Adaptation and translation of mental health interventions in Middle Eastern Arab countries: A systematic review of barriers to and strategies for effective treatment implementation

Abstract

Aim:

All too often, efficacious psychosocial evidence-based interventions fail when adapted from one culture to another. International translation requires a deep understanding of the local culture, nuanced differences within a culture, established service practices, and knowledge of obstacles and promoters to treatment implementation. This research investigated the following objectives to better facilitate cultural adaptation and translation of psychosocial and mental health treatments in Arab countries: (1) identify barriers or obstacles; (2) identify promoting strategies; and (3) provide clinical and research recommendations.

Methods:

This systematic review of 22 psychosocial or mental health studies in Middle East Arab countries identified more barriers (68%) than promoters (32%) to effective translation and adaptation of empirically supported psychosocial interventions.

Results:

Identified barriers include obstacles related to acceptability of the intervention within the cultural context, community and system difficulties, and problems with clinical engagement processes. Whereas identified promoter strategies centre on the importance of partnering and working within the local and cultural context, the need to engage with acceptable and traditional intervention characteristics, and the development of culturally appropriate treatment strategies and techniques.

Conclusions:

Although Arab cultures across the Middle East are unique, this article provides a series of core clinical and research recommendations to assist effective treatment adaptation and translation within Arab communities in the Middle East.

Keywords

Adaptation translation mental health interventions Arab countries Middle East

Introduction

Mental disorders are a significant individual, family and societal burden experienced in countries and cultures throughout the world (WHO, 2001). From limited research, the prevalence of mental illness in the Middle East has been found to be comparable to other parts of the world (Karam et al., 2006), with overall 12-month prevalence rates of 17% and lifetime rates of 33% (Kessler et al., 2007; WHO World Mental Health Survey Consortium, 2004). Compared to individuals in western countries, however, those in the Middle East with mental illness receive treatment at considerably lower rates (Karam et al., 2006; WHO World Mental Health Survey Consortium, 2004).

In seeking to treat mental illness, agencies and governmental organizations in Arab countries in the Middle East are increasingly turning to established evidence-based practices and empirically supported treatments. However, such treatments are often developed and tested outside of Arab countries; notably evidence-based interventions have been developed in North America and Europe. Consequently, adaptation and translation of these interventions to the Arab context has received little scientific scrutiny. A small cadre of experts in the Middle East has argued for specific adaptations to interventions developed in the West. For instance, Al-Krenawi and Graham (2000) and Al-Makhamreh, Hasna, Lewnadow-Hundt, Smeiran and Alzaroo (2012) point out that mental health interventions need to be localized to the specific Arabic context. They argue that effective mental health interventions in the Middle East must give consideration to the overriding value placed on family membership, the role and status of women, stigma associated with mental health symptoms, a preference for indigenous healing, and the lack of formal mental health interventions in most Arabic countries (Al-Makhamreh & Lewando-Hundt, 2012; Al-Makhamreh & Libal, 2011). This literature echoes broader themes in the adaptation of evidence-based interventions where it is argued that the effectiveness of interventions hinges on specific cultural adaptations in implementation and therapeutic processes (Alvidrez, Azocar, & Miranda, 1996; Atkinson, Bui, & Mori, 2001; Betancourt, Green, Carrillo, & Ananeh-Firempong, 2003; Miranda et al., 2005; Sue, 1998; Sussman & Palinkas, 2008; Whaley & Davis, 2007).

The adaptation of evidence-based interventions for diverse cultural contexts can be strengthened through empirical research that identifies ways to tailor mental health care for diverse populations (Miranda et al., 2005). Research highlights the need to both test adaptations of evidence-based practices and to document the process in clear and systematic ways as this can serve to further advance research and inform practice (Bernal, Jiménez-Chafey, & Domenech Rodríguez, 2009). Although the Middle East is very broad and diverse, there has been no synthesis of this literature for Arab countries. This systematic review aims to: (1) identify core barriers or obstacles to the implementation of psychosocial or mental health treatment, services or interventions in Arab countries; (2) identify core promoter strategies that assist or facilitate the effective implementation of psychosocial or mental health treatment, services or interventions in Arab countries; and (3) provide a series of clinical and research recommendations to better facilitate cultural adaptation and translation of psychosocial and mental health treatments in Arab countries.

Methods

PsycINFO and MEDLINE databases were searched over the past 25 years, from 1 January 1985 to 1 December 2010 (see Figure 1 for a diagram of the review and selection of articles) to identify studies that reported quantitative or qualitative data about the adaptation and implementation of evidence-based psychosocial interventions in the Middle Eastern region. The search strategy matched the following criteria: (1) psychosocial treatment, treatment, intervention, evidence-based practice, mental health services, services, therapy or best practices; (2) culture, culture change, cross culture, cross-cultural difference, cross-cultural comparisons or cultural translation; (3) Middle East, Arab, Arabic, Islam, Muslim, Palestine, Jordan, Iran, Iraq, Syria, Saudi Arabia, United Arab Emirates, Kuwait, Lebanon, Bahrain, Qatar, Oman, Yemen or Egypt; (4) published in the English language; and (5) published as peer-reviewed articles. Exclusion criteria included: (1) studies that did not specifically address psychosocial or mental health interventions, services or treatment; (2) studies on psychosocial interventions, services or treatment conducted exclusively outside of the identified Middle East region; (3) review articles; (4) theoretical articles; and (5) letters to the editor.

Figure 1.

Review and Selection of articles.

The articles included in this review were assessed and coded by the research team according to established criteria (Figure 1). The initial search identified 278 articles in PsycINFO and 490 articles in MEDLINE. A review of the abstracts by the research team resulted in the inclusion of 59 articles. These articles were reviewed and coded by two authors resulting in a final inclusion of 22 articles.

Eligible articles were independently reviewed and coded by three authors (REG, MJM and KBB). Codes were reviewed in regular meetings and any discrepancies were resolved through discussion and consensus. The coders maintained over 90% inter-rater reliability. Each study was coded for factors that interfered with, and that promoted, the implementation of mental health or psychosocial treatment, services or interventions. Barriers are obstacles or challenges that impede adaptation or translation of evidence-based interventions into Middle Eastern cultures; promoters are strategies that assist or facilitate the effective adaptation or translation of evidence-based interventions into the Arab context. After barriers and promoters were identified for each study, the reviewers grouped and classified them into three discrete categories based on the conceptual content: (1) local or cultural environment; (2) initial engagement with treatment or service; and (3) continued use of services or psychosocial treatment adherence. Each category was further divided into relevant subcategories. In addition, studies were coded for demographics (i.e. population, sample size, age, gender) and intervention characteristics (i.e. study methods, mental health/psychosocial outcomes).

Results

Twenty-two studies were included in the review (Table 1). Seventeen (77%) of the studies were published between 2000 and 2010, four (18%) were published in the 1990s, and only one (5%) was published in the 1980s. Methodologically, the research was diverse. The majority, 15 (68%) studies employed questionnaires or surveys. Six (27%) investigated an intervention; however, only three (14%) of these studies employed a comparison group. Five (23%) studies used qualitative methodology, either alone or in a mixed-method approach. One (5%) employed secondary data analysis. The mental health outcome investigated centred on service utilization in seven (32%) studies, attitudes and beliefs in six (27%) studies, functioning in five (23%) studies, and both awareness and prevalence in two (9%) studies.

Table 1.

Literature summary and demographics.

Author	Year	Population	Method	MH outcome	N	Age (years)	Male (%)	Barrier	Promoter
Al-Eissa & Almuneef	2010	Saudi Arabian	Sd	Prevalence	188	5	53	3	2
Al-Krenawi	1999	Bedouin Negev	S	Attitudes/beliefs	60	33^a	40	3
Al-Krenawi & Graham	1999	Bedouin Negev	Qu	Service utilization	47	31^a,b	50^b	15	4
Al-Krenawi et al.	2009	Arab-Israeli, Egyptian, Kuwaiti, Palestinian	S	Attitudes/beliefs	716	22	39	3	2
Al-Krenawi et al.	2004	Emirati, Jordanian, Muslim-Arab Israeli	S	Attitudes/beliefs	262	21^a	0	1	4
Al-Krenawi et al.	2003	Arab- and Jewish-Israeli	S	Service utilization	7,344	34^a	43^a		1
Al-Krenawi et al.	2000	Jordanian	S	Service utilization	87	69^a	70^a	3	2
Al-Krenawi et al.	2001	Muslim-Arab Jordanian, Jewish-Moroccan Israeli	S	Service utilization	148	55^a	59^a	5	1
Bader et al.	2007	Bedouin Negev	S, Qu, I	Engagement, Awareness	20	15^a	50		2
Eapen & Ghubash	2004	Emirati	S, Qu	Attitudes/beliefs, Service utilization	325	45	52^a	10	4
Hoven et al.	2008	Armenian, Azerbaijani, Brazilian, Chinese, Egyptian, Georgian, Israeli, Russian, Ugandan	Qe, S, I	Awareness	3,574	14^b	47^a,b		2
Karam et al.	2006	Lebanese	S	Prevalence	2,857	N/A	45	3
McConkey et al.	2008	Irish, Jordanian, Taiwanese	S, Qu	Functioning	206	42	0		1
Mohammadi et al.	2008	Iranian	Qe, I	Functioning	20	23	0		2
Murray et al.	2006	Bedouin Negev, Brazilian, Egyptian, Lebanese	P, I	Functioning	N/A	N/A	N/A	7	3
Oveisi et al.	2010	Iranian	RCT, I	Engagement, Functioning	224	30	0	2	1
Reiter et al.	1986	Arab-Israeli	S	Attitudes/beliefs	358	N/A	49	1
Savaya	1998	Arab-Israeli	S	Service utilization	242	37	0	7	1
Schwartz et al.	2002	Arab- and Jewish-Israeli	S	Service provision	101	35^a	N/A	4	3
Shalhoub-Kevorkian	2005	Palestinian	Qu	Service utilization, Service provision	28	15^a	0	6
So et al.	2006	Bedouin Negev, Brazilian, Egyptian, Lebanese	P, I	Functioning	N/A	N/A	N/A	3	1
Wahass & Kent	1997	Saudi Arabian, British	S	Attitudes/beliefs	281	35^a	61^a	2	1
Total K	22							17	18
M (SD)					854(1,798)	31.2 (15.6)	34.6 (25.2)

I = intervention, P = pilot, Qe = quasi-experimental, Qu = qualitative, RCT = randomized control trial, S = survey/questionnaire, Sd = secondary data analysis.

Calculated from article data, ^bBased on partial sample.

Sample characteristics varied widely across the studies. The age range of participants was from five to 69 years, with a mean of 31 years (SD = 16). Ten (46%) studies did not report a mean age, but provided data to calculate age from the article. Four (18%) did not report or provide sufficient data to calculate age. The average male participant rate across all studies was 34.6% (SD = 25.2%). In six (27%) studies gender percentages were calculated from the available data. Three (14%) studies did not provide gender demographics.

Barriers to psychosocial treatment and service implementation

In total 78 individual barriers and challenges to the implementation of mental health or psychosocial treatment, services or interventions in Arab countries were reported in 17 studies (Figure 2). The majority of barriers (42, 54%) related to acceptability of the intervention within the cultural context, whereas 21 (27%) barriers related to community and system factors, and another 15 (19%) related to clinical engagement processes.

Figure 2.

Frequency of barriers to mental health intervention implementation by studies.

The first area of barriers or obstacles is related to the local cultural context and was further coded into four sub-categories: beliefs and values, stigma, etiological perceptions, and communication and language. Beliefs and values comprised the majority of barriers relating to the local or cultural environment. A common barrier identified was a lack of general public awareness of mental illness and psychosocial treatment (Eapen & Ghubash, 2004; Karam et al., 2006). It was felt that increased awareness of mental health issues was a prerequisite to greater utilization and acceptability of mental health interventions. Another barrier to treatment was a preference for traditional networks of support over the utilization of westernized professional mental health services, which are often perceived as ignoring Arab values (Al-Krenawi & Graham, 1999; Al-Krenawi, Graham, Al-Bedah, Kadri, & Sehwail, 2009; Savaya, 1998). In some studies, nearly all research participants utilized traditional services before or during mental health treatment, including religious or Koranic healers, visiting holy tombs, or wearing amulets to protect themselves from the evil eye (Al-Krenawi, Graham, Ophir, & Kandah, 2001; McConkey, Truesdale-Kennedy, Chang, Jarrah, & Shukri, 2008; Okasha, Saad, Khalil, el Dawla, & Yehia, 1994). Treatment from religious and traditional healers is perceived as less stigmatizing and is widely considered suitable by clients as such care focuses on the root of the problem as defined within the culture (Al-Krenawi & Graham, 1999; Wahass & Kent, 1997).

Beliefs and values related to gender were repeatedly identified as a barrier to treatment (Al-Krenawi, 1999; Al-Krenawi, Graham, Dean, & Eltaiba, 2004; Eapen & Ghubash, 2004; Murray, Fayyad, Jensen, Hoagwood, & Azer, 2006; Savaya, 1998; Shalhoub-Kevorkian, 2005). In some traditional segments of society, females are accompanied by males in public; consequently, in interactions with mental health service providers, females may need a chaperone to access and receive services (Al-Krenawi & Graham, 1999). Young males presenting with behavioural problems are often not perceived as requiring professional services (Eapen & Ghubash, 2004).

Thirty-six per cent of barriers related to the local and cultural environment involved stigma; they were derived from six studies. Most stigma barriers highlighted the negative consequences of engaging or receiving treatment on the individual and their family. There emerged general taboos and social shame related to mental illness (Eapen & Ghubash, 2004; Karam et al., 2006) and to the utilization of services (Eapen & Ghubash, 2004; Murray et al., 2006; Shalhoub-Kevorkian, 2005). In addition, families of individuals with mental illnesses or seeking treatment risked a damaged reputation or diminished social status in the community (Shalhoub-Kevorkian, 2005). In particular, young females were affected by stigma, from disclosing sexual abuse or by having a mental disorder that is often identified through the seeking or receiving of treatment, which may damage marital prospects or affect current marital relationships (Al-Krenawi & Graham, 1999; Shalhoub-Kevorkian, 2005).

Differences in beliefs concerning the etiology of mental illnesses were identified as barriers in six studies. Symptoms and mental disorders are often perceived to be caused by external or supernatural origins, such as the will of God, divine punishment, evil spirits or sorcery (Al-Krenawi, 1999; Al-Krenawi, et al., 2001; Reiter, Mar’i, & Rosenberg, 1986; Wahass & Kent, 1997). Further, men tend to attribute the causality to God’s will, whereas women often attribute mental illness to evil spirits or sorcery (Al-Krenawi, 1999; Al-Krenawi, et al., 2001). Consequently, treatments for mental illness are often sought from traditional and spiritual healers to the exclusion of professional mental health services.

A final sub-category of barriers within the local cultural and environmental context was related to language and translation, specifically between providers and patients of differing cultures. Such mental health professionals lack sufficient language skills and relied on the use of translators that inhibited patient–provider communication, and a lack of cultural understanding around somatic presentation of symptoms resulted in misdiagnosis (Al-Krenawi & Graham, 1999).

The second domain of barriers relates to community and system factors that impede initial engagement with services and includes two sub-categories: access to services and availability of services. A total of 15 individual barriers across nine articles identified access as an obstacle to mental health treatment. General access barriers include personal financial constraints (Eapen & Ghubash, 2004; Karam et al., 2006; Murray et al., 2006), women’s access to service limited by gender norms (Al-Krenawi & Graham, 1999) and insufficient local transportation (Eapen & Ghubash, 2004). Access barriers located within the mental health professional service sector include non-reporting or misdiagnosis of mental health needs (Al-Eissa & Almuneef, 2010; Eapen & Ghubash, 2004; Oveisi et al., 2010), lack of professional training (Shalhoub-Kevorkian, 2005) and an overly complicated referral process (Al-Krenawi & Graham, 1999). Six individual barriers across five articles were identified addressing the availability of services. Specifically, lack of professional community-based service providers (Eapen & Ghubash, 2004; Murray et al., 2006), as well as insufficient resources needed to provide the required services (Schwartz, Duvdevany, & Azaiza, 2002; So et al., 2006) were highlighted as factors in the lack of the availability of services.

Clinical engagement processes that influence adherence to psychosocial treatment comprise the third category of barriers. This barrier domain was further divided into three sub-categories: client expectations of treatment, inappropriate treatment modalities and therapeutic alliance. Fifteen barriers across 10 studies identified client expectations as impediments to ongoing treatment. Expectation barriers include: the lack of client understanding of diagnosis, treatment goals or nature of the treatment (Al-Krenawi & Graham, 1999; Murray et al., 2006); misunderstandings about treatment, such as instrumental or concrete support (Al-Krenawi, et al., 2001; Savaya, 1998); and a preference for a more medical model or directive authoritarian approach (Al-Krenawi et al., 2001; Al-Krenawi, Graham, & Kandah, 2000; Schwartz et al., 2002). Barriers to ongoing treatment adherence included inappropriate treatment modalities, such as provision of generalized rather than specialized service (Schwartz et al., 2002), or culturally incongruent methods of treatment (Shalhoub-Kevorkian, 2005). A final barrier resulting in difficulties within the therapeutic alliance may result from patient mistrust of mental health services (Eapen & Ghubash, 2004).

Strategies for overcoming implementation barriers

Eighteen studies advanced 37 individual strategies to mitigate the effect of barriers for the implementation of mental health or psychosocial treatment, services or interventions in Arab countries (Figure 3). Consistent with the distributions observed in barriers, 70% of promoters (26) across 13 studies related to strategies to increase the acceptability of the intervention within the local cultural context. The remaining strategies addressed barriers associated with culturally appropriate clinical engagement strategies. Strategies to overcome barriers associated with barriers in the community and system factors domain were not addressed in the studies located for this review.

Figure 3.

Frequency of promoting strategies to mental health intervention implementation by studies.

Articles included in this review described four strategies to overcome acceptability barriers related to the local cultural context. First, acceptability of services can be increased by adapting intervention protocols to local customs and language (Castro, Barrera, & Steiker, 2010). So et al. (2006) accomplished this adaptation of evidence-based interventions for children by partnering with local task forces of service providers that took responsibility for adapting intervention protocols. The involvement of local stakeholders in the adaptation process is critical for a successful adaptation. Second, interventions can leverage the widespread acceptance of existing health systems to promote broader utilization of mental health services. For instance, mental health agencies can work closely with primary health care providers and clinics and co-locate services within these facilities (Eapen & Ghubash, 2004). Third, acceptance of mental health intervention programmes is increased with buy-in and support from key community leaders. Buy-in and support of village leaders and elders can make a substantial difference to programme acceptance, and the importance of programme staff buy-in should not be overlooked (Murray et al., 2006). In addition, partnerships with local and national governmental agencies can also promote programme acceptance (Al-Eissa & Almuneef, 2010). Fourth, studies illustrated the important role of public awareness and education campaigns to increase intervention acceptability (Hoven et al., 2008). Education may influence beliefs and attitudes about psychotherapy, specifically increased receptivity to psychotherapy and recognition of a personal need for psychotherapy that may increase engagement (Al-Krenawi et al., 2009). Furthermore, increased public awareness was associated with reduced acceptability of child abuse and neglect and increased incidence of reporting (Al-Eissa & Almuneef, 2010).

The remaining strategies for overcoming implementation barriers addressed obstacles associated with culturally congruent clinical engagement strategies. First, culturally congruent treatment modalities facilitate client engagement with mental health interventions. For some mental health and psychosocial problems, group treatment models that incorporate group or community discussions or focus on specific concrete skills, such as relaxation training or stress management, may be viewed as effective and more acceptable than other approaches (Bader, Wanono, Hamden, & Skinner, 2007; Mohammadi, Sajadinejad, Taghavi, & Ashjazdeh, 2008). In addition, the use of home visits within the treatment was perceived to be a normative part of social services (Schwartz et al., 2002). The provision of services through an anonymous and confidential call service that is accessible from the home was found to increase engagement, especially among Arab women (Al-Krenawi, Graham, & Fakher-Aldin, 2003). Second, active and directive clinical strategies have been advanced to increase acceptability of mental health interventions and to promote stronger therapeutic alliances among Arab clients (Al-Krenawi et al., 2000; Al-Krenawi & Graham, 1999). Whereas western approaches favour a more client-centred, passive approach to clinical practice, service providers in Middle Eastern contexts should adopt a more authoritative approach that includes more actively directing the helping process and the utilization of advice giving as a therapeutic approach. Finally, employing local service providers who are familiar with regional cultural norms may facilitate acceptance and engagement with services (Savaya, 1998). Al-Kranawi and Graham (1999) reported on the importance of insider/outsider status in their study of service utilization among Arab mental health patients. The insider status of local service providers is marked by intimate knowledge of culture and language along with tribal affiliation and reputation, attributes that are difficult for community outsiders to establish.

Discussion

Mental illness is a significant burden, confronting individuals and families across cultural, regional and national borders (WHO, 2001). As scientific support for mental health treatments has increased, diverse governmental and non-governmental organizations (NGOs) are seeking to adapt and translate these established and efficacious evidence-based practices into their own local communities. In providing psychosocial treatment, Arab countries throughout the Middle East have sought to adapt empirically supported treatment to their own needs. To our knowledge, this is the first systematic review focusing on the adaptation and translation of mental health interventions in the Middle East.

This review has found that research into mental health interventions, services and treatment in Arab countries has increased in each of the past three decades, with a notable increase in the past 10 years. Overall, research in this area remains sparse and is methodologically limited. The majority of the research employed a survey design. Six studies employed an intervention design, of which three used a comparison group, two were quasi-experimental and only one was a randomized controlled trial (RCT) design. However, these three quasi-experimental and RCT-designed studies have been published since 2008, indicating a potential positive trend towards more rigorous research.

Of the 22 studies eligible for inclusion in this review, a total of 78 barriers and 37 promoters to the implementation of psychosocial or mental health treatment, services or interventions in Arab countries were coded. Promoters and barriers have coalesced around three general categories; notably, barriers related to acceptability of the intervention within the cultural context, community and system factors that influence service access and availability, and clinical engagement processes.

A series of clinical and research recommendations can be drawn from this nascent and emergent area of research that may offer insight and guidance to better facilitate adapting and translating evidence-based interventions for use in the Middle East. Recommendations drawn from this systematic review of 22 studies (Table 2) are presented as strongly recommended (identified in four or more studies) or recommended (identified in two or three studies).

Table 2.

Recommendations by studies.

	Strongly Recommended	Recommended
Working within the local and cultural environment
Explore and understand how beliefs/values may influence the treatment	√
Connect with local and cultural beliefs	√
Engage with traditional social service systems	√
Identify and understand local etiological differences of mental illness	√
Incorporate strategies to work with or reduce stigma	√
Provide education and public awareness	√
Locate services within established health service systems		√
Partner and/or build in local ownership		√
Treatment engagement
Identify strategies to open access of the treatment	√
Identify strategies to improve availability of the treatment	√
Incorporate locally accepted treatment modalities	√
Partner and employ local practitioners		√
Treatment continuance/adherence
Assess and incorporate client expectations into treatment	√
Focus on developing and maintaining a positive therapeutic alliance		√
Align treatment modalities with cultural norms and standards		√
Continue to use ongoing strategies to reduce stigma		√
Total	10	6

The first area of recommendations centres on working within the local and cultural environment. These recommendations highlight the importance of exploring and engaging local cultural beliefs and values to more effectively adapt and translate mental health treatment. As most individuals engage religious and traditional healers prior to or during professional mental health treatment (Al-Krenawi et al., 2001; Bener & Ghuloum, 2011; McConkey et al., 2008), practitioners and researchers may need to develop specific cultural knowledge of, and sensitivity to, these informal local traditional service providers to better inform and facilitate effective adaptation of treatment. Further, understanding and incorporating traditional and local healing systems may increase the cultural relevance of professional mental health practice (Al-Krenawi et al., 2009). In addition, individuals are wary of seeking treatment outside of their families or tradition, in non-culturally congruent models of care (Al-Krenawi & Graham, 1999; Savaya, 1998; Schwartz et al., 2002; Wahass & Kent, 1997). Thus, adaptation of treatment may require concerted efforts to actively involve and incorporate family and Arab values. Gender roles among traditional cultural groups and individuals may prohibit females from travelling or interacting alone with non-family male members; whereas the male role involves protecting females and the provision of guidance to the family (Al-Krenawi & Graham, 1999, 2000). Thus, the involvement of family in treatment can facilitate and support both female and male participation, while respecting cultural values. Efforts to increase public awareness of mental illness and incorporation of strategies to reduce stigma are strongly recommended in the adaptation and translation of treatment within the local and cultural environment. Stigma may be reduced by the explicit integration of interventions with the Arab cultural canon and, if possible, aligning services with currently utilized traditional healing systems in order to reduce stigma (Al-Krenawi, 2002). Integration of mental health services into non-stigmatizing frameworks, such as general medical clinics (Al-Krenawi et al., 2004) or established health care systems, and partnering with local leaders, government officials and NGO stakeholders may also be beneficial. Research has identified that establishing strong relationships with village leaders and including them in programme planning and implementation increases acceptance of new services (Murray et al., 2006). Similarly, governmental support and acceptance has been found to improve the adaption of treatment (Al-Eissa & Almuneef, 2010; Murray et al., 2006).

The second area of recommendations focuses on treatment engagement. In the Middle East, successful adaptation and translation of mental health interventions will require strategies that foster improved availability and access. As insufficient professional service providers and, in countries that do not subsidize mental health care, resources restrict availability of treatment (Eapen & Ghubash, 2004; Murray et al., 2006; Schwartz et al., 2002; So et al., 2006), it is recommended to develop the professional capacity needed to deliver interventions and provide adequate resources to support the treatment. This review found that access to mental health treatment in Middle Eastern countries is limited by economics (Eapen & Ghubash, 2004), such as fee-for-service (Al-Krenawi et al., 2001; Murray et al., 2006) or lack of private insurance to cover mental health services (Karam et al., 2006). Thus, to enhance access, adaptation of services may need to establish alternative payment structures and/or partner with local governments or NGOs to offset delivery costs. Access is also limited by medical professionals’ lack of knowledge about mental health effects related to abuse (Oveisi et al., 2010) or under-reporting of abuse (Al-Eissa & Almuneef, 2010). In addition, doctors may misdiagnose psychiatric conditions due to somatic presentation of mental health symptoms (Al-Krenawi et al., 2001; Eapen & Ghubash, 2004). Education and professional training of existing health care providers on mental health symptoms, psychiatric illness and psychosocial responses to abuse and trauma may improve increased awareness and subsequent referral to mental health services. Further, the existing referral systems for psychosocial services are often complex and associated with increased patient anxiety that may limit access (Al-Krenawi, 1999; Al-Krenawi et al., 2001). It is recommended that improved access strategies be implemented to streamline referral processes to mental health services; this may be facilitated by partnering with local health care institutions and professionals.

The third area of recommendations direct attention to clinical treatment processes to improve engagement and maintain treatment. The strongest recommendation focuses on assessing and working with the client’s treatment expectations. Studies have repeatedly found that in the Middle East, patients often do not understand mental diagnoses or treatment (Al-Krenawi, 1999; Al-Krenawi, 2002; Schwartz et al., 2002). Mental health patients expect a medical approach to care that focuses on medication (Al-Krenawi, 2002; Al-Krenawi et al., 2000; Al-Krenawi & Graham, 1999) or instrumental/concrete support (Al-Krenawi et al., 2001; Savaya, 1998). The utilization of local providers who are seen as ‘insiders’ and the use of traditional casework skills such as role induction can facilitate engagement (Al-Makhamreh et al., 2012; Hepworth, Rooney, Dewberry-Rooney, Strom-Gottfried, & Larsen, 2009).

Also, patients in Middle Eastern Arab countries typically expect a more authoritative and directive style of treatment from their provider (Al-Krenawi et al., 2001), rather than process-oriented care (Al-Krenawi et al., 2000). Thus, client understanding, knowledge and preferences for treatment need to be taken into careful account. For example, therapies incorporating group discussion may be effective and culturally acceptable (Mohammadi et al., 2008). In adapting a mental health treatment within this context, it is essential to assess and incorporate client treatment expectations, including educating clients on their mental health symptoms and established treatments. Clarifying treatment and role expectations may strengthen a more positive therapeutic alliance, which is another identified factor for improving adherence and maintenance to treatment within an Arab context. It is also recommended that mental health services align treatment modalities with cultural norms. Psychotherapy or talk therapy is often unfamiliar and unacceptable; at times, it may become culturally incongruent due to the divulgence of personal and family problems to outsiders (Al-Krenawi et al., 2000; Al-Krenawi et al., 2003; Shalhoub-Kevorkian, 2005) and may need to be modified. Client education on the process of treatment, informing clients of established professional ethical guidelines on confidentiality, treatment delivered by locally trained service providers and awareness of cultural norms may all foster treatment continuance. For example, use of Arab service providers and agencies may increase trust and service use (Savaya, 1998). A final recommendation to promote ongoing adherence to treatment highlights the continued use of strategies to reduce stigma. Studies have identified that locating services within non-stigmatizing settings, such as medical or health care, can reduce stigma (Al-Krenawi et al., 2000; Oveisi et al., 2010).

Limitations

This review is limited by the quality and quantity of the research in this area. Notably, there are few comparison studies and only one RCT that was identified, thereby eliminating the potential to subject this literature to meta-analysis. Due to the limited number of studies relating to barriers, it is important to be careful to avoid overgeneralization of data collected on one area, such as occupied territories, to wider Arab nations. Also, the inclusion of only peer-reviewed published empirical studies may have limited the scope of this study’s findings. For example, whereas calls have recently been made for a blended a bio-psychosocial and community-based approach to mental health in the region (Al-Makhamreh & Lewando-Hundt, 2012), such a treatment model was not explicitly identified in any of the eligible articles identified for this review. Additionally, the high frequency of some barriers and promotive strategies over others may be an artifact of the type of studies currently found in the literature.

Conclusion

Despite its limitations, the results of this study are consistent with recent calls for the localization of mental health services within the Arabic countries of the Middle East, where mental health professionals straddle a tension between institution-led secular care and traditions of care rooted in tribal and kin relationships and in religious traditions (Al-Krenawi & Graham, 2000; Al-Makhamreh et al., 2012; Al-Makhamreh & Libal, 2011). Accommodating mental health interventions to this cultural context by partnering with traditional healers and by adopting a family-based approach may be necessary to increase the acceptability of evidence-based mental health interventions among community stakeholders and potential clients. Increasing the availability of services in conjunction with professional education to increase the mental health knowledge of local health providers may facilitate access and engagement in services. Finally, the capacity of clients to take advantage of mental health interventions when they are offered can be increased by utilizing providers with an intimate knowledge of local cultural practices, utilizing a more directive therapeutic approach, and educating clients about the process of treatment. Future research into cultural adaptation is warranted (Castro et al., 2010) with specific attention to the Arab context, as such information and knowledge can guide treatment and policy (Okasha & Karam, 1998). It is recommended that more rigorous research methodologies be applied to facilitate more sophisticated analysis. Also, research on adaptation needs to integrate assessment and procedures to ensure intervention fidelity. Adaptation and translation studies in this region should focus on the influence of gender, tribalism and religiosity. Clearly, it is vital to adapt and translate interventions to the local culture and environment, as Arab culture is very diverse reflecting various religious sects, tribal affiliations and social and political influences. Future research will need to explore these unique differences within the wider Arab world. However, in researching within the Arab context it is important to avoid broad-stroke views of culture regionally, which minimize important inter- as well as intra-country cultural differences in the region.

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