Culturally adapting internet- and mobile-based health promotion interventions might not be worth the effort: a systematic review and meta-analysis

Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective

We introduce the bias and equivalence framework to highlight how concepts, methods, and tools from cultural psychology can contribute to successful cultural adaptation and implementation of behavioral interventions. To situate our contribution, we provide a review of recent cultural adaptation research and existing frameworks. We identified 68 different frameworks that have been cited when reporting cultural adaptations and highlight three major adaptation dimensions that can be used to differentiate adaptations. Regarding effectiveness, we found an average effect size of zr = 0.24 (95%CI 0.20, 0.29) in 24 meta-analyses published since 2014, but also substantive differences across domains and unclear effects of the extent of cultural adaptations. To advance cultural adaptation efforts, we outline a framework that integrates key steps from previous cultural adaptation frameworks and highlight how cultural bias and equivalence considerations in conjunction with community engagement help a) in the diagnosis of behavioral or psychological problems, b) identification of possible interventions, c) the selection of specific mechanisms of behavior change, d) the specification and documentation of dose effects and thresholds for diagnosis, e) entry and exit points within intervention programs, and f) cost-benefit-sustainability discussions. We provide guiding questions that may help researchers when adapting interventions to novel cultural contexts.

The PICOTS-ComTeC Framework for Defining Digital Health Interventions: An ISPOR Special Interest Group Report

OBJECTIVES

Digital health definitions are abundant, but often lack clarity and precision. We aimed to develop a minimum information framework to define patient-facing digital health interventions (DHIs) for outcomes research.

METHODS

Definitions of digital-health-related terms (DHTs) were systematically reviewed, followed by a content analysis using frameworks, including PICOTS (population, intervention, comparator, outcome, timing, and setting), Shannon-Weaver Model of Communication, Agency for Healthcare Research and Quality Measures, and the World Health Organization's Classification of Digital Health Interventions. Subsequently, we conducted an online Delphi study to establish a minimum information framework, which was pilot tested by 5 experts using hypothetical examples.

RESULTS

After screening 2610 records and 545 full-text articles, we identified 101 unique definitions of 67 secondary DHTs in 76 articles, resulting in 95 different patterns of concepts among the definitions. World Health Organization system (84.5%), message (75.7%), intervention (58.3%), and technology (52.4%) were the most frequently covered concepts. For the Delphi survey, we invited 47 members of the ISPOR Digital Health Special Interest Group, 18 of whom became the Delphi panel. The first, second, and third survey rounds were completed by 18, 11, and 10 respondents, respectively. After consolidating results, the PICOTS-ComTeC acronym emerged, involving 9 domains (population, intervention, comparator, outcome, timing, setting, communication, technology, and context) and 32 optional subcategories.

CONCLUSIONS

Patient-facing DHIs can be specified using PICOTS-ComTeC that facilitates identification of appropriate interventions and comparators for a given decision. PICOTS-ComTeC is a flexible and versatile tool, intended to assist authors in designing and reporting primary studies and evidence syntheses, yielding actionable results for clinicians and other decision makers.

Challenges in implementing cultural adaptations of digital health interventions

Differences in the access and use of digital health interventions are driven by culture, in addition to economic and physical factors. To avoid the systematic exclusion of traditionally underserved cultural groups, creating inclusive digital health interventions is essential. One way to achieve this is through cultural adaptations, defined as the systematic modification of an existing intervention that aligns with a target audience's cultural norms, beliefs, and values. In theory, cultural adaptations can potentially increase the reach and engagement of digital health interventions. However, the evidence of whether and how that is achieved is limited. Justifying, planning, and implementing an adaptation comes with various challenges and takes time and money. This perspective provides a critical overview of the field's current state and emphasizes the need for technology-specific frameworks that address when and how to culturally adapt digital health interventions.

Needs for mobile and internet-based psychological intervention in patients with self-injury and suicide-related behaviors: a qualitative systematic review

BACKGROUND

In recent years, mobile psychological interventions have proven effective in reducing self-injury and suicide-related behaviors. Therefore, it is essential to continually enhance the user experience and address patients' needs to facilitate the development of mobile mental health interventions. Identifying patients with mobile mental health needs can be challenging for mental health professionals. To address this, we conducted a systematic review of qualitative research to synthesize the needs of patients engaged in self-injury and suicide-related behaviors for mobile and internet-based psychological interventions.

METHODS

This study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement (PRISMA) and the Enhancing Transparency in Reporting the Synthesis of Qualitative Research statement (ENTREQ). We explored 11 databases and synthesized the results using thematic analysis.

RESULTS

Sixteen qualitative and mixed-method studies were included. The study found that the needs of patients with self-injury and suicide-related behaviors for mobile psychological intervention included therapy, technology, culture, privacy, communication, emotional support, personalization, and self-management. Consistent with the Technology Acceptance Model (TAM), the needs of patients with self-injury and suicide-related behaviors are influenced by the perceived ease of use and perceived usefulness of the mobile intervention. However, the findings also highlight the importance and unmet needs of peer support, communication, self-management, and empowerment in using mobile psychological interventions for patients with self-injury and suicide-related behaviors.

CONCLUSIONS

Studies in this area have shown that the needs of patients with self-harm and suicide-related behaviors cover multiple stages, including basic therapeutic and technical needs and advanced emotional needs. This complexity makes it challenging to address the needs of patients engaged in self-injury and suicide-related behaviors through digital interventions. In the future, mental health professionals should be encouraged to participate in multidisciplinary collaborations to expand the use of digital interventions, enhancing remote self-management for patients and providing new strategies for the ongoing care of psychiatric patients. We registered the review protocol on PROSPERO (CRD42022324958).

Cultural adaptations and tailoring of public health nutrition interventions in Indigenous peoples and ethnic minority groups: opportunities for personalised and precision nutrition

Indigenous peoples and ethnic minority groups often experience poor diet quality and poor health outcomes. Such inequities may be partially due to nutrition interventions not meeting the unique cultural and linguistic needs of these population groups, which could be achieved using co-creation and/or personalised approaches. Cultural adaptation or tailoring of nutrition interventions has shown promise in improving some aspects of dietary intake, but this requires careful consideration to ensure it does not inadvertently exacerbate dietary inequities. The aim of this narrative review was to examine examples of cultural adaptations and/or tailoring of public health nutrition interventions that improved the dietary intake and to consider implications for the optimal design and implementation of personalised and precision nutrition interventions. This review identified six examples of cultural adaptation and/or tailoring of public health nutrition intervention in Indigenous peoples and ethnic minority groups across Australia, Canada and the US. All studies used deep socio-cultural adaptations, such as the use of Indigenous storytelling, and many included surface-level adaptations, such as the use of culturally appropriate imagery in intervention materials. However, it was not possible to attribute any improvements in dietary intake to cultural adaptation and/or tailoring per se, and the minimal reporting on the nature of adaptations limited our ability to determine whether the interventions used true co-creation to design content or were adapted from existing interventions. Findings from this review outline opportunities for personalised nutrition interventions to use co-creation practices to design, deliver and implement interventions in collaboration with Indigenous and ethnic minority groups.

Cultural accommodation of internet-based interventions for substance use and related disorders: a proposed comprehensive framework based on a pilot study and a literature review

Despite the low utilization rates of substance use and related disorders services, and the ability of internet-based interventions for substance use and related disorders (IBIS) to address challenges related to service engagement, limited attention has been placed on the processes for the accommodation of these interventions to diverse cultural settings. This study aimed to develop a framework for the cultural accommodation of IBIS across populations based on a pilot study and a literature review. A pilot study of cultural accommodation of an existing internet intervention for alcohol use was carried out in Israel, which involved focus groups and daily online surveys of prospective consumers (N = 24) as well as interviews with experts (N = 7) in the substance abuse treatment field. Thematic analysis revealed a range of themes that relate to the general Israeli culture and the specific Israeli drinking subculture, identified as needing to be addressed in the process of intervention accommodation. A comprehensive framework for cultural accommodation of IBIS is suggested, consisting of five stages: Technical and cultural feasibility; Engagement of target group; Identification of accommodation variables, Accommodation, and evaluation of the accommodated intervention. In addition, the framework consists of four dimensions of accommodation: Barriers and facilitators; Audio-visual materials and language; Mechanisms of change; Intersectional factors. We suggest that the proposed framework may serve as a guide for the cultural accommodation of existing internet-based interventions for substance use and related disorders across a range of cultural and geographical settings, thus augmenting the ecological validity of internet-based interventions for substance use and related disorders, expanding cross-cultural intervention research, and reducing health disparities worldwide.

An Online Mindfulness Intervention for International Students: A Randomized Controlled Feasibility Trial

Background

Student mobility across borders poses challenges to health systems at the university and country levels. International students suffer from stress more than their local peers, however, do not seek help or underutilize existing help offers. Some barriers to help-seeking among international students are insufficient information regarding the health offers, stigma, and language, which might be overcome via culturally adapted internet and mobile-based interventions (IMI).

Method

A randomized controlled feasibility trial with a parallel design assessed the feasibility and potential efficacy of an online mindfulness intervention adapted for international university students. Participants were randomized into either an adapted online mindfulness intervention (StudiCareM-E) (IG, n = 20) or a waitlist control group (WL, n = 20). Participants were assessed at baseline (t0) and eight-week post-randomization (t1). The feasibility of StudiCareM-E was evaluated regarding intervention adherence, client satisfaction, and potential negative effects. The potential efficacy of StudiCareM-E was measured by means of the level of mindfulness, perceived stress, depression, anxiety, presenteeism, and wellbeing. Efficacy outcomes were evaluated with regression models on the intention-to-treat (ITT) sample (n = 40), adjusting for the baseline values.

Results

Participants' formative feedback suggested improvements in the content of the IMI. There were no crucial negative effects compared to WL. Assessment dropout was 35% (IG: 50%: WL: 20%), and intervention dropout was 60%. StudiCareM-E yielded significant improvements in mindfulness (β = .34), well-being (β = .37), and anxiety (β = -.42) compared to WL.

Conclusion

StudiCareM-E might be used among culturally diverse international student populations to improve their well-being. Future studies might carefully inspect the extent of the adaptation needs of their target group and design their interventions accordingly.

A modern web-based health promotion program for patients in Greece with diabetes 2 and obesity: an interventional study

BACKGROUND

Health promotion programs are most beneficial in chronic diseases such as diabetes and morbid obesity, which can be positively affected by changes in attitudes, beliefs, and lifestyle.

OBJECTIVES

This study aimed to develop an internet-based modern Health Promotion model using interactive online applications through continuing education and participation.

METHODS

The goal was to positively impact knowledge, behavior, and quality of life for patients with obesity and/or diabetes. This is a prospective interventional study on patients with obesity or type 2 diabetes. Seventeen two patients who met the inclusion criteria were distributed randomly into two groups (control and intervention) from 2019 to 2021 in Greece. All the participants were given questionaries concerning quality of life anxiety and depression (HADS) attitudes and beliefs, knowledge about their condition and general questions to establish a baseline. A traditional health promotion model was followed for the control group. For participants in the intervention group, a web-based health promotion program was created according to the goals of the research. Participants were instructed to log on 1-2 times a week for 5-15 min, with the understanding that the research team would be monitoring their activities. The website included two knowledge games and personalized educational material based on their needs.

RESULTS

The sample comprised 72 patients (36 in control and 36 in the intervention groups). The mean age was 47.8 years for the control group and 42.7 years for the intervention group (p = 0.293). Both study groups had a significant increase in knowledge score on diabetes (Control group:3,24, Intervention group 11,88 p < 0,001) and obesity (Control group:4,9, Intervention group 51,63 p < 0,001) along with a positive attitude score towards fighting obesity (Control group: 1,8, Intervention group 13,6 p < 0,001). Still, the overall change was more remarkable for the intervention group, as indicated by the significant interaction effect of the analysis. Anxiety was decreased only in the intervention group (Control group:0,11, Intervention group - 0,17 p < 0,005). Analysis for QOL during follow-up showed that Physical Health and Level of Independence was improved in both study groups but the degree of improvement was more significant in the intervention group (Control group 0,31,Intervention group 0,73 p < 0,001). Psychological Health was improved only in the intervention group, with better scores at 6 and 12 months compared to controls (Control group 0,28,Intervention group 1,42 p < 0,001). Furthermore, Social relationships were improved only in the intervention group (Control group 0,02, Intervention group 0,56 p < 0,001).

CONCLUSIONS

The results of the present study showed that the participants in the intervention group showed significant improvement in knowledge, attitudes, and beliefs after using the internet as a learning tool. The intervention group also showed significantly reduced anxiety and depression arising from chronic illness. All of this resulted in an improved quality of life regarding physical Health, mental Health, and social relationships. Technology and online-based health promotion programs can revolutionize how we approach the prevention and management of chronic and terminal illnesses by improving accessibility, personalizing care, increasing engagement and motivation, improving data analysis, and disease management.

Culturally Responsive Telepsychology & mHealth Interventions for Racial-Ethnic Minoritized Youth: Research Gaps and Future Directions

Telepsychology and mHealth (TPmH) services for youth and their families have become increasingly prevalent in recent years. However, significant limitations in theory, research, and policy introduce questions about the effectiveness of such interventions, particularly for racial-ethnic minoritized youth and their families, who already contend with inequities in mental health treatment access and outcomes. Although TPmH have the potential to reduce barriers to mental health services in ways that may benefit racial-ethnic minoritized youth and their families, the mental health field must first grapple with limitations in culturally responsive TPmH work to avoid perpetuating existing mental health inequities. As such, this article begins by briefly reviewing extant literature on (1) TPmH for youth, (2) culturally adapted or culturally responsive evidence-based interventions for racial-ethnic minoritized youth and families, and (3) the intersection of TPmH and culturally responsive interventions. Informed by the gaps identified by this review, we provide recommendations for future directions in culturally responsive TPmH for racial-ethnic minoritized youth and families. These recommendations have been organized into four overarching categories: (1) conceptual and theoretical recommendations, (2) research priorities, (3) practice and policy recommendations, and (4) engagement and access recommendations. These recommendations offer novel ideas for researchers, clinicians, funding agencies, policy-makers, and other key stakeholders and are intended to facilitate equity in TPmH for racial-ethnic minoritized youth and their families.

Self-Assessment of Health Professionals' Cultural Competence: Knowledge, Skills, and Mental Health Concepts for Optimal Health Care

Current research often refers to cultural competence to improve health care delivery. In addition, it focuses on the cultural uniqueness of each health service user for optimal personalized care. This study aimed to collect self-assessment data from health professionals regarding their cultural competence and to identify their development needs. A mixed methods design was adopted using the Cultural Competence Self-assessment Checklist of the Central Vancouver Island Multicultural Society. This was translated into Greek, validated, and then shared with health professionals in Cyprus. Subsequently, a semi-structured interview guide was designed and utilized. This was structured in exactly the same question categories as the questionnaire. Data collection took place between October 2021 and May 2022, and convenience sampling was used to recruit 499 health scientists in Cyprus. The sample comprised doctors, nurses, psychologists, midwives, social workers, and physiotherapists. Subsequently, 62 interviews were conducted with participants from the same specialties. The results showed that (compared to other health professionals) nurses and psychologists are more sensitive to issues of cultural competence. It would appear that the more socially oriented sciences had better-prepared healthcare staff to manage diversity in context. However, there is a gap between knowledge and skills when comparing doctors to nurses; they seem to be more skilled and willing to intervene actively in cases of racist behavior or problem-solving. In conclusion, participants identified the importance of their cultural competence; they also realized the importance of optimal planning of personalized health care. There is a significant need for continuous and specialized cultural competence training for all health professions.