this program (Ministry of Public Health, the World Health Organization and Foundation d’Harcourt). No one from *insert name of NGO* will be present when we are conducting the focus group discussion with you.

Your participation in this focus group does not immediately involve any physical risk or emotional risk to you beyond the risks of daily life. that listening to the story might cause you some emo-There is a slight chance and you can choose to discontinue the interview or wait a while and then continue.

You receive no direct benefits from participating in this research; yet, you may learn some tips to

125 support your own mental health. Your participation does help to improve the program and inform the adaptation of an intervention that will have potential to promote mental health of persons living in adversity in Lebanon. Refreshments will be available; there are no financial benefits for

participating in the discussion but we will provide LL10,000 for any transportation costs you might incur.

To secure the confidentiality of your responses, no identifiers will be kept. We will only note age, gender, nationality, and marital status to use for descriptive statistics. We will take handwritten notes without referring to your identity so that we accurately remember all the information you provide while preparing the project report. Hard copies will be stored in a locked cabinet in the office of the research. Soft copies will be saved on a password protected computer. Data access is limited to the Principal Investigator and staff working directly on this project. Records may be monitored by the IRB, but all information will remain confidential. All data will be destroyed responsibly after the required retention period (usually three years).

You will be provided a copy of the consent form. If you have any questions, feel free to ask them now.

You may also communicate now or in the future with the Principle Investigator responsible for the research: Dr. Rabih El Chammay Phone: +961 1 611 672 ext.: 125; E-mail:

Are you interested in participating in the focus group?

o Yes o No

Consent to quote from the focus group:

I may wish to quote from this focus group either in presentations or in reports resulting from this work. A pseudonym will be used in order to protect your iden- tity. You can still participate in the interview even if you do not want us to use quotes.

Do you permit me to quote from this focus group?

o Yes o No

Participant’s name:



Printed name of person obtaining consent:


Signature of person obtaining consent:



Dans le document Design and cultural adaptation of an e-mental health intervention for depression (Page 119-128)